What is the best course of treatment for a patient with a suspected infected or inflamed Bartholin's duct cyst or small inflammatory collection/abscess?

Management of Suspected Bartholin's Duct Cyst/Abscess or Small Inflammatory Collection

For a suspected infected or inflamed Bartholin's duct cyst or small inflammatory collection, proceed with incision and drainage followed by placement of a Word catheter or marsupialization, combined with broad-spectrum antibiotics only if surrounding cellulitis is present. 1

Initial Assessment and Diagnosis

Clinical examination should focus on:

• Location of the mass (4 o'clock or 8 o'clock position at the posterior introitus) 1
• Size of the collection (drainage indicated when >2 cm) 2
• Presence of surrounding cellulitis or erythema 1
• Fluctuance on palpation indicating abscess formation 2

The differential diagnosis must exclude epidermal inclusion cyst, Skene's duct cyst, hidradenoma papilliferum, and lipoma. 1 In menopausal or perimenopausal women with irregular, nodular masses, excisional biopsy is required to rule out adenocarcinoma. 1

Treatment Algorithm Based on Clinical Presentation

For Asymptomatic or Small (<2 cm) Cysts

Expectant management is appropriate as many Bartholin duct cysts remain asymptomatic and resolve spontaneously without intervention. 2 No drainage is required for collections smaller than 2 cm that are not causing symptoms. 2

For Symptomatic Cysts or Abscesses >2 cm

Drainage is mandatory because these collections do not resolve spontaneously and will recur without intervention. 2

Primary drainage options include:

1. Word catheter placement (most common ED/office approach):

   • Administer local anesthetic 3
   • Make a small stab incision inside the hymenal ring 4
   • Insert Word catheter with inflated bulb to remain in place 4-6 weeks 4
   • This allows epithelialization of a drainage tract 3, 4
   • Caution: Word catheters frequently dislodge before epithelialization, leading to recurrence 3

2. Marsupialization (preferred for cysts, NOT for acute abscesses):

   • Creates a permanent opening for drainage 1
   • Reported 0% recurrence rate in available studies 5
   • Should NOT be used for acute gland abscesses 1
   • Healing typically occurs within 2 weeks 5

3. Alternative catheter technique (when Word catheter unavailable):

   • Use a small loop of plastic tubing secured to prevent expulsion 3
   • Allows drainage while preventing premature dislodgement 3

Antibiotic Therapy

Antibiotics are indicated ONLY when cellulitis is present. 1 Broad-spectrum coverage should target common pathogens including gram-negative bacteria and anaerobes. 6

Duration: 3-5 days of antibiotics after drainage if cellulitis present. 6 Do not continue antibiotics based on imaging findings of residual fluid—base discontinuation on clinical resolution of infection signs. 6

Management of Recurrent or Refractory Cases

Recurrence rates vary by treatment method:

• Marsupialization: 0% 5
• Word catheter/fistulization: Variable, generally low 5
• Simple aspiration alone: Highest recurrence (up to 38%) 5
• Simple incision and drainage without catheter placement: High recurrence risk 4

For recurrent infections:

• Consider marsupialization as definitive treatment 1, 5
• Gland excision reserved for multiple recurrences or severe cases requiring surgical referral 2
• CO₂ laser ablation is an alternative option 5

Common Pitfalls to Avoid

Never perform simple incision and drainage alone without catheter placement or marsupialization, as this results in high recurrence rates. 4 This is the most common error in management.

Do not use marsupialization for acute abscesses—this technique is appropriate for cysts but contraindicated in acute glandular abscesses. 1

Avoid prescribing antibiotics without cellulitis—the abscess itself does not require systemic antibiotics if adequately drained and no surrounding soft tissue infection is present. 1

Do not remove drainage devices prematurely—Word catheters must remain in place 4-6 weeks to allow complete epithelialization of the drainage tract. 4 Early removal leads to recurrence.

Follow-Up

Reassess at 3 weeks to confirm healing and remove drainage device if epithelialization is complete. 3 The goal is to preserve gland function whenever possible. 1