Bartholin Gland Diseases

Updated: Oct 24, 2022
Author: Antonia Quinn, DO; Chief Editor: Erik D Schraga, MD 

Overview

Practice Essentials

The Bartholin glands are paired glands approximately 0.5 cm in diameter and are found in the labia minora in the 4- and 8-o’clock positions. Typically, they are nonpalpable. Each gland secretes mucus into a 2.5-cm duct. These 2 ducts emerge onto the vestibule at either side of the vaginal orifice, inferior to the hymen. Their function is to maintain the moisture of the vaginal mucosa's vestibular surface.

Bartholin gland cysts, abscesses, and masses may significantly affect a woman’s life. Pain and swelling can prevent sitting, walking, and intercourse. The diagnosis of Bartholin cysts and abscesses is often clinical. Atypical masses may require imaging (such as magnetic resonance), tissue biopsy, or complete excision.[1]

Bartholin gland cysts present as painless masses that are usually detected during a routine pelvic examination. Rarely, larger cysts may cause sexual discomfort or vulvar disfiguration.[1]  Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema. Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis. Bartholin abscesses are very rarely caused by sexually transmitted pathogens.

Diagnosis

Bartholin cyst abscesses do not frequently require laboratory or radiographic studies; however, wound culture and biopsy may be performed during incision and drainage of the abscess. If sexually transmitted infection is suspected, a sexually transmitted infection panel (including gonorrhea, chlamydia) should be considered and appropriate treatment initiated. A biopsy should be considered if malignancy is suspected because of atypical presentation of the mass or if the patient is older than 40 years.[2]

Although rare, carcinoma of the gland should be considered in women with an atypical presentation. Primary carcinoma of the Bartholin gland accounts for approximately 5% of vulvar carcinomas.[3, 4, 5, 6, 7]  Its incidence is highest among women in their 60's. Atypical presentation should raise suspicion of a possible carcinoma. Malignant masses may also be fixed to underlying tissues.[1]  Because published information on the diagnosis and treatment of Bartholin gland carcinoma is limited, this tumor is prone to misdiagnosis; most cases are found at an advanced stage and diagnosis is delayed.[8]

Smooth muscle tumors of the vulva are more difficult to diagnose and are frequently mistaken as Bartholin cysts prior to surgery. Labia majora leiomyoma at the site of the Bartholin gland is rather uncommon. Some cases can develop into atypical leiomyoma or even leiomyosarcoma with local tissue infiltration. If the clinical picture is unusual, it is better to send the patient for ultrasound and magnetic resonance imaging to exclude other causes; wide local surgical excision of the mass allows proper histopathologic and/or immunohistochemistry examination to differentiate between benign and malignant tumors.[9]

Kessous et al has described the most common microbial pathogens associated with Bartholin abscesses. Escherichia coli was the most common (43.6%), followed by Staphylococcus aureus (6.4%), group B streptococci (4.8%), and Enterococcus spp. (4.8%). Less than 10% of cases were polymicrobial in origin. E. coli–positive cultures were more common in recurrent infections (56.8%) than in primary infections (37%). Sexually transmitted infections were seldom causative, but testing for chlamydial and gonococcal infections remains important in susceptible patients. Broad-spectrum antibiotic coverage is advised in the absence of microbial sensitivities.[1]

Bartholin glands are generally nonpalpable when not obstructed. Cysts and abscesses are often found after onset of puberty, with decreased incidence after menopause. Both are difficult to differentiate on a physical exam. The cyst is usually 2-4 cm in diameter and may cause dyspareunia, urinary irritation, and vague pelvic pain. The cyst is usually filled with nonpurulent fluid that contains staphylococci, streptococci, and E. coli.[2]

Treatment

Excision of a Bartholin cyst or abscess may be required when office-based treatments fail. Possible complications include increased risk of bleeding, postsurgical infection, pain secondary to scar tissue, and complications from general anesthesia. Surgical removal of Bartholin glands has not been shown to interfere with sexual function. A specialist should perform this procedure.[1]

A Bartholin abscess is generally painful and therefore usually requires incision and drainage. In one study, Word catheter treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess.[10]  Patients with an abscess often feel immediate pain relief after the drainage procedure; however, they may require oral analgesia for several days after the procedure.[11, 12]

A patient whose presentation is concerning for malignancy should receive close outpatient gynecologic follow-up for biopsy and possible excision. Those with an uncomplicated, asymptomatic cyst may be discharged with sitz bath instructions. Sitz baths (3 times daily) for several days may promote improvement with resolution or spontaneous rupture with resolution of the cyst.

Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.

