What is the best treatment approach for a patient with an infected Bartholin's gland and a siton (Word catheter) insertion?

Treatment of Infected Bartholin's Gland with Word Catheter (Seton) Insertion

For an infected Bartholin's gland abscess, perform immediate incision and drainage with Word catheter placement, followed by empiric broad-spectrum antibiotics covering polymicrobial flora (co-amoxiclav or similar), and leave the catheter in place for 4-6 weeks to allow epithelialization of a drainage tract. 1, 2

Immediate Surgical Management

The primary treatment is surgical drainage, not antibiotics alone. 2, 3

• Perform incision and drainage under local anesthesia at the mucosal surface of the abscess, creating an adequate opening for drainage 1, 3
• Insert a Word catheter (or alternative loop drainage device) immediately after drainage to maintain patency and prevent premature closure 1, 4
• The catheter must remain in place for 4-6 weeks minimum to allow complete epithelialization of the drainage tract and prevent recurrence 1, 4
• Secure the catheter properly - the Word catheter balloon should be inflated with 2-4 mL of saline, or if using alternative tubing, create a secure loop to prevent premature expulsion 1

Antibiotic Selection

Adjuvant antibiotic therapy should cover polymicrobial aerobic and anaerobic organisms, as Bartholin's abscesses are commonly caused by opportunistic mixed flora. 2

Empiric Antibiotic Regimen:

• First-line: Co-amoxiclav (amoxicillin-clavulanate) provides broad-spectrum coverage for the polymicrobial infections commonly seen (coliforms, anaerobes, and gram-positive cocci) 2
• Alternative: Combination of flucloxacillin plus metronidazole if beta-lactam allergy or local resistance patterns warrant 2
• Duration: 7-10 days of oral antibiotics following drainage 2, 3

Key Microbiological Considerations:

• Coliforms (E. coli, Klebsiella) are the most common pathogens in Bartholin's abscesses 2
• Polymicrobial infections are extremely common, often involving both aerobic and anaerobic organisms 2
• Gonorrhea and Chlamydia are rarely causative in Bartholin's abscesses (contrary to common assumptions) 2

Post-Procedure Management

• Instruct the patient on sitz baths 2-3 times daily to promote drainage and comfort 3
• Schedule follow-up at 3 weeks to assess healing and catheter position 1
• Remove the catheter at 4-6 weeks once epithelialization is complete, leaving permanent drainage tracts 1, 4
• Monitor for premature catheter dislodgement, which is the most common cause of treatment failure and recurrence 1

Recurrence Rates and Treatment Comparison

• Word catheter recurrence rate: 8.3-18.8% depending on technique and catheter retention time 4, 5
• Marsupialization recurrence rate: 8.3% with higher patient satisfaction but longer operative time 5
• Simple incision without catheter placement has the highest recurrence rate and should be avoided 1, 3

Common Pitfalls to Avoid

• Never rely on antibiotics alone without surgical drainage - this will fail in virtually all cases of abscess 2, 3
• Do not remove the Word catheter prematurely (before 4 weeks) - this is the primary cause of recurrence 1
• Avoid single-agent narrow-spectrum antibiotics (like flucloxacillin alone) given the polymicrobial nature of these infections 2
• Do not assume sexually transmitted infections are the cause - routine STI testing is not indicated unless other risk factors present 2
• Ensure adequate local anesthesia before drainage to allow proper exploration and catheter placement 1, 3

Alternative if Word Catheter Unavailable

If a commercial Word catheter is not available, create a drainage loop using a small plastic feeding tube (5-8 French), securing it with sutures to prevent expulsion. 1 This technique is equally effective and uses readily available materials in any emergency or outpatient setting 1.