Epidemiology

Cysts or abscesses are usually unilateral. They occur in about 2% of women. Abscesses are probably about 3 times as common as cysts. The most common age of presentation is in the 20s.

Risk factors

• They usually occur in women who are nulliparous or of low parity.
• It is said that the risk factors are as for the risks of sexually transmitted infections but, as will be discussed below, the incidence of Neisseria gonorrhoeae in cultures is very much lower than was originally thought.

History

• Onset is rapid over a matter of days or even hours.
• There is initially labial oedema before a swelling forms.
• The swelling may be very painful and there is superficial dyspareunia.
• If the cyst or abscess bursts spontaneously there is sudden relief of pain.
• Small cysts may be asymptomatic and discovered incidentally - for example, when performing a routine cervical smear.

Examination

• The patient's gait is a wide-legged swagger.
• There is usually a unilateral labial mass that may be as large as a hen's egg; it may be soft and fluctuant, or tense and hard.
• Inguinal nodes may be palpable if it is infected and there may be fever, but this affects fewer than a third.
• If the cyst or abscess bursts, there may be little to find.

Investigations

A swab should be taken from the contents of the cyst; often the organisms that are cultured, even from the contents of an abscess, are skin commensals rather than pathogens.

Infecting organisms

There is remarkably little literature on organisms grown from these abscesses.
A wide variety of organisms has been reported, but Chlamydia trachomatis seems to be growing in importance, perhaps as appropriate culture techniques are used more often.

• Most infections seem to be by a single organism with a predominance of anaerobic bacteria.^[1] Of the 28 cases from North London with 25 cultures, no mention is made of gonococcus.
• Gonococcus is mentioned in an American paper, but not with the frequency that textbooks seem to suggest.^[2]
• A series from Japan showed 219 cultures from 224 cases and gonococcus was not mentioned.^[3]
• A Dutch study found gonococcus in 4 of 77 patients.^[4]
• An American study grew flora from 24 of 34 abscesses (71%) and, of these, 4 were gonococci.^[5] These figures belie the statement that 'N. gonorrhoeae is the most commonly cultured organism, reported in up to 80% of abscesses'.^[6]
• A mini-meta-analysis of the 4 series in which numbers were given, shows 365 patients with 331 positive cultures of which 8 were for N. gonorrhoeae. This means that culture was positive in 90.7% but the gonococcus was isolated in 2.4% of cultures from 2.2% of patients.

The true frequency of gonococcus in Bartholin's abscesses may vary significantly between countries.

Differential diagnosis

• Sebaceous cyst - possibly infected.
• Over the age of 40, carcinoma of vulva should be considered.
• Lipomata can occur on the labia majora.
• Sexually transmitted diseases may also be present.

Management

If the cyst is small and not causing a problem no action should be taken. The exception is in patients over 40 years of age in whom some suggest it should be excised. Histology must be obtained to exclude malignancy. If there are no features of infection, antibiotics are not required and culture is usually sterile. Simple incision of the cyst often results in recurrence and is not recommended.

Marsupialisation

This has been the definitive procedure of choice for many years and many gynaecologists still regard it as the best technique.

• It can be performed under local anaesthesia although general anaesthetic is often used.
• A vertical elliptical incision is made just inside or just outside the hymenal ring.
• An oval wedge of skin from the vulva and cyst wall is removed.
• Loculations are broken down with the gloved finger and the cyst wall is sewn to the adjacent skin using interrupted sutures.
• A large cyst may be packed with ribbon gauze in flavine. The cyst is laid open and will shrink and epithelialise over the next 7 to 14 days. This prevents recurrence.

Catheter insertion

A more recent technique that is gaining popularity is a balloon catheter.^[7][8]

• After the usual preparation and infiltration with local anaesthetic, a stab is made into the cyst, 1 to 1½ cms deep.
• An instrument is used to break up loculations and, after the cyst has been drained, the Word catheter is passed into it; this is a small rubber catheter with an inflatable tip.
• The balloon is inflated with water or lubricating gel as it holds its pressure better than air and the other end is passed into the vagina.
• The catheter is left in situ for up to 4 weeks for complete epithelialisation of the new tract.
• The catheter is removed by deflating the balloon, and over time the resulting orifice will decrease in size and become unnoticeable. Recent research at St. George's Hospital in London found it to be a safe and effective alternative to marsupialisation.^[9]

Other techniques include incision and curettage of the cavity, application of silver nitrate to the abscess cavity, insertion of a plastic (Jacobi) ring or use of a carbon dioxide laser.^[10][11] All these techniques are less popular.

Complete excision of the gland should be avoided unless malignancy is suspected. This can cause considerable blood loss and should be performed in an operating theatre. Bartholin's gland cancer is exceedingly rare in all women, including postmenopausal women. There is little evidence to justify excision. Drainage and selective biopsy may be sufficient as initial management.^[12] If antibiotics are required, metronidazole in combination with amoxicillin is appropriate.

Prognosis

There is a high rate of recurrence (2-25%).^[10] As yet, no definitive advice as to choice of procedure to minimise this is available. Recurrence is highest after aspiration alone.

Historical note

Caspar Bartholin was born in Copenhagen in 1655. He came from an eminent family and started his medical studies in 1671 at the age of 16. In 1674, at the age of 19, the King appointed him as Professor of philosophy. He described the glands that bear his name in 1677 and died in 1738.