The Bartholin glands are posterior to the vestibular bulbs, and function to produce mucus that aids in vaginal and vulvar lubrication. They drain into ducts that open onto the vulvar vestibule at roughly 4 and 8 o’clock.

Blockage of the Bartholin duct, resulting in a cyst or abscess, is a common etiology of a vulvar mass and accounts for 2% of all gynecological visits per year.

Risk Factors:

• There are no established risk factors for Bartholin cysts and abscesses.
• A previous Bartholin cyst or abscess is a risk factor for recurrence.

Clinical Presentation:

• Cysts usually present as asymptomatic, painless masses. Patients may find a larger cyst disfiguring. Larger cysts may cause discomfort with ambulation, sexual intercourse, or sitting.
• Abscesses typically present with severe pain and swelling resulting in difficulty sitting, walking, or engaging in sexual intercourse.

Physical Examination:

• It should be noted that fever occurs in only 20% of patients with Bartholin abscess.
• A vulvar examination should be performed.

Investigations:

• There is no role for imaging in the evaluation of a Bartholin mass, nor blood tests, if systemic infection is not suspected.

Diagnosis:

• The diagnosis of a cyst or abscess are clinical in nature.
• A cyst can be diagnosed based on the physical findings of a nontender, soft mass at the site of the Bartholin gland and duct
• An abscess can be diagnosed based on the physical findings of a large, tender, soft, warm, or fluctuant mass at the site of the Bartholin gland and duct. There may be erythema, edema, or purulent discharge.

• Diagnostic Considerations:
  • The key to correctly identifying a Bartholin mass is its anatomical position (the lower medial labia majora/lower vestibular area).
  • Always consider alternative causes of vulvar masses when assessing these patients.

Management:

• In general, management depends on the size of the mass. A diameter <3cm is a small mass, whereas ≥3cm is large.
• If there is purulent material cultures should be obtained.
• ED providers should consider sexually transmitted infection testing in patients who are considered high risk.

Small masses (<3cm):

• Manage expectantly. Sitz bath or warm compresses for symptomatic relief.
• If there this an abscess, also perform an I&D.

Large masses (≥3 cm):

• First or second presentation: Incision and drainage (I&D) under local anesthesia is the mainstay of treatment. After, a Word catheter should be placed and left in for up to 4 weeks. Have the patient follow up with a local gynecologist or their primary care provider. Latex allergy is a contraindication to Word catheter.
• Recurrent (third or more) presentations: Consult your local gynecologist for operative marsupialization or alternative options.
• Less common strategies include silver nitrate sclerotherapy, which can be used after drainage but is associated with postprocedural discomfort.
  • Jacobi ring catheters may also be beneficial, but there is limited clinical experience with them.

When to biopsy to assess for Bartholin gland carcinoma:

• Mass has a solid component.
• Cyst or abscess wall is fixed to the surrounding tissue.
• Mass is unresponsive or worsening despite treatment.
• Patient is postmenopausal.

When to use antibiotics:

• Recurrent Bartholin abscess (second or more).
• High risk of complicated infection (extensive cellulitis, pregnant, immunocompromised, MRSA risk factors).
• Positive MRSA culture from I&D for current abscess.
• Signs of systemic infection (fever/chills).
• Common choices for antibiotics include 3rd generation cephalosporins, amoxicillin-clavulanate, or doxycycline.

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