Introduction

The Bartholin’s Glands are bilateral structures, present in women on the labia minora and adjacent to the posterolateral aspect of the vaginal introitus. Each gland is approximately pea-sized, producing a mucoid substance which is secreted through an inch-long duct during sexual arousal. The glands are named after Thomas Bartholin, best known for the discovery of the Lymphatic System, in the 17th century. Pathology of the glands is relatively common.

Aetiology and Epidemiology

A blockage in the duct may cause a cyst to develop, termed Bartholin’s Cyst, and occurs at any age in around 2% of women during their life. The cyst may be complicated by infection and become a Bartholin’s Abscess. Bacterial abscess can occur in conjunction with Sexually-Transmitted Infections (STIs), or due to skin or faecal flora. Common pathogens include:

  • Neisseria gonorrhoea
  • Staphylococcus aureus
  • Escherichia coli

 

A Bartholin’s cyst is usually of little concern, being asymptomatic in the majority of cases and resolving spontaneously. The cyst may enlarge enough to cause irritation during sitting or intercourse. Concomitant infection leads to abscess formation with which the patient may experience extreme pain due to expansion of the gland against the ligaments of the perineum and pelvis. Cysts and abscesses are usually unilateral.

 

    Investigations

    Diagnosis of Bartholin’s cyst and abscess is clinical, although any vulval lump should be cast with a suspicious eye to exclude malignancy particularly in older women as Bartholin’s glands shrink post-menopause. Both Lichen Sclerosus and Human Papilloma Virus (HPV) infection are risk factors for development of Vulval Squamous Cell Carcinoma (SCC). The four classic signs of inflammation suggest an infection: rubor (heat), dolor (pain), calor (erythema) and tumor (mass). Infection necessitates a different management plan. Any associated vaginal discharge should be swabbed and sent to microbiology for culture.

     

    Differential Diagnosis

    Other less common causes of a lump around the Bartholin’s gland should be considered:

    • Sebaceous cyst – a similar pathogenesis
    • Haematoma – caused by straddle or sporting injuries
    • Endometriosis
    • Benign tumours – eg Fibroma, Lipoma
    • Malignant tumours – vulval SCC, Bartholin’s Gland adenocarcinoma (very rare)

     

    Management

    Cysts are usually managed conservatively with:

    • NSAIDS if the cyst causes discomfort
    • Warm baths to encourage the duct to unblock

     

    The majority of cysts will resolve spontaneously. If large enough, some cysts may be managed as abscesses, described below.

     

    Smaller abscesses will respond to a course of antibiotics, particularly if an underlying STI has been cultured. Larger abscesses may need to be referred to surgery as pharmacologic agents will prove futile. Abscesses that require surgical intervention may be approached in one of three ways:

     

    • A simple ‘Incision and Drainage’ may be performed, although the recurrence rate is high due the anatomy so this option is not commonly used.
    • Marsupialisation of the cyst involves incising the lesion, draining it and suturing the inner wall of the gland to the labia minora so the gland is no longer a pocket for pus to collect in. This renders the gland obsolete but vastly reduces the chance of the abscess reforming.
    • A ‘Word catheter’ can be used after a small incision is made and the abscess drained. It is inflated with water to maintain patency of the duct and gland to allow new tissue to form. The catheter should remain in place for around 4 weeks.

     

    Advertisement

    Fastbleep © 2019.