Bartholin’s cysts are cysts that arise from the Bartholin’s gland, most often due to occlusion of the duct that drains into the vestibule.
🦴 Anatomy
The Bartholin’s glands/greater vestibular glands are small pea-shaped glands located on either side of the vaginal orifice (introitus), posterior to the bulbs of the vestibule. They are located in the deep perineal pouch and the ducts course through to the superficial compartment to exit onto the vestibule at the 5 and 7 o’clock positions.
With sexual arousal, they secrete lubricating mucous into the vestibule via small ducts.
Pathophysiology
Ductal obstruction may occur secondary to mucus, trauma, infection or oedema that compresses the duct. This leads to fluid accumulation within the gland. This cyst can rapidly enlarge during sexual activity. The cyst is identified usually when it is 1-4cm large.
⚠️ Risk factors
- 20-50 years of age - women of reproductive age are at higher risk.
- Previous Bartholin’s cyst - especially if the initial treatment wasn’t complete. It can lead to stenosis and scarring of the duct which increases recurrence.
- Sexual activity - glandular secretion and size increases with sexual arousal. Diminished sexual activity also leads to shrinkage of the cyst.
😷 Presentation
- Vulval or perineal mass
- Vulval pressure - small cysts are asymptomatic but as they increase in size, so does the pressure or feeling of fullness.
- Pain - pain may occur with abscess formation. However large cysts may cause discomfort and noted when walking or sitting. This pain may be palpable at the 5 or 7 o’clock positions.
- Dyspareunia
🔍 Investigations
It is a clinical diagnosis.
If there is a suspicious looking appearance, especially in elderly women, a biopsy might be useful to rule out Bartholin’s gland cancer.
🧰 Management
- Warm salt bath or warm compression - this aids drainage from the ducts.
- Analgesia
- Marsupialisation - a vertical incision is made into the cyst, behind the hymenal ring, allowing for spontaneous drainage of the cavity. The cyst wall is then everted and approximated to the end of the vaginal mucosa by sutures. This requires a general anaesthetic.
- Word catheter drainage - an incision is made into the cyst or abscess, and a catheter is inserted. The tip is inflated with 2-3ml of saline. It is left in place for 4-6 weeks to allow epithelisation of the surgically created tract. This technique is not suitable for deep cysts or abscesses. It can be performed under local anaesthesia in a clinic as an outpatient.
🚨 Complications
These result from polymicrobial infections of the cyst. They can present with pain and fever and induration (hardening) and surrounding cellulitis.
🦠 The most common pathogens are:
- E.coli
- S.aureus
- Group B streptococci
- Enterococcus spp.
🧰 It can be treated with broad-spectrum antibiotics:
- 🥇 Trimethoprim/sulfamethoxazole are first-line.
- 🥈 Co-amoxiclav + clindamycin are second-line alternatives.