How should a typical reproductive‑age woman with a Bartholin gland cyst be managed, including indications for observation, incision and drainage with Word catheter or marsupialization, antibiotic use, pregnancy considerations, and treatment of recurrences?

Management of Bartholin Gland Cysts

Initial Assessment and Observation

Most asymptomatic Bartholin duct cysts require no intervention and resolve spontaneously, particularly when small (<2 cm). 1, 2

• Asymptomatic cysts of any size can be observed expectantly with comfort measures, as many resolve without treatment. 2, 3
• Infected cysts or abscesses larger than 2 cm should be drained because they rarely resolve spontaneously and tend to recur without intervention. 2
• The primary goal is to preserve gland function whenever possible, avoiding excision unless absolutely necessary. 1

Indications for Intervention

Drainage is indicated when:

• The cyst or abscess exceeds 2 cm in diameter 2
• Significant pain or functional impairment is present 2, 3
• Signs of infection (abscess formation) develop 1, 3

Surgical Management Options

Word Catheter Placement (First-Line for Office/ED Management)

Word catheter insertion is the most frequently employed office-based technique for both cysts and abscesses. 1, 4, 3

• After local anesthesia, make a small stab incision inside the hymenal ring at the mucosal surface of the cyst. 3
• Insert the Word catheter into the cavity, inflate the balloon with 2-3 mL of saline, and tuck the external portion into the vagina. 3
• The catheter must remain in place for 4-6 weeks to allow epithelialization of a permanent drainage tract. 3
• Common pitfall: Premature catheter dislodgement before epithelialization leads to recurrence; counsel patients about this risk and proper catheter care. 4

Marsupialization (Alternative Technique)

Marsupialization should be used for Bartholin duct cysts but NOT for acute gland abscesses. 1, 5

• This procedure creates a permanent opening by suturing the cyst wall edges to the surrounding vestibular mucosa. 5, 3
• Marsupialization can be performed in the office setting and has lower recurrence rates than simple incision and drainage. 3
• This technique is more time-intensive than Word catheter placement but may be preferred for recurrent cysts. 5

Simple Incision and Drainage (Avoid)

Simple lancing without catheter placement or marsupialization results in high recurrence rates and should be avoided. 3

Antibiotic Therapy

Antibiotics are indicated ONLY when surrounding cellulitis is present, not for routine abscess drainage. 1

• Broad-spectrum antibiotic coverage should target common vulvovaginal pathogens when cellulitis extends beyond the gland. 1
• Routine antibiotic therapy after simple drainage without cellulitis is not necessary. 1

Management During Pregnancy

• Office-based procedures (Word catheter, marsupialization) can be safely performed during pregnancy using local anesthesia. 1, 2
• The same management principles apply regardless of pregnancy status. 2

Recurrent Cysts

For recurrent Bartholin cysts after initial drainage:

• Repeat Word catheter placement or marsupialization can be attempted. 5, 2
• Consider MRI evaluation to assess for unusual anatomy or complications in cases of multiple recurrences. 5
• Surgical excision is reserved for multiple treatment failures, though this carries higher morbidity (bleeding, dyspareunia, loss of gland function). 1, 5

Malignancy Considerations

Excisional biopsy is mandatory for irregular or nodular Bartholin gland masses in perimenopausal or postmenopausal women to rule out adenocarcinoma. 1

• Bartholin gland carcinoma is rare but occurs almost exclusively in women over age 40. 1
• Any atypical presentation in older women warrants tissue diagnosis before conservative management. 1

Differential Diagnosis to Consider

The following vulvar lesions may mimic Bartholin cysts and require different management: 1

• Epidermal inclusion cyst 1
• Skene's duct cyst 1
• Hidradenoma papilliferum 1
• Lipoma 1

Key Clinical Pitfalls

• Never perform marsupialization on an acute abscess—this is appropriate only for cysts; abscesses require Word catheter or alternative drainage. 1
• Do not remove Word catheter before 4-6 weeks—premature removal before tract epithelialization guarantees recurrence. 4, 3
• Do not prescribe antibiotics routinely—reserve for documented cellulitis only. 1
• Do not miss malignancy in older women—always biopsy irregular masses in perimenopausal/postmenopausal patients. 1