When does a Bartholin cyst become a medical emergency?

When Does a Bartholin Cyst Become an Emergency?

A Bartholin cyst becomes a medical emergency when it presents with signs of severe systemic infection (sepsis), hemodynamic instability, or acute urinary retention due to mass effect—though these scenarios are exceedingly rare.

Emergency Presentations

Severe Systemic Infection

• Sepsis or septic shock from an infected Bartholin gland abscess would constitute a true emergency requiring immediate hospitalization, intravenous antibiotics, and urgent surgical drainage 1.
• However, most Bartholin gland abscesses present with localized symptoms (pain, swelling, fever) rather than systemic toxicity 1.

Acute Urinary Retention

• Giant Bartholin cysts (≥10 cm) can theoretically cause acute urinary retention through mass effect, requiring urgent decompression 2.
• Such massive cysts are extremely rare but have been documented, with sizes reaching up to 20 cm in diameter 2.

Hemodynamic Compromise

• While hemorrhage into liver cysts can cause hemodynamic instability 3, 4, hemorrhage within a Bartholin cyst causing shock has not been documented in the available literature and would be extraordinarily unusual given the anatomic location and vascular supply.

Non-Emergency Urgent Situations

Infected Bartholin Gland Abscess

• An abscess >2 cm should be drained promptly but does not constitute an emergency unless systemic signs are present 1.
• These can be managed in an outpatient or emergency department setting with incision and drainage, Word catheter placement, or other drainage techniques 5, 1.
• Patients can be discharged home with oral antibiotics after drainage 5.

Large Symptomatic Cysts

• Cysts causing severe pain or functional impairment warrant urgent (not emergency) intervention but can typically be scheduled within days 1, 6.
• Most Bartholin duct cysts that are not infected remain asymptomatic and resolve spontaneously without intervention 1.

Common Pitfalls to Avoid

• Do not confuse "urgent" with "emergency": Most Bartholin cysts and abscesses, even when infected and painful, are urgent conditions that can be managed in office or ED settings, not true emergencies requiring immediate operating room intervention 1, 6.
• Do not delay drainage of abscesses >2 cm: These do not tend to resolve spontaneously and will recur without intervention 1.
• Consider malignancy in postmenopausal women: While not an emergency, any Bartholin mass in a postmenopausal woman requires biopsy to rule out malignancy, as this age group has increased cancer risk 6.

Practical Management Algorithm

For suspected Bartholin pathology, assess:

1. Vital signs and systemic symptoms: Fever with hypotension, tachycardia, or altered mental status → emergency management with IV antibiotics and urgent drainage 1
2. Urinary function: Inability to void → urgent drainage required 2
3. Size and infection status: Abscess >2 cm → same-day or next-day drainage; smaller cysts without infection → expectant management acceptable 1
4. Pain severity: Severe pain impairing function → urgent (within 24-48 hours) drainage 1, 6