Bartholin Cyst


 INDICATIONS 
  • Enlarged or painful Bartholin's cyst or abscess

  CONTRAINDICATIONS
  • Surgery on an acutely, severely inflamed abscess (relative contraindication)
  • Asymptomatic cysts (relative contraindication)
  • Latex allergy (e.g., to Word catheter)

 
EQUIPTMENT
  • Sterile skin preparatory solution and drapes
  • Lidocaine 1%
  • Normal saline (0.9% NaCl)
  • Syringe, 3 mL
  • Syringe, 5 mL
  • Syringe, 10 mL
  • Needles, 18 gauge (3)
  • Needle, 25 or 27 gauge, 1.5 inch (for injection of anesthesia)
  • Scalpel blade (No. 11) and handle
  • Gauze pads (4 X 4)
  • Hemostat
  • Culture swab
  • Word catheter (see images below) Word catheter.
  • Word catheter.

 


 
PROCEDURE
  • The most common procedure for treating a Bartholin abscess is insertion of a drainage catheter. This single-barreled, sealed-stopper, balloontipped catheter serves as initial and long-term therapy. No patient required marsupialization.
  • The procedure involves fistulization of the duct cavity by a 1-inch catheter with an inflatable balloon tip. Although not a traditional incision and drainage procedure, the technique permits continued drainage of the gland.
  • In preparation for insertion of the catheter, place the patient in standard dorsal lithotomy position and drape the perineum.
  • Cleanse the area with povidone-iodine solution.
  • If an anesthetic is deemed necessary for patient comfort and cooperation, lidocaine can be infiltrated just external to the hymen ring, where the distal duct opening should be located (at the 5 or 7 o’clock position).93 Make a small incision into the mucosa.
  • Use the scalpel or a hemostat to puncture the abscess cavity.
  • (It can be difficult to enter this deep abscess cavity.) Failure to obtain frank pus or to appreciate the “pop” of entering the abscess usually prognosticates failure of the procedure.
  • Stabilize the abscess with the thumb and forefinger, hold the hemostat in place, and skewer the abscess onto the hemostat.
  • Pushing the hemostat into the immobilized abscess is technically more difficult.
  • Make a stab incision large enough to accommodate the catheter but small enough to prohibit the inflated balloon from being extruded. Once the abscess has been entered (signaled by a palpable pop or the free flow of pus), place the deflated balloon in the abscess cavity.
  • Using a 25-gauge needle to minimize the hole in the stopper, fill the balloon with 2 to 4 mL of water (not air).
    • Persistent pain indicates that too much fluid has been used.
  • Most abscesses drain for a few days, and the Word catheter often falls out within a week.
    • Ideally, the device is left in place for 2 to 4 weeks to allow fistula formation, so follow-up is required. If the catheter falls out prematurely, it should be replaced quickly to fulfill the time needed for fistulization.
  • Some clinicians do not reinsert the catheter if healing has progressed significantly after the first drainage procedure.

Procedure W/O Catheter:

  • Standard incision and drainage can give the patient immediate relief, but this procedure is not recommended because the abscess recurrence rate is so high.
    • But if a Word catheter is not available, incision and drainage can be performed, with the caveat that the clincian and the patient must appreciate the likelihood of unfavorable long-term outcome.
  • The incision is made over the medial surface of the introitus (on the mucosa, not on the skin) on a line parallel to the posterior margin of the hymenal ring.
  • The abscess cavity is slightly deeper than most cutaneous abscesses, so the clinician must be certain to enter the actual abscess cavity to achieve complete drainage.
    • This is most easily accomplished by inserting a hemostat through the mucosal incision and spreading the tips of the instrument in the deeper soft tissue.
  • After the contents have drained, the abscess is packed for 24 to 48 hours, and sitz baths are started thereafter.
  • Broadspectrum antibiotics are not required after routine incision and drainage, but they can be prescribed for patients with significant cellulitis and for those in whom an actual abscess has not yet formed.
  • If the abscess recurs, more definitive therapy in the form of marsupialization or complete excision of the gland may be required; however, these procedures are not performed initially and, when chosen, should be done in an OR.
  • Alternative treatment strategies have been explored.
    • A rubber ring catheter (the Jacobi ring) from an 8-French T-tube threaded with 2-0 silk suture material.
    • The catheter enters and exits the abscess through separate incisions, forming a closed ring when the suture ends are tied.

Treatment:

  • Empirical antibiotics are indicated only for patients with frank abscess and local cellulitis.
  • No growth is obtained on more than 80% of cultures from Bartholin cysts and a third of cultures from abscesses.
  • Cultures that are positive typically show polymicrobial growth, usually anaerobes, especially Bacteroides species and other colonic bacteria.
  • Much less often, Neisseria gonorrhoeae is cultured from the abscess cavity.
  • Chronic low-grade inflammation from gonococcal infections has been implicated as a causative factor in cyst formation and occasionally in the development of an abscess; therefore, the antibiotic chosen should provide coverage for N. gonorrhoeae.
  • It is reasonable to take cervical and anal cultures for gonorrhea from women with Bartholin gland abscesses because of the association of these infections with sexually transmitted disease, but one need not routinely treat patients for gonorrhea unless the clinician suspects that it is present.
  • At the current time, CA-MRSA infections of the Bartholin glands are uncommon.
  • Particular care must be taken when treating pregnant women with Bartholin gland abscess, because they are at high risk for complications.
  • The development of sepsis in a pregnant woman after marsupialization of an abscess has been reported.
  • Postmenopausal women presenting with what appears to be a Bartholin gland abscess should be referred to a gynecologist to rule out malignancy.
  • A vulvar abscess in an HIV-positive woman should raise suspicion for Kaposi sarcoma.

Word catheter::::

  • Use of the Word catheter for outpatient drainage of a Bartholin gland abscess.
  • This is a fistulization procedure rather than a standard incision and drainage.
  • A, A stab incision is made on the mucosal surface. A catheter is inserted into the cyst cavity (B) and filled with 3–4 mL of water (C).
  • D, Inflatable bulb-tipped catheter.
  • Left, Uninflated. Right, Inflated with 4 mL water.


I&D:

  • A, An alternative to formal incision, drainage, and packing for the treatment of this Bartholin abscess is to place a Word catheter.
  • B, The abscess is stabilized with the thumb and index finger, and a local anesthetic is injected into the mucosal (not skin) surface.
  • C, A stab incision is made with a scalpel. Copious pus drainage signals entrance into the abscess cavity.
  • D, The abscess is punctured with a hemostat. Deep abscesses may be difficult to puncture.
  • E, It is technically easier to enter the Bartholin gland abscess cavity if the hemostat is held steady and the abscess, held with the thumb and index finger, is skewered onto the hemostat. Attempting to puncture the deep immobilized abscess by stabbing with the hemostat may be more difficult. A palpable pop when entering the abscess or drainage of frank pus is expected, and confirm the diagnosis and proper technique.
  • F, The catheter (arrow) is placed to its hilt into the abscess cavity, and the balloon is filled with 3–4 ml saline. Use a 25-gauge needle to fill the balloon.
  • G, The catheter is left in place for 2–4 wk to form a fistula.
  • Antibiotics are of no proven value once drainage is performed, but practice varies.