Nan G. O’Connell
History of present illness
A 25-year-old gravida 0 woman presents to the emergency department complaining of swelling and exquisite pain“down there.” She had felt some soreness 2–3 days prior, but the symptoms acutely worsened 24 hours before her presentation.
Her pain is exacerbated by sitting and walking. She denies fever, vaginal discharge, and dysuria. Her last menstrual period was two weeks ago. She is sexually active with the same partner for the past 10 months and uses an oral contraceptive. She was treated for chlamydia when she was 19 years old. She has never had symptoms like this before.
The patient’s past medical history is notable for obesity.
Her past surgical history is negative. She works as a nursing assistant and had to call in sick today because of her symptoms.
Physical examination
General appearance:Woman is obviously uncomfortable, ambulating slowly, and leaning to the left while seated on the stretcher
Vital signs:
Temperature: 36.9°C Pulse: 90 beats/min
Blood pressure: 118/76 mmHg Respiratory rate: 16 breaths/min HEENT:Normal
Chest:Clear to auscultation Cardiac:Regular rate and rhythm
Abdomen:Obese, nontender, no obvious masses Pelvic:The lower aspect of the right labium majorum is swollen and very tender. Fluctuance of the mass is noted and the area is warm and erythematous. The mass measures approximately 5 × 6 cm. The left side appears normal. Gentle palpation of the mass reveals that it does not extend into the vagina (Fig. 46.1)
How would you manage this patient?
This patient has an abscess of the right Bartholin’s duct. After local anesthesia, the abscess was incised and drained giving the patient immediate relief. To help prevent recurrence, a Word catheter was placed in the abscess cavity. The catheter was uneventfully removed in four weeks. The patient did well and remains symptom free.
Bartholin ’ s abscesses
The Bartholins, or greater vestibular glands, are paired vulvar glands measuring approximately 0.5 cm in width, with a 2.5 cm duct that opens onto the vestibule at the 4 and 8 o’clock positions between the hymen and the labia minora. These glands produce very small amounts of mucus, which provides some moisture to the vulva but is not critical for sexual functioning. Unless diseased, the glands are not palpable and the ductal orifice is not usually visualized. The ducts, however, are prone to obstruction at their distal end due to the small size of the orifice. This obstruction in turn leads to cystic dilation of the duct. A Bartholin’s abscess may arise from a secondarily infected Bartholin’s cyst or, as with this patient, as a primary infection of the gland and duct. Gradual involution of the glands occurs with age; thus, a cyst or abscess in a woman aged over 40 should raise the suspicion of a possible cancer and warrant further investigation in the form of a biopsy or excisional procedure, particularly if there is fixation of the gland to the underlying tissues.
The diagnosis of a Bartholin’s abscess is generally made by physical examination with the finding of a very tender, fluctuant mass at the lower aspect of the labia majora. The size of abscesses varies, but they may measure up to approximately 8 cm. The differential diagnosis includes vulvar abscesses, infected sebaceous cysts, hematomas, fibromas, lipomas, or hydradenitis suppurativa. A Bartholin’s abscess is usually a polymicrobial infection. The more prominent organisms
Fig. 46.1 Right Bartholin’s abscess. (Photo courtesy of Stephen A. Cohen MD.)
Acute Care and Emergency Gynecology, ed. David Chelmow, Christine R. Isaacs and Ashley Carroll. Published by Cambridge University Press.
© Cambridge University Press 2015.
cultured areEscherischia coli,Staphlococcus aureas,Streptococ- cus faecalis, Bacteroidies sp., Peptostreptococcus sp., Neisseria gonorrhoeae, andChlamydia trachomatis.
The treatment described for this patient using the Word catheter is probably the most common treatment modality used in the outpatient setting in the United States. Drainage of the abscess will give immediate relief of the pain caused by the abscess; however, simple incision and drainage has a high rate of recurrent abscess formation. To prevent recurrence, the abscess can be drained through a linear incision and then a Word catheter can be placed to allow epithelialization and formation of a new, permanent orifice for the duct [1]. The Word catheter is small balloon-tipped catheter with a sealed end that can be inflated with saline or sterile water using a syringe and needle (Fig. 46.2).
