Bartholin gland cyst and abscess: Word catheter placement

INTRODUCTION — The Bartholin glands (also called the greater vestibular glands) are located in the vulva, and blockage of the Bartholin ducts is a common etiology of a vulvar mass. The most common Bartholin masses are cysts or abscesses. The mainstay of management of a Bartholin mass is incision and drainage (I&D), and a Word catheter is often placed as well (picture 1). The Word catheter is a balloon that is placed in the Bartholin gland after I&D to allow continued drainage and re-epithelialization of a tract for future drainage.

This topic will review the procedure for incision, drainage, and placement of a Word catheter for treatment of a Bartholin cyst or abscess. General principles of the diagnosis and management of a Bartholin cyst or abscess and the management of other types of vulvar abscess are discussed in detail separately. (See "Bartholin gland masses" and "Vulvar abscess".)

INDICATIONS AND CONTRAINDICATIONS — The indication for incision and drainage (I&D) and Word catheter placement is the presence of an uncomplicated Bartholin mass. Placement of a Word catheter into the mass allows the contents to drain and, over time, to form around the catheter a fistulous tract from the dilated duct or abscess to the vestibule to allow future drainage.

The stem of the Word catheter is latex, and thus use of this device is contraindicated in patients with latex allergy. There are few other contraindications to Word catheter placement.

PREPROCEDURE EVALUATION AND PREPARATION — The patient is evaluated prior to the procedure to confirm that a vulvar mass is a Bartholin cyst or abscess, rather than another vulvar mass. (See "Bartholin gland masses", section on 'Evaluation'.)

Informed consent is obtained, including a discussion of risks and benefits. This is documented in the medical record.

Ensure that the patient does not have any allergies or hypersensitivity reactions to any agents that will be administered (eg, latex, iodine, amide-type anesthetics).

For patients ≥40 years old, most experts advise a biopsy of a Bartholin gland mass. Bartholin gland carcinoma is rare, but the risk is increased in this age group. (See "Bartholin gland masses", section on 'Biopsy'.)

EQUIPMENT AND INSTRUMENTS — Assemble the following supplies [1,2]:

●Sterile gloves.

●Sterilizing solution, such as povidone-iodine swab sticks, to prepare the surgical site.

●Local anesthetic, such as 1 or 2 percent lidocaine (without epinephrine). Oral or intravenous sedatives or analgesics may also be given if necessary.

●25- or 30-gauge needle and 3 mL syringe to inject the local anesthetic.

●Small forceps, which will be used to hold the cyst or abscess wall.

●Scalpel with a number 11 blade for performing a stab incision.

●Microbiologic testing supplies – Culture swab for sending sample of abscess contents for microbiologic identification and nucleic acid amplification of gonorrhea and chlamydia test kit.

●Hemostat to break up loculations.

●Word catheter – This is a balloon-tipped device that is placed into the cyst or abscess cavity (picture 1). The catheter can hold 3 to 5 cc of liquid. The total length of the catheter is typically 5 cm. Test the catheter to confirm there are no leaks when the balloon is filled.

●A small syringe containing 3 mL saline or water and attached to a small-gauge needle, for inflating the catheter balloon.

●Gauze pads to control bleeding and effluents.

PROCEDURE — Anatomy of the Bartholin gland is discussed in detail separately (figure 1 and figure 2). (See "Bartholin gland masses", section on 'Bartholin gland'.)

The incision and drainage and Word catheter placement procedure includes the following steps [1,2]:

●Position patient in dorsal lithotomy position.

●Prepare the area of the cyst or abscess with sterilizing solution.

●Inject 1 to 3 mL of local anesthetic to infiltrate the site planned for the stab incision. This site is usually at or behind the hymnal ring.

●Hold the cyst or abscess wall with small forceps to maintain traction and prevent collapse of the cyst wall after puncture.

●Incise the cyst or abscess with a 5 mm stab incision, 1.5 cm deep, in the introitus at or behind the hymnal ring to prevent vulvar scarring. If the incision is too large, the catheter will fall out.

●Drain the cyst or abscess contents completely by breaking up loculations with the hemostat. Culture abscess contents with a culture swab and send for microbiologic identification.

●Place the Word catheter through the incision, as deep as possible. Make sure the catheter is in the duct cavity. Holding onto the cyst wall with forceps helps to prevent creation of a false passage separate from the cavity.

●Inflate the balloon of the Word catheter with 2 to 3 mL of saline or water injected into the catheter hub with a needle and syringe.

●Tuck the end of the Word catheter into the vagina to minimize discomfort (figure 3).

●Empiric broad spectrum antibiotics may be given if patient is at risk of complicated infection. (See "Bartholin gland masses", section on 'Role of antibiotics'.)

COMPLICATIONS AND OUTCOME — Rare complications of bleeding, infection, and scarring leading to dyspareunia or distortion of anatomy may occur. Recurrence rates of between 2 and 15 percent have been reported with this procedure [3-5]. If recurrence occurs, we perform a second incision and drainage and Word catheter placement and also treat with antibiotics. If a second recurrence occurs, we perform a marsupialization.

FOLLOW-UP

●The patient should wear a peripad to absorb discharge.

●The patient should maintain pelvic rest (ie, nothing in the vagina) while the Word catheter is in place, and should call to be examined if experiencing increasing swelling, pain, vaginal discharge, or fever.

●The patient may use sitz baths and mild analgesics to treat pain if present during the first postoperative day or two.

●The catheter is left in place for at least four weeks to promote formation of an epithelialized tract for permanent drainage of glandular secretions. Epithelialization may occur as soon as three weeks.

●In patients with a catheter in place who have persistent discomfort despite analgesics, we remove 0.5 to 1 mL of fluid from the balloon.

●When the tract appears well-epithelialized, remove the catheter by deflating the balloon in the office.

●If the catheter falls out, determine further treatment based on examination results. With normal wound healing and no sign of recurrence, no further treatment is necessary [6].

●If a recurrence occurs or as an alternative to Word catheter placement, marsupialization or excision may be performed, usually in an operating room or ambulatory surgical facility. Marsupialization refers to a procedure whereby a large (1.5 to 3 cm) incision is made over the center of the Bartholin mass and then the inside edges of the mass are everted and sewn with interrupted stitches to the vestibular mucosa (figure 4).

If the catheter falls out before the tract is epithelialized and the cyst or abscess remains, the patient may need a repeat Word catheter placement or another procedure, such as marsupialization or excision. If the problem has resolved, the patient can be followed for complete resolution and recurrence.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Bartholin gland cyst (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Placement of a Word catheter into the Bartholin cyst or abscess allows the contents to drain and, over time, to form around the catheter a fistulous tract from the dilated duct to the vestibule. (See 'Introduction' above.)

●The cyst or abscess is incised with a 5 mm stab incision, 1.5 cm deep, in the introitus at or behind the hymnal ring. Loculations are broken down and a Word catheter is placed in the cavity, its balloon inflated with 2 to 3 mL of saline or water, and the end tucked into vagina. (See 'Procedure' above.)

●The catheter is left in place for at least four weeks to promote formation of an epithelialized tract for permanent drainage of glandular secretions, although epithelialization may occur as soon as three weeks. When the tract appears well-epithelialized, the catheter is removed. (See 'Follow-up' above.)