Bartholin gland abscess: Difference between revisions

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==Background==
==Background==
*Bartholin glands are located at the at the 4 o'clock and 8 o'clock positions, posterolaterally to introitus
**Ducts of the glands drain into posterior vestibule and contribute to vaginal lubrication
**Glands are generally nonpalpable when cyst/abscess is not present<ref>Lee WA, Wittler M. Bartholin Gland Cyst. [Updated 2023 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.</ref>
*Obstruction of ducts may lead to focal cyst formation, which may become infected to form an abscess
**A cyst does not need to be present for an [[abscess]] to develop
*Most common in young, adult women (20-30 years old)


==Clinical Features==
[[File:Barthonlincyst2011.png|thumb|Bartholin gland cyst (non-infected) of right labia at 7-8 o'clock position)]]
*Pain and pressure worse with walking, sexual intercourse
**If small cyst or abscess, may also be asymptomatic
*Mass in posterior introitus near 4 o'clock or 8 o'clock position
**May appear erythematous, tender, and swollen
**May develop over days or longer time (if preceded by cyst)
*Systemic symptoms (e.g. [[fever]]/chills) are rarely present


Pathogens: E.coli, lesser GC/C
==Differential Diagnosis==
*Cysts of other glandular structures
*Leiomyoma
*Lipoma
*Carcinoma  (consider in older women who present with introital mass)
{{Pelvic pain DDX}}
{{SSTI DDX}}


== ==
==Evaluation==
*Usually a clinical diagnosis
*If there is suspicion of MRSA, may culture the specimen drained


==Management==
===[[I&D|Incision and Drainage]]===
''I&D only perform once [[abscess]] is well-defined, walled-off structure''
====Word Catheter====
[[File:Wordcatheter.jpg|thumb|Uninflated word catheter]]
[[File:Inflatedwordcatheter.jpg|thumb|Word catheter inflated with approximately 2 ml of saline (blunt needle preferred for injection)]]
*Consider parenteral analgesics or sedatives prior to local infiltration
#Inject [[local anesthetics]]
#Using an #11 blade, stab incision is made on the mucosal surface (avoid incising the skin surface on labia minora)
#Extend incision for several mm but not so many that the Word catheter will fall out (fully inflated it is not much larger than 1cm)
#Insert Word catheter and inflate balloon with 2-4mL of water. The safest way to do this is with a blunt needle tip (just long enough if pressure applied); the kit comes with a long 22-27 gauge needle but if using this be careful
#Tuck end of catheter into the vagina
#Catheter should remain in place for 4-6wk to avoid recurrence
Jacobi rocks


==Work-Up==
====Rubber Ring Catheter (Jacobi Ring)<ref>Gennis P, Li SF, Provataris J, Shahabuddin S, Schachtel A, Lee E, Bobby P. Jacobi ring catheter treatment of Bartholin’s abscesses. Am J Emerg Med. 2005 May;23(3):414-5</ref><ref>Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. 2009 May;36(4):388-90</ref>====
[[File:Jacobi.jpg|thumb|Jacobi ring catheter<ref>[http://www.ajemjournal.com/article/S0735-6757(05)00083-5/fulltext Gennis P, et al. Jacobi ring catheter treatment of Bartholin's abscesses. American Journal of Emergency Medicine. May 2005. 23(3);414-415 DOI:https://doi.org/10.1016/j.ajem.2005.02.033]</ref>]]
[[File:To_do.jpg|thumb|Jacobi ring catheter placement technique.<ref>[http://www.ajemjournal.com/article/S0735-6757(05)00083-5/fulltext Gennis P, et al. Jacobi ring catheter treatment of Bartholin's abscesses. American Journal of Emergency Medicine. May 2005. 23(3);414-415 DOI:https://doi.org/10.1016/j.ajem.2005.02.033]</ref>]]
''Less cumbersome for the patient and less likely to fall out and similar in procedure as a loop drain for a cutaneous abscess''
#Additional equipment: 7-cm length of an 8–French T tube (can also use tubing from butterfly catheter) threaded with a 20-cm length of 2-0 silk suture.
#Inject local anesthetic
#Stab incision is made on the mucosal surface
#Pass hemostat into [[abscess]] cavity to lyse adhesions, and tunnel to make indentation for second incision
#Grab one end of Jacobi ring and pull through [[abscess]] cavity
#Tie two ends to form closed ring. DO NOT TIE TOO TIGHT (pressure necrosis risk)


===Antibiotics===
''No randomized trials, general approach from expert opinion''


Labs: GC/C
'''Limit antibiotic treatment to patients with:'''


Pts >40 yr/non-healing abscesses - r/o malignancy
*Recurrent Bartholin Abscess
*High risk of complications
*Surrounding Cellulitis, immunocompromise, pregnancy
*Systemic Infection (eg, fever, chills)


'''Regimens:'''


==Diagnosis==
*[[Bactrim]] 1 DS PO BID + [[Amoxicillin-clavulanate]]: 875mg PO BID
*[[Cefixime]] 400mg PO QD x7d + [[clindamycin]] 300mg PO QID x7d


===Wound Care===
*Sitz bath x2 days, analgesics
*Abstain from vaginal intercourse


Anatomy: 4 and 8 o'clock position at vag orifice
==Disposition==
 
*Usually outpatient management
*Refer to GYN if >40yr (might need biopsy to rule out CA) and recurrence (complete excision vs. marsupialization)
 
==Treatment==
 
 
I&D, sitz baths, CTX/doxy for GC/C, clinda/metro/augmentin, word catheter (keep >6 wks better)
 
 
==Complications==
 
 
Reinfection common; keeping Word catheter in >6 wks increases likelihood of epithelializ. of new tract
 


==See Also==
==See Also==
*[[Incision and Drainage]]


==External Links==
*[https://www.merckmanuals.com/professional/gynecology-and-obstetrics/miscellaneous-gynecologic-disorders/bartholin-gland-cysts Merck Manual - Bartholin Gland Cyst]
*[https://first10em.com/word-catheters/ First10EM - What's the word on Word Catheters?]


