How is marsupialization performed as the definitive treatment for a symptomatic Bartholin cyst or recurrent Bartholin abscess in an adult woman, including anesthesia, antibiotic coverage, postoperative care, and alternative options?

Marsupialization of Bartholin Cyst

Marsupialization is the preferred definitive treatment for symptomatic Bartholin cysts and recurrent abscesses, with comparable recurrence rates to Word catheter (10-12%) but superior patient satisfaction, and should be performed under local anesthesia in the office setting or under general anesthesia for larger lesions. 1, 2

Procedural Technique

Anesthesia:

• Local anesthesia is sufficient for office-based marsupialization 1
• General anesthesia may be used for larger or more complex cases, though this increases costs significantly (€1584 vs €216 for office procedure) 3

Surgical Steps:

• Make a 1.5-2 cm vertical incision along the inner aspect of the labia minora at the site of maximal fluctuance 4
• Evacuate cyst contents completely 4
• Excise an ellipse of cyst wall to create a permanent opening 4
• Evert and suture the cyst wall edges to the surrounding vestibular skin using interrupted absorbable sutures, creating a pouch-like opening that allows continuous drainage 5, 4
• The goal is to create a new duct opening that will epithelialize over 4-6 weeks 4

Antibiotic Coverage

Antibiotics are NOT routinely required for simple Bartholin cysts or abscesses after adequate drainage in immunocompetent patients 5, 6

Indications for antibiotics include:

• Extensive surrounding cellulitis (>5 cm of erythema) 5
• Systemic signs of infection (fever, tachycardia) 5, 6
• Immunocompromised patients 5

When indicated, use:

• Cephalexin 500 mg four times daily PLUS metronidazole 500 mg three times daily for 7 days 6
• Alternative: Clindamycin 300-450 mg three times daily for 7 days (covers both aerobes and anaerobes) 7

Postoperative Care

• Sitz baths 2-3 times daily for comfort and hygiene 4
• Avoid sexual intercourse for 4 weeks to allow complete epithelialization 4
• No packing is required; the marsupial pouch drains spontaneously 4
• Follow-up at 2-4 weeks to ensure proper healing and epithelialization 1
• Analgesics: 74% of marsupialization patients use analgesics in first 24 hours vs 33% with Word catheter 2

Recurrence Rates and Outcomes

Marsupialization demonstrates:

• 10% recurrence rate at 1 year 2
• 8.3% recurrence rate in retrospective studies 1
• Superior patient satisfaction scores: median VAS 4/5 vs 3/5 for Word catheter 1
• Higher likelihood patients would recommend the procedure to others 1

Common pitfall: Inadequate excision of cyst wall leads to premature closure and recurrence. Ensure adequate eversion and suturing of cyst lining to vestibular skin 4

Alternative Treatment Options

Word Catheter:

• Comparable recurrence rate (12-18.8%) but lower patient satisfaction 1, 2
• Advantage: shorter procedure time (1 hour vs 4 hours for marsupialization) 2
• Disadvantage: catheter dislodgement occurs in 37% before 4-week treatment period ends 3
• Cost-effective (€216 vs €1584 for surgical marsupialization with overnight stay) 3
• Reasonable first-line option for small cysts in office setting 3, 2

Excision:

• Reserved for recurrent cases after failed marsupialization or suspected malignancy 4
• Higher morbidity, requires general anesthesia, risk of bleeding and dyspareunia 4
• Not recommended as primary treatment 4

Incision and drainage alone:

• Associated with nearly 100% recurrence rate 5, 6
• Only acceptable for acute symptom relief when definitive treatment cannot be performed immediately 5