Bartholin’s Glands Cysts – Causes, Symptoms, Treatment

Bartholin glands, also known as the greater vestibular glands, are a pair of 0.5 cm glands located in the lower right and left portions at the 4 o’clock and 8 o’clock positions of the vaginal introitus. The Bartholin gland is a mucus-secreting gland, which plays a role in vaginal lubrication. Bartholin glands are generally nonpalpable when not obstructed. Cysts and abscesses are often found after the onset of puberty and a decrease in incidence after menopause.[rx]

A cyst is a sac filled with liquid or semisolid material that forms under the skin or somewhere inside the body. The Bartholin’s gland is one of two small glands on each side of the labia minora, just outside of the opening to the vagina. During sexual arousal, the Bartholin’s gland releases a lubricating fluid. A Bartholin’s gland cyst develops when the gland becomes blocked. The Bartholin’s gland can become blocked for a variety of reasons, such as infection, inflammation, or long-term irritation.

Causes of Bartholin’s Glands Cysts

A Bartholin gland cyst is a benign blockage of the Bartholin gland that is usually unilateral, asymptomatic, and maybe incidentally found during a pelvic exam or imaging studies. Bartholin gland obstruction may occur after trauma to the area, episiotomy, or childbirth; however, it may also occur without an identifiable cause.[rx]

The Bartholin’s glands produce a lubricating fluid that helps reduce friction during sexual intercourse. This fluid travels from the Bartholin’s glands down ducts into the lower part of the entrance to the vagina.

If there is a blockage of mucus in these ducts, the lubricant accumulates. This buildup causes the ducts to expand and a Bartholin’s cyst to form. The reaction of the immune system to a bacterial infectious agent may cause the blockage and subsequent abscess. Examples of these agents include:

• Neisseria gonorrhoeae, which causes gonorrhea, a disease that is transmissible via sexual contact
• Chlamydia trachomatis, which causes chlamydia
• Escherichia coli, which can affect the water supply and cause hemorrhagic colitis
• Streptococcus pneumonia, which can cause pneumonia and middle ear infections
• Haemophilus influenza, which can cause ear infections and respiratory infections

While doctors do not consider Bartholin’s cyst to result exclusively from sexual transmission, N. gonorrhoeae is among the most common pathogens that doctors isolate when testing the cysts.

Symptoms of Bartholin’s Glands Cysts

Most of Bartholin’s cysts do not cause any symptoms,

• Although some may cause pain during walking, sitting,^[rx], or sexual intercourse (dyspareunia).^[rx] They are usually between 1 and 4 cm, and are located just medial to the labia minora.
• Most of Bartholin’s cysts only affect the left or the right side (unilateral).
• While small cysts are usually not painful, larger cysts can cause significant pain.
• A tender, painful lump near the vaginal opening
• Discomfort while walking or sitting
• Pain during intercourse
• Fever
• You may feel a soft, painless lump. This does not usually cause any problems.
• But if the cyst grows very large, it can become noticeable and uncomfortable. You may feel pain in the skin surrounding the vagina (vulva) when you walk, sit down or have sex.
• The cyst can sometimes affect the outer pair of lips surrounding the vagina (labia majora). One side may look swollen or bigger than usual.
• If the cyst becomes infected, it can cause a painful collection of pus (abscess) to develop in 1 of the Bartholin’s glands.

Diagnosis of Bartholin’s Glands Cysts

History and Physical

When examining a patient with a suspected Bartholin gland cyst/abscess, it is important to inquire about the duration of symptoms; tenderness with activities such as walking, sitting, standing, or sexual intercourse; purulent drainage; and history of previous Bartholin gland cyst/abscess, vaginal bleeding/discharge, or sexually transmitted infections. Bartholin cysts often have a protracted course as they are mainly asymptomatic. Take into consideration the patient’s age, because malignancy, while rare, may have a similar presentation.

The physical exam will often reveal asymmetry with a protrusion of one side (left or right) of the inferior aspect of the vulva. Bartholin gland abscesses, unlike Bartholin cysts, are very painful. While both are primarily unilateral, Bartholin abscesses are often tender to palpation, erythematous, indurated, and may have an area of fluctuance and/or purulent drainage.

Evaluation

Bartholin cyst abscesses do not frequently require further laboratory or radiographic studies; however, wound cultures and biopsy may be performed during incision and drainage of the abscess. If sexually transmitted infections are suspected, then a sexually transmitted infection panel (including gonorrhea, chlamydia) should be considered and appropriate treatment initiated.

If malignancy is suspected due to an atypical presentation of the mass or if the patient is over 40 years old, then a biopsy should be considered.[rx]

Treatment of Bartholin’s Glands Cysts

Asymptomatic Bartholin cysts do not require further treatment. Bartholin cysts or abscesses that are spontaneously draining may be managed conservatively with sitz baths and analgesics.