A case report describing the use of nutraceutical supplements in the treatment of women with pelvic pain shows that clinical cases support clinical trial results showing the benefits of alpha-lipoic acid + palmitoylethanolamide + myrrh for management of gynecologic pelvic pain, allowing other analgesic, anti-inflammatory, and antineuropathic medications to be reduced or withdrawn.[13]

(See the image below.)

Bartholin abscess. (Image courtesy of Dr. Gil Shla Bartholin abscess. (Image courtesy of Dr. Gil Shlamovitz.)

Pathophysiology

Bartholin glands are known to form cysts and abscesses in women of reproductive age. Cysts and abscesses are often clinically distinguishable. Bartholin cysts form when the ostium of the duct becomes obstructed, leading to distention of the gland or duct with fluid. Obstruction is usually secondary to nonspecific inflammation or trauma. The cyst is usually 1-3 cm in diameter and is often asymptomatic, although larger cysts may be associated with pain and dyspareunia.[3, 4, 14, 15]

Bartholin abscesses result from either primary gland infection or infected cyst. Patients with abscesses complain of acute, rapidly progressive vulvar pain. Studies have shown that these abscesses are usually polymicrobial and are rarely attributable to sexually transmitted pathogens. A retrospective cohort study found the incidence of Bartholin gland abscesses to be low (0.13%) during pregnancy. No significant difference was noted among pathogens found in culture-positive samples of pregnant and nonpregnant women.[1]

Adenocarcinoma and squamous cell carcinoma are the 2 most common histologic types of primary Bartholin gland carcinoma. Other, more rare types are transitional, adenoid-cystic, and undifferentiated carcinomas. Human papillomavirus (HPV) type 16 has been detected via polymerase chain reaction in squamous cell carcinoma.[1]  Adenocarcinoma of the Bartholin glands is rare, accounting for 1-2% of all vulvar malignancies. Typically, this lesion presents as a gradually enlarging gland in an asymptomatic, postmenopausal woman.[5]

Etiology

Uncomplicated Bartholin cysts are filled with nonpurulent mucous. Several studies have aimed to identify the most common bacterial pathogens responsible for Bartholin abscess formation. Studies from the 1970-1980s named Neisseria gonorrhoeae and Chlamydia trachomatis as common pathogens. More recent studies report the predominance of opportunistic bacteria such as Staphylococcus species, Streptococcus species, and, most commonly, Escherichia coli.[11]

In a retrospective study, Kessous et al found that a substantial percentage of patients with Bartholin gland abscess were culture-positive, with E coli being the single most common pathogen (43.7%); 10 cases (7.9%) were polymicrobial. Culture-positive cases were significantly associated with fever, leukocytosis, and neutrophilia. Infection with E coli was significantly more common in recurrent infection than in primary infections (56.8% compared with 37%).[16]

Epidemiology

Approximately 2% of women of reproductive age will experience swelling of one or both Bartholin glands.[17]

Bartholin gland diseases are rarely complicated by systemic infection, sepsis, and bleeding secondary to surgical treatment. Missed diagnosis of malignancy may result in poorer outcome for those patients.

These diseases typically occur in women between the ages of 20 and 30 years. Bartholin gland enlargement in patients older than 40 years is rare and should be referred to a gynecologist for possible biopsy.

If abscesses are properly drained and reclosure is prevented, most abscesses have a good outcome. Recurrence rates are generally reported to be less than 20%.

 

Presentation

History

Patients with cysts may present with painless labial swelling. Abscesses may present spontaneously or after a painless cyst with the following symptoms:

  • Acute, painful unilateral labial swelling

  • Dyspareunia

  • Pain with walking and sitting

  • Sudden relief of pain followed by discharge (highly suggestive of spontaneous rupture)

Adenoid cystic carcinoma (ACC) of the Bartholin gland is a rare form of vulval cancer and can present as a vulval mass, with or without symptoms such as pain, ulceration, pruritus, abnormal bleeding, or dyspareunia. It may also present as palpable solid, cystic, or abscessed area within a Bartholin cyst. The mass rarely occurs bilaterally. Clinicians should have heightened suspicion for malignancy when there is palpable solid mass within the cyst, underlying fixation to surrounding tissues, and/or cyst or abscess that does not respond or worsens despite treatment. [18]   

Physical Examination

The following physical examination findings are seen in Bartholin abscess, as shown in the image below:

  • Patients typically have an exquisitely tender, fluctuant labial mass with surrounding erythema and edema.

  • In some cases, areas of cellulitis surrounding the abscess may be present.

  • Fever, though not typical in healthy patients, may occur.

  • If the abscess has spontaneously ruptured, purulent discharge may be noted. If completely drained, no obvious mass may be observed.

