What is the recommended treatment for a swollen Bartholin cyst?

Treatment for Bartholin Cyst Swelling

Incision and drainage is the definitive treatment for a swollen Bartholin cyst, particularly when symptomatic, with Word catheter placement being the preferred technique that can be performed in the office under local anesthesia. 1, 2

Primary Treatment Approach

For symptomatic Bartholin cysts or abscesses, perform incision and drainage with placement of a drainage device rather than simple lancing, as simple incision alone results in high recurrence rates. 2

Word Catheter Technique (Preferred Method)

• Insert a Word catheter under local anesthesia in the office setting, which allows for epithelialization of a drainage tract over 4 weeks. 1
• The catheter should remain in place for 4 weeks to allow proper tract formation. 1
• This approach achieved 97% abscess resolution in a prospective study of 35 women. 1
• 77% of patients successfully retained the catheter for the full 4-week period. 1
• Recurrence rate was only 3% (1 of 35 patients) at 6-month follow-up. 1
• 89% of patients stated they would choose this method again if recurrence occurred. 1

Alternative Drainage Techniques

• If Word catheters are unavailable, use a small loop of plastic tubing secured to prevent expulsion before epithelialization. 3
• Marsupialization under general anesthesia is an alternative definitive treatment but requires operating room resources. 1, 4
• Other options include silver nitrate application or CO2 laser cauterization, though these are less commonly employed. 4

Antibiotic Considerations

Antibiotics are NOT routinely necessary for Bartholin cysts or abscesses unless systemic signs of infection are present. 2, 5

Indications for Antibiotic Therapy

Add systemic antibiotics only when the following criteria are met:

• Temperature >38°C or <36°C 6
• Tachycardia >90 beats per minute 6
• Tachypnea >24 breaths per minute 6
• White blood cell count >12,000 or <4,000 cells/µL 6
• Extensive surrounding cellulitis with erythema >5 cm beyond wound margins with induration 6
• Immunocompromised state or markedly impaired host defenses 6

Antibiotic Selection When Indicated

• Choose agents active against common pathogens including Staphylococcus aureus, Streptococcus pneumoniae, and Haemophilus influenzae. 5
• For MSSA: cephalexin 500 mg every 6 hours orally or cefazolin 1 g every 8 hours IV 6
• For suspected MRSA: trimethoprim-sulfamethoxazole 1-2 double-strength tablets twice daily, doxycycline 100 mg twice daily, or clindamycin 300-450 mg four times daily (if local resistance <10%) 6
• Consider drug-resistant organisms (PRSP, BLNAR) in treatment failures, as documented in case reports. 5
• Duration is typically 5-7 days depending on clinical response. 6

Management of Treatment Failure or Recurrence

If the cyst recurs or drainage persists beyond 2-3 weeks, re-open the incision and ensure complete evacuation of all contents with thorough probing to break up loculations. 7, 8

• Most wounds should heal within 2-3 weeks; persistent drainage beyond this indicates inadequate initial treatment. 8
• For recurrent infections at the same site, search for retained foreign material or incomplete drainage. 7, 8
• Consider complete surgical excision of the cyst and its wall once acute inflammation has resolved to prevent future episodes. 7, 4

Critical Pitfalls to Avoid

• Never perform simple lancing without placement of a drainage device, as this results in high recurrence rates. 2
• Do not routinely prescribe antibiotics in the absence of systemic infection signs. 6, 2
• Do not pack the wound with gauze, as this increases pain without improving healing outcomes. 7, 6
• Do not assume ongoing drainage beyond 2-3 weeks is normal healing—this requires re-evaluation and likely re-drainage. 8
• Avoid closing the wound without adequate drainage, as this leads to recurrent infection. 7, 6