What are the clinical features, diagnosis, and management of a Bartholin cyst in women of reproductive age?

Bartholin Cyst: Clinical Features, Diagnosis, and Management

Definition and Anatomy

A Bartholin cyst is a fluid-filled swelling that develops when the duct of the Bartholin gland becomes obstructed, located in the posterior vestibule at the 4 and 8 o'clock positions of the vaginal opening. 1

• The Bartholin glands are normally pea-sized and non-palpable unless a cyst or abscess develops 2
• These glands drain through ducts that empty into the vestibule bilaterally 2
• Bartholin cysts account for approximately 2% of all gynecologic visits annually 3

Clinical Presentation

Asymptomatic Cysts

• Many Bartholin duct cysts remain asymptomatic and resolve spontaneously without intervention 4
• Small, non-infected cysts may be discovered incidentally during routine examination 4

Symptomatic Cysts and Abscesses

• When infected, Bartholin glands present with swelling, erythema, and tenderness that can extend into the entire labia minora 1
• Infected cysts or abscesses can be extremely painful and restrict physical activity 5
• The gland becomes palpable as a fluctuant mass in the posterolateral vaginal vestibule 2

Microbiology

• Any vaginal organism can infect the glands 1
• Bartholin gland infections are commonly caused by sexually transmitted infection (STI) pathogens, including gonorrhea and chlamydia 1
• Even uninflamed cysts contain normal skin flora 6

Differential Diagnosis

The differential diagnosis includes other vulvar lesions: 2

• Epidermal inclusion cyst
• Skene's duct cyst
• Hidradenoma papilliferum
• Lipoma
• In menopausal/perimenopausal women: adenocarcinoma (requires excisional biopsy for irregular, nodular masses) 2

Management Algorithm

Asymptomatic Cysts

Expectant management is appropriate for asymptomatic Bartholin duct cysts, as they often resolve spontaneously without intervention. 4

Symptomatic Cysts or Abscesses

Size-Based Decision Making

• Cysts or abscesses larger than 2 cm should be drained, as they do not tend to resolve spontaneously and can recur 4
• Cysts smaller than 2 cm may be managed expectantly with comfort measures 4

Drainage Procedures (Office-Based)

The goal of management is to preserve the gland and its function if possible. 2

Primary drainage options include: 2, 7

1. Word catheter placement (most frequently employed technique for office and ED management) 7

   • Used for both duct cysts and gland abscesses
   • Allows for epithelialization of drainage tract
   • Potential drawback: tendency to dislodge before complete healing 7

2. Marsupialization 2

   • Appropriate for cysts only
   • Should NOT be used to treat a gland abscess 2
   • Creates a permanent opening for drainage

3. Alternative drainage techniques 7

   • Loop of plastic tubing secured to prevent expulsion
   • Allows drainage while epithelialization occurs
   • Removed at 3-week follow-up 7

4. Alcohol sclerotherapy 5

   • Destroys epithelial covering through coagulative necrosis
   • Prevents reformation of fluid through fibrosis
   • Low recurrence rate with shorter treatment time compared to simple aspiration 5

Antibiotic Therapy

Broad-spectrum antibiotic therapy is warranted only when cellulitis is present. 2

• Antibiotics are rarely necessary for inflamed cysts unless complicating factors exist 1
• Complicating factors requiring antibiotics include: 1
  • Multiple lesions
  • Cutaneous gangrene
  • Severely impaired host defenses
  • Extensive surrounding cellulitis
  • Severe systemic manifestations of infection

Surgical Excision

• Reserved for recurrent cases unresponsive to conservative management 3
• Required for excisional biopsy in menopausal or perimenopausal women with irregular, nodular Bartholin's gland mass to rule out adenocarcinoma 2
• Historically required general anesthesia but modern techniques allow office-based procedures 3

Common Pitfalls and Caveats

Do Not Perform Gram Stain and Culture

• Gram stain and culture of pus from inflamed cysts is not recommended 6
• Cysts contain normal skin flora even when uninflamed 6

Understand the Pathophysiology

• Inflammation and purulence typically occur as a reaction to rupture of the cyst wall and extrusion of contents into the dermis, rather than as a primary infectious process 6
• This explains why antibiotics are rarely necessary 6

Screen for STIs

• Given the common association with gonorrhea and chlamydia, consider STI testing in appropriate clinical contexts 1
• Test for other STI pathogens if clinically indicated 1

Age-Specific Considerations

• In reproductive-age women: focus on gland preservation 2
• In menopausal/perimenopausal women: maintain higher suspicion for malignancy and consider biopsy for atypical presentations 2