• Pain relievers – Taking over-the-counter pain relievers, including acetaminophen and ibuprofen, may help a person with a Bartholin’s cyst relieve discomfort.
• A warm bath – Soaking the cyst for 10–15 minutes may help it burst and heal.
• A warm compress – Applying gentle pressure to the cyst with a flannel or cotton wool ball soaked in hot water can help.
• Although no modality of treatment – surgical or conservative, is superior to any other in terms of recurrence rate,[rx] first-time Bartholin abscesses may be treated with incision and drainage with Word catheter placement due to ease and effectiveness of treatment. Allergy history should be obtained before beginning the procedure as the Word catheter stem is composed of latex, and marsupialization is the procedure of choice in those with latex allergies. Although this is not a sterile procedure, a mask with a face shield and a gown is recommended.[rx]
• Antibiotic therapy – Antibiotic choices include trimethoprim-sulfamethoxazole alone, amoxicillin-clavulanate plus clindamycin, or cefixime plus clindamycin. Referral to gynecology for marsupialization may also be considered at this time. It should be considered for those who have failed initial I&D (incision and drainage) with Word catheter placement, patients with systemic symptoms including fever, patients who have suspected sepsis, and those considered at high risk for recurrence.

• Sitz baths – Soaking in a tub filled with a few inches of warm water (sitz bath) several times a day for three or four days may help a small, infected cyst to rupture and drain on its own.
• Surgical drainage – You may need surgery to drain a cyst that’s infected or very large. Drainage of a cyst can be done using local anesthesia or sedation. For the procedure, your doctor makes a small incision in the cyst, allows it to drain, and then places a small rubber tube (catheter) in the incision. The catheter stays in place for up to six weeks to keep the incision open and allow complete drainage.
• Marsupialization – is performed by a gynecologist in the operating room, and for this reason, incision and drainage with Word catheter placement are usually attempted first. Marsupialization is performed by creating a 2-cm incision lateral to the hymenal ring, everting the edges with forceps, and suturing the edges onto the epithelial surface with interrupted absorbable sutures.[rx]
• Silver nitrate ablation – carbon dioxide laser vaporization,[rx] Jacobi ring placement [rx], and Bartholin gland excision as a last resort when other modalities have failed. Women who are pregnant and have Bartholin abscesses should be treated in the same manner as nonpregnant women, with the exception of Bartholin gland excision due to the increased risk of bleeding.
• Carbon dioxide Laser treatment – One retrospective cohort study reported an average healing time of 2.2 weeks; six case series reported a healing time of three weeks to three months. The frequency of recurrence ranged from 2% to 20%.
• Marsupialization – Treatment demonstrated a healing time of fewer than two weeks. No recurrence was observed in any studies with marsupialization. However, when compared with patients treated by incision and drainage before primary closure, patients with marsupialization healed significantly more slowly (one to 21 days versus three to 11 days, p<0.05). There was no significant difference in abscess recurrence.
• Needle aspiration – Healing occurred within one week. Recurrence ranged from 0 to 38% at six months (n=96 patients). Compared with alcohol sclerotherapy, needle aspiration was associated with more than twice the frequency of recurrence. All patients who received alcohol sclerotherapy had their abscesses healed within one week. The recurrence rate was 8% to 10% at seven months (two studies).
• Balloon catheter insertion – Balloon catheter insertion, sometimes known as catheter placement or fistulization, is a procedure used to drain the fluid from the abscess or cyst. A permanent passage is created to drain away any fluid that builds up in the future. This is an outpatient procedure, which means you won’t need to stay in hospital overnight. It’s usually carried out under local anesthetic, where you remain conscious, but the area is numbed so you cannot feel anything. It can also be carried out under general anesthetic, where you’re unconscious and unable to feel anything. A cut is made in the abscess or cyst and the fluid is drained. A balloon catheter is then inserted into the empty abscess or cyst. A balloon catheter is a thin, plastic tube with a small, inflatable balloon on one end. Once inside the abscess or cyst, the balloon is filled with a small amount of saltwater. This increases the size of the balloon so it fills the abscess or cyst. Stitches may be used to partially close the opening and hold the balloon catheter in place. The catheter will stay in place while new cells grow around it (epithelialization). This means the surface of the wound heals, but a drainage passage is left in place.  Epithelialisation usually takes around 4 weeks, although it can take longer. After epithelialization, the balloon will be drained and the catheter removed.
• Fistulisation – Treatment took three weeks for healing to occur (one RCT) and recurrence occurred in 4% to 17% of patients at six months.
• Gland Excision – The frequency of recurrence was 0 to 3%. Adverse events were uncommon in all interventions and when they occurred were not life-threatening.
• Removing the Bartholin’s gland – Surgery to remove the affected Bartholin’s gland may be recommended if other treatments haven’t been effective and you have repeated Bartholin’s cysts or abscesses. This operation is usually carried out under general anesthetic and takes about an hour to complete. You may need to stay in the hospital for 2 or 3 days afterward. Risks of this type of surgery include bleeding, bruising, and infection of the wound. If the wound does become infected, this can usually be treated with antibiotics prescribed by your GP.