CHAPTER II

LITERATURE REVIEW
Bartholins Gland Cysts/Abscess
Anatomy
The Bartholins glands or greater vestibular gland were first described by
the Danish Anatomist, Casper Bartholin in the 17th century. They are a
pair of pea-sized glands located symmetrically at the posterior region of
the vaginal wall, lateral to the bulbocavernosus muscle and considered as
major gland. They are oval in shape with an average size of 0.5 - 1 cm and
drain through ducts about 1.5 - 2 cm in length and 0.5 mm in diameter
that open at distal of hymenal ring, at the 5 and 7 oclock positions. The
organs play an important role in the female reproductive system and its
main function is to secret mucus that lubricates the vagina and vulva
especially during sexual intercourse.

Figure 2.1. Anatomy of Bartholins gland

Epidemiology
Bartholins gland cysts and abscesses are the commonest gynaecological
cystic disease of the vulva. Approximately 2% of women, mostly in their
reproductive age would develop Bartholins gland cyst or abscess at some
point. Whereas abscesses happen three times more than cysts.
Etiology and Risk Factors
The most common bacteria isolated from abscesses include anaerobic
Bacteroides, Escherichia coli, Staphylococcus
aureus, Neisseria
gonorrhoeae and Chlamydia trachomatis.
Clearly identified causes for Bartholins cysts and abscesses are still not
defined, however the risk profile is similar to those of women at risk for
sexually transmitted diseases. Some risk factors include previous history
of Bartholins gland cyst, multiple sexual partners, sexually transmitted

infection (STD), mediolateral episiotomies, vulva trauma. There is a

gradual involution of the gland as from 30 years of age, hence a higher
incidence occurs between 20-30 years while high parity seems to be
associated with lower incidence.
Obstruction of this glands duct is common, may follow infection, trauma,
and changes in mucus consistency or congenitally narrowed ducts. When
the distal ducts are blocked, there is mucus build-up with continued
secretion (retention), cystic dilation of the duct leading to cyst formation.
The cyst may become infected and an abscess may develop in the gland.
Infection of this cyst is likely to result in Bartholins gland abscess. A
Bartholins duct cyst does not necessarily have to be present before a
gland abscess develops.
Clinical Manifestation
Most Bartholins gland cysts are small asymptomatic except for minor
discomfort while sexual contact, and may be discovered on routine pelvic
examination. With larger or infected cysts/abscesses can be associated
with significant discomfort and disruption of the sexual function and daily
activities of women.
Bartholins cysts or abscesses are usually unilateral distends the affected
labia majora causing vulva asymmetry and a vaginal discharge may be
present. When palpable, it is round or ovoid in shape, fluctuant and may
or may not be tender but abscesses can be extremely tender. The mass is
usually located in inferior labia majora or lower vestibule. Bartholins
abscesses that are on the verge of spontaneous decompression will show
an area of softening as the possible area of rupture.
Diagnosis
Usually Bartholins cysts/abscesses are diagnosed using physical
examination and will be verified using culture and sensitivity test of
discharge from the gland (if present). In its absence, swabs are taken from
endo-cervix, rectum, vagina and urethra for microbial culture and
sensitivity. Isolated organisms are usually polymicrobial, but Bacteroides
spp. and E. coli predominate. Other organisms such as S. aureus, N.
gonorrhea, C. trachomatis have also been implicated. For women over 40
years, biopsy and histology is recommended due to fear of possible
malignancy.
Treatment
Asymptomatic Bartholins gland cyst may be managed expectantly.
Conservative management of symptomatic cysts or abscesses may
include warm sitz baths, compresses, analgesics and antibiotics when
appropriate. Persistent and symptomatic cysts and abscesses are best
treated surgically. Although there are many treatment modalities for this
condition. Marsupialization is generally favored especially in low resource
setting because it has low recurrence rate and the function of the gland is
preserved. Post-operatively, antibiotics chemotherapy should be given
depending on sensitivity pattern but the drug should be broad spectrum.

