Bartholin gland abscess

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
• 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

• Normal variants may be noted on exam but generally do not cause pain or other symptoms
  • Nabothian cysts: Epithelial cells within mucous glans that appear as yellow inclusions on the cervix
  • Cervical Ectropion: Edothelial cells on the exterior of the cervix
  • Parous cervix: The is no longer round but may have multiple shapes after birth
• Pregnancy-related
  • Ectopic pregnancy
  • Spontaneous abortion, threatened or incomplete
  • Septic abortion
• Pelvic organ prolapse
• Acute Infections
  • Herpes
  • Cervicitis
  • Endometritis
  • Bartholin gland abscess
  • Pelvic inflammatory disease (PID)
  • Tubo-ovarian abscess
• Vulvovaginitis
  • Bacterial Vaginosis
  • Candida Vaginitis
  • Trichomonas
  • Contact Vulvovaginitis
  • Atrophic vaginitis
• Adnexal Disorders
  • Hemorrhage/rupture of ovarian cyst
  • Ovarian torsion
  • Twisted paraovarian cyst
• Other
  • Myoma (degenerating)
  • Genitourinary trauma
  • Ovarian hyperstimulation syndrome
  • Sexual assault
• Recurrent
  • Mittelschmerz
  • Primary/Secondary Dysmenorrhea
  • Pelvic Congestion Syndrome
  • Endometriosis

Genitourinary

• Cystitis
• Pyelonephritis
• Urethritis (e.g. N. gonorrhoeae/Chlamydia)
• Urolithiasis

Gastrointestinal

• Gastroenteritis
• Appendicitis
• Bowel obstruction
• Perirectal abscess
• Diverticulitis
• Inflammatory bowel disease
• Irritable bowel syndrome
• Mesenteric adenitis

Musculoskeletal

• Abdominal wall hematoma
• Psoas hematoma, psoas abscess
• Hernia

Vascular

• Pelvic thrombophlebitis
• Abdominal aortic aneurysm
• Ischemic bowel (Mesenteric Ischemia)

Skin and Soft Tissue Infection

• Cellulitis
  • Hand cellulitis
  • Facial cellulitis
  • Orbital cellulitis
• Erysipelas
• Lymphangitis
• Folliculitis
• Hidradenitis suppurativa
• Skin abscess
  • Anorectal abscess
  • Bartholin gland abscess
  • Pilonidal abscess
  • Scrotal abscess
• Necrotizing soft tissue infections
  • Necrotizing fasciitis
  • Necrotizing myositis
  • Necrotizing cellulitis
  • Fournier's gangrene
• Mycobacterium marinum

Look-A-Likes

• Sporotrichosis
• Osteomyelitis
• Deep venous thrombosis
• Pyomyositis
• Purple glove syndrome
• Tuberculosis (tuberculous inflammation of the skin)

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)

Jacobi ring catheter

Jacobi ring catheter placement technique.

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:

• 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

Disposition

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

See Also

• Incision and Drainage

External Links

• Merck Manual - Bartholin Gland Cyst
• First10EM - What's the word on Word Catheters?

Videos

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