Marsupialization of Bartholin Cyst and Abscess

• Glands composed of columnar cells that secrete mucous
• Openings in the groove between the hymen and labia minora
• Located at approximately 5 and 7 o'clock at the vulvar vestibule, bilaterally
• Bulbospongiosus muscle and fascia overly these glands superficially

• Result from obstruction of the opening of the glands
• Obstruction leads to accumulation of secretions
• Accumulation can be a nidus for infection, causing a Bartholin gland abscess (typically polymicrobial)
  • Lifetime risk 2%
  • Usually caused by opportunistic bacteria, most commonly Escherichia coli
  • Occasionally caused by sexually transmitted bacteria, particularly in adolescents
  • Previous abscess is a risk for recurrence

• Cysts are typically 1-4 cm, often asymptomatic
• Larger cysts: vaginal pressure, dyspareunia, pain that limits walking or sitting
• Abscess: rapid vulvar enlargement (typically unilateral), pain, fever, fluctuant mass

• Bartholin gland cyst: 
  • Asymptomatic --> No treatment necessary, conservative measures
  • Symptomatic --> Word catheter or marsupialization
• Bartholin gland abscess: 
  • Drainage via Word catheter or marsupialization is preferred
  • Addition of antibiotics for systemic symptoms or if concurrent cellulitis
  • Testing for gonorrhea and chlamydia in adolescents or patients at increased risk
  • Consider antibiotics as first-line therapy for immature abscess
• Indications for excision of gland
  • Recurrent abscesses 
  • Solid masses 
  • Suspicion for malignancy
    • Women > 40 years of age with Bartholin gland cyst or abscess should have a cyst wall biopsy given increased risk of malignancy

• Similar recurrence rate
• Word catheter advantages:
  • Less need for analgesia
  • Smaller incision
  • Shorter procedure
• Marsupialization preferred for:
  • Recurrent cysts that failed other methods
  • Larger cyst/abscess
  • Latex allergy (though can consider 14F Foley in lieu of Word catheter)

* Some studies have found slightly higher risk of hematoma, scaring and superimposed infection with marsupialization, others have found no difference.

• Risks:
  • Recurrence (5-15%) and need for additional procedures
  • Rare complications:
    • Dyspareunia
    • Deep tissue infection 
    • Rectovaginal fistula
    • Scarring
    • Bleeding
    • Hematoma formation
• Benefits:
  • Resolution of discomfort and/or infection

1. Place patient in standard lithotomy position.
2. Vaginal/vulvar prep.
3. Skin incision: 2 - 3 cm incision on skin overlying the cyst, parallel to the hymen, with a #15 or #11 scalpel blade. 
4. Cyst wall incision: vertical incision to open the cyst wall.
5. Open up cyst wall: place Allis clamps on superior, inferior, right, and left lateral wall cyst edges and cavity opened/drained.
6. If abscess, collect cultures of purulent drainage.
7. Cavity exploration with cotton swab, +/- cyst biopsy.
8. Wound closure: suture cyst wall edges to adjacent skin edges using interrupted sutures with 2.0 or 3.0 delayed-absorbable suture.

• Simple cyst drainage: no antibiotics needed
• Abscess drainage: 7-day course of antibiotics if concomitant cellulitis (TMP-SMX, doxycycline, or cephalexin)
• Consider admission and IV antibiotics for immunocompromised patients
• Cold packs for initial 24 hours
• Sitz baths 1-2x daily after 24 hours
• Resume activities as tolerated
• Delay sexual intercourse until healing complete
• 1 week post-operative visit