Bartholin gland cyst

A Bartholin gland cyst refers to cystic dilatation of one of the greater vestibular glands due to obstruction.

The Bartholin glands, also known as the greater vestibular glands, form part of the vulva (external female genitalia). A common abnormality of these glands is the formation of a cyst due to obstruction. A Bartholin gland cyst may become infected forming an abscess.

Cysts can be small and asymptomatic or large and cause discomfort. Infection of the Bartholin glands often causes severe pain and swelling due to abscess formation. Management depends on the cyst size and presence or absence of abscess but usually involves incision and drainage (I&D).

The Bartholin glands are a paired structure about 0.5cm in size, which are located in the vulva.

The Bartholin glands, or greater vestibular glands, are located deep to the posterior labia majora. They are approximately 0.5cm in size and contain a small 2.5cm long duct that opens at 4 and 8 o’clock at each side of the vaginal orifice.

The glands produce a mucus fluid involved in vaginal and vulval lubrication, similar to the bulbourethral glands (known as Cowper’s glands) in males.

Bartholin gland cysts or abscesses most commonly affect sexually active women.

A Bartholin gland abscess is more common than a cyst. A previous cyst or abscess is a risk factor for recurrent episodes. They do not usually affect children because the glands are not fully active until puberty. In addition, they are uncommon in older woman because they atrophy with menopause.

Obstruction to the flow of mucus from the Bartholin glands can lead to cyst formation.

Local or diffuse vulval oedema can lead to obstruction of the Bartholin glands. This leads to cyst dilatation proximal to the obstruction with accumulation of mucus. The cysts are sterile but can become infected and lead to abscess formation.

Bartholin abscess

Any obstruction to the Bartholin glands can lead to infection and abscess formation. An abscess refers to an accumulation of pus. Commonly implicated organisms include:

• Escherichia coli
• Polymicrobial infection (multiple organisms)
• Staphylococcus aureus
• Enterococcus spp
• Sexually transmitted infections (e.g. Neisseria gonorrhea, Chlamydia trachomatis).

A Bartholin gland cyst is characterised by a painless swelling in the vulva.

Bartholin cysts

A Bartholin cyst is classically painless and detected incidentally by the patient or on routine examination (e.g. cervical cancer screening).

• Unilateral, painless swelling: ~1-3cm in size
• Discomfort (if large): may be experienced on sitting, walking or during sexual intercourse
• Disfiguring: large cysts may significantly alter the appearance of the vulva
• Vaginal examination: soft, non-tender mass. A normal Bartholin gland should not be palpable

Bartholin abscess

Abscesses are characterised by pain and swelling.

• Unilateral, painful swelling
• Difficulty sitting, walking or having sex
• Surrounding erythema
• Fever (uncommon): around 20%
• Purulent exudate (if spontaneous drainage)
• Vaginal examination: fluctuant, soft, painful mass

The diagnosis of a Bartholin cyst or abscess is usually made clinically based on the history and examination.

Formal investigations are usually not required unless the diagnosis is unclear or the patient is systemically unwell. For an abscess, a swab can be taken of any purulent material for cultures and sensitivities, and a formal sexual health screen should be completed including chlamydia and gonorrhoea testing. Patients who are systemically unwell should have blood tests and these may be requested prior to any surgical intervention.

If there are any suspicious areas, or concern for underlying malignancy, a biopsy can be taken.

The management depends on the size of the cyst and presence or absence of an abscess.

Small cysts (<3 cm)

No specific management is required for small asymptomatic cysts. Symptomatic cysts may be managed with warm compresses or baths in an attempt to allow drainage of the cyst content.

Large cysts (≥3 cm) or abscess

Surgical incisions and drainage may be opted for large cysts or abscess of any size. This can be completed under local or general anaesthetic. I&D is combined with an additional procedure to maintain opening of the tract:

• Word catheter: involves placement of a small plastic tube with an inflatable balloon. This can be done under local anaesthetic and usually remains for 4 weeks. After this time a follow-up appointment is made to deflate and remove the balloon.
• Marsupialisation: this involves opening the cyst or abscess and suturing the edges. It usually requires a general anaesthetic. The stitches should dissolve over four weeks. This is usually offered if the word catheter has failed, there is a complex or unusual abscess or patient choice.

Antibiotics are generally reserved for patients with recurrent abscess, systemic features (e.g. fever, rigors), complicated infection (e.g. immunosuppressed, extensive cellulitis), or resistant organisms (e.g. MRSA). If an STI is detected, antibiotics should be directed towards this isolated organism.

Patients may develop recurrent Bartholin gland abscesses.

Major complications associated with a Bartholin cyst or abscess include systemic infection (if abscess), recurrent disease, and complications associated with anaesthesia or surgery. Patients with recurrent abscesses despite word catheter and marsupialisation may be considered for Bartholin gland excision.