What is the appropriate treatment for a Bartholin's gland cyst?

Treatment of Bartholin's Gland Cyst

For symptomatic Bartholin's gland cysts or abscesses, perform incision and drainage with placement of a Word catheter or marsupialization, as these procedures offer low recurrence rates and can be performed in the office setting. 1

Initial Assessment and Diagnosis

• Bartholin's glands are located at the 4 and 8 o'clock positions in the posterior vaginal vestibule, and when obstructed, they form cysts that may become infected and progress to abscesses. 1
• Diagnosis is clinical, based on physical examination revealing a tender, fluctuant mass at the vaginal introitus. 1
• Assess for signs of cellulitis, systemic infection, or extensive inflammation extending into the labia minora. 1
• Consider testing for sexually transmitted infections (gonorrhea and chlamydia) as these pathogens can cause Bartholin gland infections. 1

Management Based on Presentation

Asymptomatic or Small Cysts (<2 cm)

• Expectant management is appropriate for asymptomatic Bartholin duct cysts, as many resolve spontaneously without intervention. 2
• No surgical intervention is required unless the cyst becomes symptomatic or infected. 2

Symptomatic Cysts or Abscesses (>2 cm)

Surgical drainage is indicated because cysts or abscesses larger than 2 cm do not tend to resolve spontaneously and have high recurrence rates without intervention. 2

Preferred Surgical Options (in order of recommendation):

1. Word Catheter Placement

   • Most frequently employed technique for office and emergency department management. 3
   • The catheter remains in place for 4-6 weeks to allow epithelialization of a drainage tract. 3, 4
   • Caveat: The catheter can dislodge before complete epithelialization, leading to recurrence. 3

2. Marsupialization

   • The American Academy of Pediatrics recommends this as a simple procedure with low morbidity, minimal recurrence risk, and excellent functional and cosmetic results. 5
   • Healing and recurrence rates are similar to fistulization and sclerotherapy. 4
   • Creates a permanent opening for drainage. 6

3. Alternative Drainage Techniques

   • A loop of plastic tubing can be used when Word catheters are unavailable, secured to prevent expulsion before epithelialization. 3
   • This technique creates dual drainage tracts and can be removed at 3-week follow-up. 3

Sclerotherapy Options:

• Alcohol sclerotherapy destroys the epithelial lining through coagulative necrosis and subsequent fibrosis, preventing fluid reformation. 7
• Has comparable healing and recurrence rates to marsupialization and fistulization. 4
• Offers shorter treatment time compared to simple aspiration. 7
• Silver nitrate cauterization is another sclerotherapy option with similar efficacy. 6, 4

Procedures NOT Recommended:

• Simple needle aspiration and incision and drainage without catheter placement have relatively increased recurrence rates and should be avoided. 4

Antibiotic Therapy

Prescribe antibiotics when there are signs of cellulitis or systemic infection. 1

Appropriate antibiotic options for perineal infections include:

• Metronidazole
• Ciprofloxacin
• Levofloxacin
• Ceftriaxone 1

The American Academy of Pediatrics and the Infectious Diseases Society of America support antibiotic therapy in the presence of cellulitis or systemic infection. 1

Surgical Excision

• Reserved for recurrent cysts despite conservative surgical management. 2, 6
• Requires general anesthesia and is more complicated than office-based procedures. 6
• Removal of a Bartholin gland does not affect vaginal lubrication due to the presence of other glands. 4

Referral Indications

Refer to a gynecologist for:

• Bartholin gland lesions of undetermined etiology 8
• Severe or recurrent infections not responding to initial management 2
• Suspected malignancy (rare, but must be excluded in older women or atypical presentations) 6

Common Pitfalls

• Do not perform simple aspiration alone, as this has high recurrence rates compared to catheter placement or marsupialization. 4
• Ensure the Word catheter or drainage device remains in place for adequate time (4-6 weeks) to allow complete epithelialization. 3, 4
• Do not confuse Bartholin glands with Skene glands, which are located lateral to the urethra at the urethral meatus, not at the 4 and 8 o'clock positions. 5