Procedurally, after injection of a local anesthetic, a small incision is made with a scalpel on the inner aspect of the abscess near the hymenal ring. The purulent material is drained and when possible the abscess is probed to break up any loculations. The tip of the Word catheter is then inserted into the cavity and inflated with 2–3 mL of saline or sterile water. The end of the catheter can be tucked into the vagina for improved patient comfort. The Word catheter should be left in place for approximately four weeks to allow for complete fistulization. The patient can then be seen back in the outpa- tient setting where the balloon is deflated with a syringe (or by simply cutting the sealed end off) and the catheter easily removed. The major complication to this technique is prema- ture expulsion of the Word catheter.
A Bartholin’s abscess can also be ablated using a small silver nitrate stick inserted into the abscess cavity after incision and drainage. The area is covered with gauze and the patient returns in 48 hours to have the area cleaned to remove necrotic tissue and excess silver nitrate. This procedure has the advan- tage of being quick and easy to perform in the outpatient setting, but can cause pain and scarring.
Another option to manage a Bartholin’s abscess is marsu- pialization. Marsupialization can be performed under local anesthesia in the outpatient office setting but, because it is a
more involved procedure, most practitioners prefer to do it in an outpatient surgical setting. This procedure involves a 1.5–2.0 cm incision made in the abscess just outside the hymenal ring. The purulent material is drained from the abscess cavity, and the cyst wall is then grasped, everted, and sutured to the edge of the vestibular skin using inter- rupted absorbable sutures. This creates a new fistular tract to permanently drain the gland and minimize the chance of recurrence.
Finally, the entire Bartholin’s gland and duct can be excised. This procedure is usually reserved for those patients who have failed other less invasive treatments as excision carries a much higher risk of complications including excessive bleeding, scarring, and dyspareunia. Because dissecting out the infected gland is more surgically involved, it should be per- formed in the operating room with appropriate anesthesia.
This may be a preferred option in patients over age 40, as this excisional approach provides a specimen for histologic analysis.
Considering all treatment options, a systematic review in 2009 failed to identify the optimal treatment for a Bartholin’s cyst or abscess, noting the lack of large, randomized con- trolled trials [2]. Given the lack of proven superiority of one procedure over another, the decision as to which technique to perform should be based on resources, patient history (especially a history of recurrent abscesses, which would favor marsupialization or excision), age of the patient, and provider experience [2].
The use of antibiotics for the treatment of Bartholin’s abscesses is not routine. In most cases, the infection is polymicrobial and will resolve with abscess drainage without antibiotic therapy. However, the increased incidence of methicillin-resistantStaphylococcus aureus (MRSA) in vulvar abscesses [3] suggests that sending an aerobic culture is prudent. Patients considered at high risk for sexually transmit- ted infections should be screened for N. gonorrhoeae and C. trachomatis as well. Broad-spectrum antibiotic therapy should be considered for patients with surrounding cellulitis, fever, diabetes, or immunosuppression.
Fig. 46.2 Inflating the Word catheter.
Case 46: A 25-year-old woman with a painful vulvar mass
Key teaching points
A Bartholin’s abscess is a commonly encountered painful gynecologic condition, which can usually be treated in the outpatient setting with surgical incision and drainage.
Because simple incision and drainage of a Bartholin’s abscess is prone to recurrence, placement of a Word catheter or use of an ablative technique is recommended to prevent such recurrences.
Antibiotic therapy is not routinely necessary but consideration should be given to screening for methicillin-resistantStaphylococcus aureus(MRSA), Neisseria gonorrhoeae, andChlamydia trachomatis.
Patients with a history of recurrent Bartholin’s abscesses, or those who have failed multiple outpatient treatments, should be considered candidates for a marsupialization or an excisional procedure.
References
1. Word B. New instrument for office treatment of cyst and abscess of Bartholin’s gland.JAMA1964;190:777–8.
2. Wechter ME, Wu JM, Marzano D, Haefner H. Management of Bartholin duct cysts and abscesses: A systematic review.Obstet Gynecol Surv
2009;64:395–404.
3. Thurman AR, Satterfield TM, Soper DE. Methicillin-resistantStaphylococcus aureusas a common cause of vulvar abscesses.Obstet Gynecol2008;112:
538–44.