What is the appropriate management and treatment for bartholinitis, including both non‑purulent inflammation and abscess, and considerations for pregnant patients?

Management of Bartholinitis

For Bartholin gland abscesses, incision and drainage with Word catheter placement or marsupialization is the primary treatment, with adjunctive broad-spectrum antibiotics reserved for cases with significant surrounding cellulitis, systemic signs of infection, immunocompromised patients, or pregnant patients.

Initial Assessment and Triage

Determine whether the presentation is:

• Simple inflammation (bartholinitis) - tender, erythematous gland without fluctuance
• Bartholin cyst - painless, non-infected fluid collection
• Bartholin abscess - fluctuant, painful mass with surrounding erythema

Look specifically for:

• Extent of surrounding cellulitis beyond the abscess borders 1
• Systemic signs (fever, elevated white blood cell count) 1
• Pregnancy status 1
• Immunocompromised state 1

Treatment Algorithm

For Simple Bartholin Abscess (No Complications)

Primary intervention is surgical drainage, NOT antibiotics alone 2, 3:

1. Word catheter placement (first-line if available) 2, 3

   • Provides continuous drainage for 4-6 weeks to allow epithelialization
   • Lower recurrence than simple incision and drainage 3

2. Marsupialization (alternative first-line) 2, 3, 4

   • Creates permanent drainage opening
   • Recurrence rate approximately 31.8% 4
   • Can be performed under local anesthesia in office setting 5

3. Incision and drainage with silver nitrate application 4

   • Lowest recurrence rate at 9.1% 4
   • Significantly superior to simple incision and drainage 4

Antibiotics are NOT routinely indicated for simple abscess after adequate drainage 1, 3.

For Complex Bartholin Abscess

Broad-spectrum antibiotics ARE indicated when 1, 6:

• Significant cellulitis extends beyond abscess borders 1
• Systemic signs of infection present (fever, sepsis) 1, 6
• Patient is immunocompromised 1
• Source control is incomplete 1
• Patient is pregnant 1

Antibiotic coverage must include 1:

• Gram-positive organisms (including MRSA if risk factors present)
• Gram-negative rods
• Anaerobes

Special Consideration: Pregnant Patients

Pregnant women with Bartholin abscess require more aggressive management 1:

• Hospitalization is strongly recommended for pregnant patients with pelvic abscess 1
• Surgical drainage remains the primary treatment 2, 3
• Adjunctive antibiotics should be administered given pregnancy status 1

Safe antibiotic options in pregnancy 7:

• Cephalosporins (cefotaxime, ceftriaxone) as first-line 7
• Ampicillin or amoxicillin 7, 8
• TMP-SMZ can be used but avoid in first trimester 7

Avoid fluoroquinolones entirely in pregnancy 7.

Management of Recurrent Cases

For patients with recurrence after initial treatment 4:

• Marsupialization or silver nitrate application are effective in >90% of recurrent cases 4
• Simple incision and drainage has only 30% success rate for recurrences 4
• Consider definitive excision for multiple recurrences 3

Critical Pitfalls to Avoid

• Do not perform simple incision and drainage alone - this has the highest recurrence rate (39.6%) and should be avoided 3, 4
• Do not prescribe antibiotics without drainage for abscess - source control is mandatory 1, 3
• Do not underestimate severity in pregnant patients - lower threshold for hospitalization and antibiotic therapy 1
• Watch for severe complications including sepsis and extensive cellulitis, which can occur after procedures 6

Follow-Up

• Remove Word catheter at 4-6 weeks after epithelialization is complete 2, 3
• Monitor for recurrence, which typically occurs within weeks to months 4
• For pregnant patients, ensure close obstetric follow-up 1