ID: Abscess
===Videos===
 
{{#widget:YouTube|id=MmxiG-0IvDE}}
 
 


==References==
<references/>


[[Category:OB/GYN]]
[[Category:ID]]
[[Category:OBGYN]]
[[Category:Procedures]]

Latest revision as of 08:05, 30 November 2023

Background

  • Bartholin glands are located at the at the 4 o'clock and 8 o'clock positions, posterolaterally to introitus
    • Ducts of the glands drain into posterior vestibule and contribute to vaginal lubrication
    • Glands are generally nonpalpable when cyst/abscess is not present[1]
  • Obstruction of ducts may lead to focal cyst formation, which may become infected to form an abscess
    • A cyst does not need to be present for an abscess to develop
  • Most common in young, adult women (20-30 years old)

Clinical Features

Bartholin gland cyst (non-infected) of right labia at 7-8 o'clock position)
  • Pain and pressure worse with walking, sexual intercourse
    • If small cyst or abscess, may also be asymptomatic
  • Mass in posterior introitus near 4 o'clock or 8 o'clock position
    • May appear erythematous, tender, and swollen
    • May develop over days or longer time (if preceded by cyst)
  • Systemic symptoms (e.g. fever/chills) are rarely present

Differential Diagnosis

  • Cysts of other glandular structures
  • Leiomyoma
  • Lipoma
  • Carcinoma (consider in older women who present with introital mass)

Acute Pelvic Pain

Differential diagnosis of acute pelvic pain

Gynecologic/Obstetric

Genitourinary

Gastrointestinal

Musculoskeletal

Vascular

Skin and Soft Tissue Infection

Look-A-Likes

Evaluation

  • Usually a clinical diagnosis
  • If there is suspicion of MRSA, may culture the specimen drained

Management

Incision and Drainage

I&D only perform once abscess is well-defined, walled-off structure

Word Catheter

Uninflated word catheter
Word catheter inflated with approximately 2 ml of saline (blunt needle preferred for injection)
  • Consider parenteral analgesics or sedatives prior to local infiltration
  1. Inject local anesthetics
  2. Using an #11 blade, stab incision is made on the mucosal surface (avoid incising the skin surface on labia minora)
  3. Extend incision for several mm but not so many that the Word catheter will fall out (fully inflated it is not much larger than 1cm)
  4. Insert Word catheter and inflate balloon with 2-4mL of water. The safest way to do this is with a blunt needle tip (just long enough if pressure applied); the kit comes with a long 22-27 gauge needle but if using this be careful
  5. Tuck end of catheter into the vagina
  6. Catheter should remain in place for 4-6wk to avoid recurrence

Jacobi rocks

Rubber Ring Catheter (Jacobi Ring)[3][4]

Jacobi ring catheter[5]
Jacobi ring catheter placement technique.[6]

Less cumbersome for the patient and less likely to fall out and similar in procedure as a loop drain for a cutaneous abscess

  1. Additional equipment: 7-cm length of an 8–French T tube (can also use tubing from butterfly catheter) threaded with a 20-cm length of 2-0 silk suture.
  2. Inject local anesthetic
  3. Stab incision is made on the mucosal surface
  4. Pass hemostat into abscess cavity to lyse adhesions, and tunnel to make indentation for second incision
  5. Grab one end of Jacobi ring and pull through abscess cavity
  6. Tie two ends to form closed ring. DO NOT TIE TOO TIGHT (pressure necrosis risk)

Antibiotics

No randomized trials, general approach from expert opinion

Limit antibiotic treatment to patients with:

  • Recurrent Bartholin Abscess
  • High risk of complications
  • Surrounding Cellulitis, immunocompromise, pregnancy
  • Systemic Infection (eg, fever, chills)

Regimens:

Wound Care

  • Sitz bath x2 days, analgesics
  • Abstain from vaginal intercourse

Disposition

  • Usually outpatient management
  • Refer to GYN if >40yr (might need biopsy to rule out CA) and recurrence (complete excision vs. marsupialization)

See Also

External Links

Videos

{{#widget:YouTube|id=MmxiG-0IvDE}}

References

  1. ↑ Lee WA, Wittler M. Bartholin Gland Cyst. [Updated 2023 Jul 5]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-.
  2. ↑ Norris DL, Young JD. UTI. EM Clin N Am. 2008; 26:413-30.
  3. ↑ Gennis P, Li SF, Provataris J, Shahabuddin S, Schachtel A, Lee E, Bobby P. Jacobi ring catheter treatment of Bartholin’s abscesses. Am J Emerg Med. 2005 May;23(3):414-5
  4. ↑ Kushnir VA, Mosquera C. Novel technique for management of Bartholin gland cysts and abscesses. J Emerg Med. 2009 May;36(4):388-90
  5. ↑ Gennis P, et al. Jacobi ring catheter treatment of Bartholin's abscesses. American Journal of Emergency Medicine. May 2005. 23(3);414-415 DOI:https://doi.org/10.1016/j.ajem.2005.02.033
  6. ↑ Gennis P, et al. Jacobi ring catheter treatment of Bartholin's abscesses. American Journal of Emergency Medicine. May 2005. 23(3);414-415 DOI:https://doi.org/10.1016/j.ajem.2005.02.033
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