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BartholinAbscessDrainage

BartholinAbscessDrainage
Author:GilZShlamovitz,MD,FACEPChiefEditor:ChristineIsaacs,MDmore...
Updated:Dec19,2014

Overview
Bartholinabscessesandcystsaccountfor2%ofallgynecologicalvisitsperyear. [1]TheBartholinglandsarea
pairofpeasized,vulvovaginal,mucoussecretingvestibularglandsthatarelocatedinthelabiaminorainthe4and
8o'clockpositions,beneaththebulbospongiosusmuscle.ABartholincystisafluidfilledsacthatdevelopsinone
oftheBartholinglandsorductswhentheductthatdrainsthefluidfromtheglandbecomesblockedandcauses
theductandglandtoswell.ABartholinglandabscessdevelopseitherwhenaBartholincystbecomesinfectedor
whentheBartholinglanditselfbecomesinfected. [2]FormoreinformationondisordersoftheBartholingland,
pleaseseeMedscapeReferencearticlesBartholinGlandDiseasesandBenignVulvarLesions.
WhileempiricantibiotictherapyisnotindicatedintheimmunocompetentpatientwhopresentswithBartholin
glandabscesswithoutcellulitis,itishelpfultoknowthatasubstantialproportionofpatientswithBartholingland
abscessareculturepositive,withEscherichiacolibeingthesinglemostcommonpathogen. [3]
DifferenttechniquesexistforthetreatmentofBartholincystsandabscesses.Themostcommonlyusedonesare:
(1)fistulizationusingaWordcatheter,Foleycatheter,orJacobiringand(2)marsupilization.
Othertechniquesinclude:(1)silvernitrateglandablation(2)cystorabscessfenestration,ablation,orexcision
usingcarbondioxide(CO2)laser(3)needleaspirationwithorwithoutalcoholsclerotherapy(4)glandexcision
and(5)incisionanddrainagefollowedbyprimarysutureclosure. [4,5,6]
Norecurrenceaftermarsupializationhasbeenreportedinavailablestudies.Recurrenceratesafterother
treatmentshasvariedrecurrencewasmostcommonafteraspirationalone(approximately38%).Healing
generallyoccurredin2weeksorless.
Althoughareviewoftheliteraturefailedtoidentifyabesttreatmentapproachforthefirstoccurrenceofa
symptomaticBartholincystorabscess,theauthorrecommendstheuseoftheWordcatheterasaninitial
approach. [6,7,8]IfaWordcatheterisnotavailable,incisionanddrainage(withtraditionalpacking)maybe
performed.

Indications
SelectedBartholincysts
Diameterof1cmorlarger
Anysymptomaticcyst(painful,tender,interfereswithphysicalorsexualactivity)
AnyBartholinabscess

Contraindications
AbsoluteNone
RelativeComplexorrecurrentabscessthatrequiresdrainageundergeneralanesthesiaintheoperating
room

Anesthesia
IncisionanddrainageofaBartholincystorabscessrequiresanesthesiaofthelabialmucosa.Because
infiltrationofthelabialmucosawithalocalanestheticmaybepainful,discussoptionssuchasintravenous
narcoticsandproceduralsedationandanalgesiawitheachpatient.
SeetheTechniquesectionbelowfortheprocedureforlocalanestheticinfiltration.Formoreinformation,see
LocalAnestheticAgents,InfiltrativeAdministration.

Equipment
Sterileskinpreparatorysolutionanddrapes
Lidocaine1%
Normalsaline(0.9%NaCl)
Syringe,3mL
Syringe,5mL
Syringe,10mL
Needles,18gauge(3)
Needle,25or27gauge,1.5inch(forinjectionofanesthesia)
Scalpelblade(No.11)andhandle
Gauzepads(4X4)
Hemostat
Cultureswab
Wordcatheter(seeimagesbelow)

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Wordcatheter.

Wordcatheterw ithinflatedballoon.

Positioning
Placethepatientinthelithotomyposition.

Technique
Explaintheprocedure,risks,benefits,possiblecomplications,alternativeoptions,andpostprocedurecare
tothepatientorherlegalrepresentativeandobtainawritteninformedconsent.Afemalechaperoneshould
bepresentintheprocedureroomthroughouttheprocedure.
Placethepatientinthelithotomypositionandspreadopenthelabia(seeimagebelow).Anassistantmay
aidwithtractionofthelabiaduringtheprocedure.

Bartholinabscess.

Usethesterileskinpreparatorysolutiontocleanthelabiaandsurroundingarea(seeimagebelow).

Skinpreparation.

Infiltrate23mLoflidocaine1%subcutaneouslyunderthemucosaofthelabiaminora(seeimageandvideo
below).

Mucosalinfiltrationw ithlidocaine.
Mucosalinfiltrationw ithlidocaine.

Largeabscessesorcyststhatseemtobeunderhighpressuremaybepartiallyneedledecompressedprior
toincisionwiththebladeinordertopreventhighpressuredrainageuponincision(seeimageandvideo
below).Completeneedledecompressioncouldmakeithardertoensureproperidentificationoftheabscess
cavityandshouldbeavoided.

Needleaspiration.
Needleaspiration.

Incisionismadeinthevestibularareathroughanareaoffluctuation(seeimageandvideobelow). [9]Usea

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No.11bladetomakeapuncture0.51cmlongintotheabscessorcystcavityonthemucosalsurfaceof
thelabiaminora.Maketheincisionwithinthehymenalring,ifpossible.IfWordcatheterplacementis
planned,theincisionshouldbejustlargerthanthecatheterdiameter.Iftheincisionistoolarge,thepatient
willnotbeabletoretainthecatheterforthedesiredtime.Conversely,ifstandardincisionanddrainageis
performed,thelargerincisionisimportant.