Bartholin abscess. (Image courtesy of Dr. Gil Shla Bartholin abscess. (Image courtesy of Dr. Gil Shlamovitz.)

The following physical examination findings are seen in Bartholin cysts:

  • Patients may have a painless, unilateral labial mass without signs of surrounding cellulitis.

  • If large, the cyst may be tender.

  • Discharge from ruptured cyst should be nonpurulent.

 

DDx

Differential Diagnoses

 

Workup

Procedures

In otherwise healthy, afebrile adults, blood tests are not necessary to evaluate an uncomplicated abscess or cyst.

Sexually transmitted disease (STD) testing should be available at the request of the patient; however, Bartholin abscesses are very rarely caused by sexually transmitted pathogens.

Cultures are rarely useful in treatment of abscess; furthermore, routine culturing of drained fluid is not recommended.

The following features are suggestive of Bartholin gland malignancy. Patients who present with any of these features should be referred to a gynecologist for biopsy:

  • Age older than 40 years

  • Chronic or gradually progressive, painless mass

  • Solid, nonfluctuant, painless mass

  • Prior history of labial malignancy

 

Treatment

Approach Considerations

Women with a Bartholin gland cyst usually are first seen by the primary care provider, nurse practitioner, or internist. Because of the extensive differential, it is important to involve the gynecologist in the care of these patients. Antibiotic therapy should be considered for (1) those who have failed initial incision and drainage with Word catheter placement' (2) patients with systemic symptoms including fever; (3) patients who have suspected sepsis; and (4) those considered at high risk for recurrence. Women who are pregnant who have Bartholin abscesses should be treated in the same manner as nonpregnant women, with the exception of Bartholin gland excision due to increased risk of bleeding.[19]

Numerous options are available for the treatment of symptomatic Bartholin cysts or abscesses. The most common interventions include incision, drainage with Word catheter placement, and abscess marsupialization. Randomized trial evidence does not support the use of any single surgical method. Outcomes of other interventions such as rubber ring catheter insertion, cavity closure, and alcohol sclerotherapy have not been sufficiently studied.[1]

Patients who present to the ED with Bartholin gland swelling rarely require emergent gynecologic consultation. Relative indications or consultation may include the following:

  • Complex or recurrent abscess requiring general anesthesia in the OR/

  • Need for biopsy, usually due to concern for malignancy.

Emergency Department Care

ED care should include a careful history and physical examination. A patient whose presentation is concerning for malignancy should receive close outpatient gynecologic follow-up for biopsy and possible excision. Those with an uncomplicated, asymptomatic cyst may be discharged with sitz bath instructions. Sitz baths (3 times daily) for several days may promote improvement with resolution or spontaneous rupture with resolution of the cyst.[11]

A Bartholin abscess is generally painful and therefore usually requires incision and drainage. Several techniques have been described,[20] but no large prospective studies have been performed to determine relative efficacy and complications. The goal of abscess treatment is to allow drainage and to prevent rapid reaccumulation of fluid.

Patient comfort is essential to successful drainage. Adequate anesthesia is necessary when incising any abscess. Apply topical anesthetics to the mucosa followed by submucosal injection of local anesthetic (the minimum pain control required). Procedural sedation may be desirable. In patients with a large or complex abscess or for a complicated procedure, general anesthesia in the operating room (OR) may be required.

In a study of patients with Bartholin gland carcinoma, high-dose-rate interstitial brachytherapy (HDR-ISBT) boost after external-beam radiation therapy (EBRT) was shown to provide excellent long-term local control. According to the authors, HDR-ISBT should be considered for positive surgical margins or residual tumor after surgery and for locally advanced malignancies treated by primary chemoradiotherapy.[21]

Incision and drainage

This technique consists of traditional incision, drainage, irrigation, and packing. Packing should be removed 2 days after the procedure. This technique requires multiple, painful packing changes and has a higher rate of abscess recurrence.

The Word catheter (see the images below) was introduced in the 1960s. It is a small catheter with a saline inflatable balloon at the distal end. This procedure should be performed using sterile technique. In one study, Word catheter treatment was successful in 26 of 30 cases (87%) of Bartholin cyst or abscess.[10] Using an #11 blade a 0.5-cm incision is made into the abscess cavity on the mucosal surface of the labia minora. Contents of the cavity are expressed manually or by hemostat. The tip of the catheter is inserted into the cavity, and the balloon is inflated with 4 mL normal saline, as shown in the image below.[10, 12, 17]

Word catheter. (Image courtesy of Dr. Gil Shlamovi Word catheter. (Image courtesy of Dr. Gil Shlamovitz.)