Antibiotics that are recommended are trimetroprom-sulfomethoxazole,

amoxicillin-clavunalate,
second-generation
cephalosporins,
or
floroquinolone and prescribed for 7-10 days. And since the risk profile of
Bartholins cyst/abscesses is similar to those of women at risk for STD,
screening to other STDs are recommended.
Surgical methods
Incision-drainage method
Preoperatively, the patient needed to be informed that it is a chance that
cysts nor abscesses may reoccur and not uncommon, and repeated
procedure can be done again. Dyspareunia is one of an infrequent long
term sequel. Most procedures are performed as an out-patient procedure
in office or emergency room, but rarely when the abscess is large or if
inadequate patient analgesia cannot be obtained, incision and drainage in
operative room may be required.
Patient is positioned in standard dorsal lithotomy position and labial skin is
cleaned by povidine-iodine solution and local analgesia can be obtained
by infiltrating the skin overlying by 1% lidocaine solution. Drainage is
done with 1 cm incision is made using a scalpel, atop the cyst is placed
outside and parallel to the hymen, at the 5 and 7 oclock positions. To
minimize scalpel injury, some recommend the use of a small Keyes punch
biopsy.

Figure 2.2. Cyst or abscess incision

Extruded pus can be used as a sample of bacterial culture, but mucus
cannot be cultured. Following drainage, the cavity is explored with a small
cotton swab tip to open potential pus or mucus loculations. Gentle probing
is to avoid perforation through the duct wall. Cyst wall biopsy following
cavity drainage to exclude rare Bartholins gland carcinoma is considered
for women older than 40 years old, for cysts with solid components, or for
multiple cyst recurrences.
A deflated Word catheter tip is placed into the empty cyst cavity and
inflated by 2-3 mL of sterile saline using syringe. Inflation should reach a
diameter sufficient to keep the catheter falling out of the incision. Or as an

alternative, non-latex Foley catheter 14F can be used as a substitute for

those with latex allergy.

Figure 2.3. Word catheter

Figure 2.4. Inflation and positioning of Word catheter

Postoperatively, Bartholins gland duct cyst drainage does not require
antibiotic treatment, but in contrast, abscesses are typically surrounded
by significant cellulitis and antibiotics are needed. Suitable choice of
antibiotics is stated above. Coitus is to be avoided for patient comfort.
Marsupialization
Marsupialization was developed as a means to create a new accessory
tract for gland drainage to prevent the incised edges from adhering and
allowing pus to reaccumulate. With introduction of the Word catheter, the
use of marsupialization for cyst or abscess has decline, because Word
catheter have several advantages that marsupialization. Marsupialization
requires a greater degree of analgesia, a larger incision, placement of
sutures and longer procedure time.
Just as incision-drainage, patients need to be informed that after
marsupialization the cyst/abscess may reoccur and dyspareunia, deep
tissue infection, and retrovaginal fistula may happen rarely.
Marsupialization is an out-patient procedure typically performed in an
operating suite using unilateral pudendal nerve block with standard dorsal
lithotomy. Skin incision is made vertically or elliptical 2 cm, that made
across the skin overlying the cystic bulge using scalpel. The incision is
made atop the cyst is placed just outside and parallel to the hymen at the

5 and 7 oclock positions, depending on the side involved.

Afterwards, cyst is incised by second vertical incision then opens the
underlying cyst wall, so the pus or mucus under pressure spills out. Pus
may be cultured as in incision-drainage method. Using clamps, the lateral
cyst wall edges are fanned out and the cavity is explored with a small
cotton swab tip to open potential fluid loculations, where gentle probing is
done to avoid perforation through duct wall. Cyst wall biopsy following
cavity drainage is done on patients older than 40 years old or if solid
components accompany the cyst is done to exclude rare Bartholins gland
adenocarcinoma. The edges of the cyst wall are sutured to adjacent skin
edges using interrupted sutures using 2-0 or 3-0 gauge delayedabsorbable suture.

Figure 2.5. Skin incision

Figure 2.1. Cyst/Abscess wall sutured open

Usage of antibiotics postoperative is similar to incision-drainage method.
Cool packs during the first 24 hours post operation is recommended to
minimize the pain, swelling and hematoma formation. After 24 hours post
operation once or twice a day warm sitz bath is used for pain relief and
wound hygiene. Activities are to resumed quickly, although intercourse is

delayed until healing is complete.

Within the first week post operation, follow up is needed to ensure that
ostium edges have not adhered to each other. Within 2-3 weeks, the
wound shrinks to create a duct opening typically 5 mm or less. Recurrence
rates following marsupialization are low.
Complications
Complications of Bartholins gland cysts or abscesses include recurrence,
severe pain, dyspareunia, difficulty in walking, psychological trauma due
to stigmatization, marital disharmony and equally those from the
treatment procedure such as hemorrhage, pyogenic granuloma, esthetic
problems, post-operative infection.