IncisionofBartholinabscess.
IncisionofBartholinabscess.

Expressthecontentsofthesacmanuallyandusethehemostattobreakadhesions(seeimagebelow).
Thecontentsmaybesentforculture,andasuctionsystemcanbeusedtocontainthemanually
expressedfluids.

DrainageofaBartholinabscess.

InsertthetipoftheWordcatheterdeepintotheabscesscavityanduse24mLofnormalsalinetoinflate
theballoon(seeimagesandvideobelow).

InsertionofaWordcatheter.

InflationofaWordcatheter.
InsertionandinflationofaWordcatheter.

Tuckthefreeendofthecatheterintothevagina.Inmanycases,thefreeendchangesitspositionto
protrudeoutsidethevagina(seeimagebelow).Thecathetershouldstayinplaceforupto4weekstoallow
epithelizationofthetract.Thepatientshouldabstainfromvaginalintercoursewhilethecatheterisinplace.

Wordcatheterinplace.

TheWordcathetermaybeleftinplaceforseveralweekstominimizethechanceofrecurrence.When
healingiscompleted,asmallpermanentfistulaiscreatedinbetweenthecystcavityandthevestibular
area.Thesizeoftheostiumisverysmallandscarcelyvisiblewithtime. [9]

Pearls
Antibiotictreatmentisatthediscretionofthetreatingclinician.Antibioticsarenotusuallyindicatedinthe
immunocompetentpatientwithadrainedBartholinabscess.Antibioticsaretypicallyadministeredif
cellulitisispresent.

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WhenaWordcatheterisnotavailable,andanurgentreferraltoaproviderwhocanplacethecatheterisnot
possible,asimpleincisionanddrainagewithpackingcanbeperformed.Warnthepatientofthehigh
probabilityofabscessrecurrenceandreferthepatienttoagynecologist. [8]Marsupializationcanalsobe
consideredinthissetting.Gauzepackingshouldberemovedwithin2448hours. [9]
Allpatientsshouldbeinstructedtobeginsitzbaths12dayspostprocedureandtoabstainfromvaginal
intercourseuntiltheWordcatheterorpackingisremoved.
Prescribeanalgesicsandreferpatientstoagynecologistforfollowup.
Patientsolderthan40yearsshouldbereferredtoagynecologistforabiopsytoruleoutBartholingland
cancer.
Patientswithmultiplerecurrenceswithprevioustreatmentsshouldbereferredtoagynecologistfor
definitivetreatment(completeexcision).

Complications
Recurrence
Recurrenceisthemostcommoncomplicationafterincisionanddrainage(~30%).
PrematuredislodgementoftheWordcatheterresultsinincisionclosureandhighratesof
recurrence.
MisseddiagnosisofBartholinductcarcinoma [10,11]
Malignanttumorsofthevulvarsofttissueareveryuncommon.WhenlocalizedintheBartholingland
area,thesetumorscanbemistakenforbenignlesions,leadingtoadelayeddiagnosis. [12]Thisrare
formofcarcinomahasanapproximateincidenceof0.1casesper100,000women.
Womenolderthan40yearsshouldbereferredtoagynecologistfordiagnosisandtreatment. [13]
Bleeding
Progressiveinfectionandsepsis [14]
Patientswithcompromisedimmunesystemsmayexhibittheserarecomplications.
Treatallimmunocompromisedpatientswithantibiotics.Closelymonitororevenadmitsuchpatients
inordertodiagnoseandtreatprogressiontoadeeperseatedinfection.
Inrareinstances,Bartholin'sabscessescanleadtocomplicationssuchasmaternalandfetaltachycardia,
chorioamnionitis(Ecoli),andsternoclavicularsepticarthritis. [15]

ContributorInformationandDisclosures
Author
GilZShlamovitz,MD,FACEPDirectorofMedicalInformatics,SectionofEmergencyMedicine,Assistant
Professor,DepartmentofMedicine,BaylorCollegeofMedicineMedicalDirectorofClinicalInformatics:
DocumentationCompliance,HarrisHealthSystemOwnerandChiefEditor,VisualDiagnosisSeries
(http://www.VisualDxSeries.com/)
GilZShlamovitz,MD,FACEPisamemberofthefollowingmedicalsocieties:AmericanAcademyof
EmergencyMedicineandAmericanCollegeofEmergencyPhysicians
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
AndrewKChang,MDAssociateProfessor,DepartmentofEmergencyMedicine,AlbertEinsteinCollegeof
Medicine,MontefioreMedicalCenter
AndrewKChang,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergency
Medicine,AmericanAcademyofNeurology,AmericanCollegeofEmergencyPhysicians,andSocietyfor
AcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
LuisMLovato,MDAssociateClinicalProfessor,UniversityofCalifornia,LosAngeles,DavidGeffenSchoolof
MedicineDirectorofCriticalCare,DepartmentofEmergencyMedicine,OliveViewUCLAMedicalCenter
LuisMLovato,MDisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,AmericanCollegeof
EmergencyPhysicians,andSocietyforAcademicEmergencyMedicine
Disclosure:Nothingtodisclose.
ChiefEditor
ChristineIsaacs,MDAssociateProfessor,DepartmentofObstetricsandGynecology,DivisionHead,General
ObstetricsandGynecology,MedicalDirectorofMidwiferyServices,VirginiaCommonwealthUniversitySchool
ofMedicine
ChristineIsaacs,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansand
Gynecologists
Disclosure:Nothingtodisclose.
AdditionalContributors
TheauthorsandeditorsofMedscapeReferencegratefullyacknowledgetheassistanceofLarsGrimmwiththe
literaturereviewandreferencingforthisarticle.

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