 

Word catheter with inflated balloon. (Image courte Word catheter with inflated balloon. (Image courtesy of Dr. Gil Shlamovitz.)

The free end of the catheter may be inserted into the vagina for patient comfort. The catheter allows for abscess drainage acutely and is left in place for several weeks to promote fistula formation.

Patients should be advised to take sitz baths 2-3 times a day for 2 days following the procedure and to abstain from sexual intercourse until the catheter is removed. Simplicity is the technique's main advantage. It is tolerable to patients and allows restoration of gland function. A recent case report describes novel use of plastic tubing for abscess drainage when a Word catheter is not available.[22]

Marsupialization

This procedure is reserved for recurrent abscesses. The acute abscess is drained prior to marsupialization. This procedure consists of a wide incision of the mass followed by suturing the inner edge of the incision to external mucosa. This complicated procedure is usually performed by a gynecologist or urologist in the OR.[12, 17]

A comparison of sexual functioning scores in patients who had marsupialization and gland excision procedures for the treatment of Bartholin gland abscesses found dyspareunia after the procedure was more common in patients who underwent marsupialization (2.9% vs 15.1%, P=0.01). The Female Sexual Function Index (FSFI) scores were less than 26.5 in both treatment groups. The total score was 24.76 ± 4.32 in the excision group and was 22.33 ± 5.15 in the marsupialization group.[23]

In the WoMan trial (Word catheter and marsupialization in women with a cyst or abscess of the Bartholin gland), a randomized controlled trial conducted in the Netherlands and in England between August 2010 and May 2014, 161 women were randomly allocated to treatment by Word catheter or marsupialization to compare recurrence of a cyst or abscess within 1 year. Recurrence occurred in 10 women (12%) in the Word catheter group and in 8 women (10%) in the marsupialization group. Within the first 24 hours after treatment, 33% in the Word catheter group used analgesics versus 74% in the marsupialization group. Time from diagnosis to treatment was 1 hour for placement of the Word catheter versus 4 hours for marsupialization. Recurrence rates in the 2 groups were comparable; however, the marsupialization group showed increased use of analgesics within the first 24 hours and increased duration of treatment.[2]

Excision

This procedure requires excision of the Bartholin gland and surrounding tissue. It is disfiguring, painful, and seldom indicated in the treatment of abscess, although it may be used to treat malignancy.

It should be performed only in the OR to ensure appropriate anesthesia.

Other techniques

Carbon dioxide laser therapy can provide cyst vaporization in the outpatient setting. A prospective, randomized trial found that silver nitrate ablation following cyst drainage was as effective as marsupialization and caused less scar formation. Researchers concluded that procedures such as cyst/abscess fenestration and needle aspiration with or without alcohol sclerotherapy require further clinical research.[1]

Some studies have examined the safety and efficacy of carbon dioxide (CO2) laser therapy, as well as alcohol sclerotherapy, to treat Bartholin abscesses.[24, 25, 26] Early studies have shown promising results. In one study, the cure rate was nearly 96% with one laser treatment.[27]

In another study of patients who received carbon dioxide laser therapy, the median operative time was 15 minutes (range, 12-35 min); median postoperative stay was 1 hour (range, 1-4 hr; stimated 3-yr relapse-free rate, 88.56%). Lesion wall thickness of 0.5-1.5 mm, multilocular lesions, and hyperechogenic lesions were correlated with recurrence.[28]

A pilot study compared the impact of CO2  laser therapy on sexual function with patients affected by a Bartholin gland cyst or abscess treated with surgical cold knife treatment. A statistically significant advantage of CO2  laser versus cold knife treatment was found in terms of lubrication, pain, and global score.[29]

Silver nitrate gland ablation has shown promise as a safe and effective treatment for both simple cysts and abscesses in a number of small studies.[20]

Medical Care

Most patients with Bartholin gland disease are discharged home. Patients with Bartholin cyst or abscess should be advised to take warm sitz baths 3 times per day for several days. Patients with an abscess often feel immediate pain relief after the drainage procedure; however, they may require oral analgesia for several days after the procedure.

All patients with a Bartholin gland mass should receive close gynecologic follow-up.

The prognosis for patients with Bartholin gland disease is excellent, but high recurrence rates have been reported following simple cyst aspiration. Healing and recurrence rates are similar among fistulization, marsupialization, and silver nitrate and alcohol sclerotherapy. Needle aspiration and incision and drainage—the 2 simplest procedures—are not recommended because of relatively high recurrence rates.[2]

Complications

Treatment of patients with Bartholin gland cysts by traditional surgery is characterized by disadvantages and complications such as hemorrhage, postoperative dyspareunia, infection, and the need for general anesthesia. It has been found that CO2 laser surgery might be less invasive and more effective, solving many of the problems of traditional surgery.[2]

The most common complication of treatment of Bartholin abscess is recurrence. Rare case reports exist of necrotizing fasciitis after abscess drainage. Nonhealing wounds may occur. Bleeding, especially in patients with a coagulopathy, may be a complication. Cosmetic scarring may result.

A theoretical risk exists for development of toxic shock syndrome with packing.

A case of cauda equina syndrome following neuraxial anesthesia for drainage of a Bartholin abscess has been reported.[30]

 

 

Medication

Medication Summary

Medications used in the treatment of Bartholin abscesses include topical and local anesthetics. Antibiotics for empiric treatment of STDs are advisable in the doses usually used to treat gonococcal and chlamydial infections. Ideally, antibiotics should be started immediately prior to incision and drainage.

Anesthetics

Class Summary

These agents may be used topically or as injectables. Topical anesthetic may be used on vaginal mucosa prior to submucosal injection.

Lidocaine anesthetic

Decreases permeability to sodium ions in neuronal membranes. Inhibits depolarization, blocking the transmission of nerve impulses, which reduces pain.

Topical preparations are available in spray and ointment form.

Injectable lidocaine is available as 1% or 2% concentration, with or without epinephrine.

Bupivacaine (Marcaine, Sensorcaine)

By increasing electrical excitation threshold, slowing nerve impulse propagation, and reducing the action potential, bupivacaine prevents the generation and conduction of nerve impulses to reduce pain.

Concentrations of 0.25% and 0.5% are commonly used for local infiltration. Duration of action is significantly longer than lidocaine. Bupivacaine is available with or without epinephrine.

Antibiotics

Class Summary

Most Bartholin abscesses are caused by opportunistic pathogens. Uncomplicated abscesses in otherwise healthy women may not require antibiotic therapy after successful drainage. Treatment of N gonorrhoeae and C trachomatis should be initiated only in patients with confirmed disease.

Ceftriaxone (Rocephin)

An effective monotherapy against N gonorrhoeae, ceftriaxone is a third-generation cephalosporin with broad-spectrum efficiency against gram-negative organisms, lower efficacy against gram-positive organisms, and higher efficacy against resistant organisms. By binding to 1 or more of penicillin-binding proteins, arrests bacterial cell wall synthesis and inhibits bacterial growth.

Ciprofloxacin (Cipro)

An alternative monotherapy to ceftriaxone. Bactericidal antibiotic that inhibits bacterial DNA synthesis and, consequently, growth by inhibiting DNA-gyrase in susceptible organisms.

Doxycycline (Bio-Tab, Doryx, Vibramycin)

Inhibits protein synthesis and bacterial replication by binding with 30S and, possibly, 50S ribosomal subunits of susceptible bacteria. Indicated for C trachomatis.

Azithromycin (Zithromax)

Used to treat mild-to-moderate infections caused by susceptible strains of microorganisms. Alternative monotherapy for C trachomatis.

 

Questions & Answers

Overview

What are Bartholin gland diseases?

What is the pathophysiology of Bartholin gland diseases?

What is the prevalence of Bartholin gland diseases?

What is the prognosis of Bartholin gland diseases?

Where are patient education resources for Bartholin gland diseases found?

Presentation

What are the signs and symptoms of Bartholin gland diseases?

What are complications of the treatment for Bartholin gland diseases?

Which physical findings are characteristic of Bartholin abscess?

Which physical findings are characteristic of Bartholin cysts?

What causes Bartholin gland diseases?

DDX

What are the differential diagnoses for Bartholin Gland Diseases?

Workup

What is the role of lab tests in the workup of Bartholin gland diseases?

When is biopsy indicated in the workup of Bartholin gland disease?

Treatment

What is included in emergency department (ED) care of Bartholin gland diseases?

How is incision and drainage performed in the treatment of Bartholin gland diseases?

What is the role of marsupialization in the treatment of Bartholin gland diseases?

What is the role of excision in the treatment of Bartholin gland diseases?

What is the role of laser therapy in the treatment of Bartholin gland diseases?

What is the role of ablation in the treatment of Bartholin gland diseases?

When is emergent gynecologic consultation indicated for the treatment of Bartholin gland diseases?

What is included in followup care after treatment of Bartholin gland disease?

Medications

What is the role of medications in the treatment of Bartholin abscesses?

Which medications in the drug class Antibiotics are used in the treatment of Bartholin Gland Diseases?

Which medications in the drug class Anesthetics are used in the treatment of Bartholin Gland Diseases?