Bartholin Cysts – Is your Vulva Swollen?

Bartholin cysts are also known as Bartholin’s glands cysts. What are Bartholin’s glands? The Bartholin’s glands (or greater vestibular glands) are round, very small and non-palpable 2 pea-sized glands are located symmetrically at the posterior region of the vaginal opening and open into the vestibule via ducts at the 4 and 8 o’clock positions at the sides of the external orifice of the vagina.

They are important organs of the female reproductive system, first described in 1677 by a Danish anatomist called Caspar Bartholin Secundus. Their primary function is the production of a mucus secretion that aids in vaginal and vulvar lubrication during sexual arousal. 

What are Bartholin Cysts?

They are the most common cystic growths in the vulva. These cysts occur in the labia majora. About two per cent of women usually those in their 20s develop Bartholin’s duct cyst or gland abscess at some time in life. Abscesses are almost three times more common than cysts but with ageing, cysts are less likely to develop.

Obstruction of the Bartholin duct causes the gland to enlarge with mucus, resulting in a cyst. The cause of obstruction is usually unknown. Rarely, do the cysts result from an STI (e.g., gonorrhoea).

Symptoms of Bartholin Cysts

Most Bartholin gland cysts are non-tender, unilateral, and palpable near the vaginal orifice.

1. Vulvar asymmetry (from cysts distending of the affected labia majora).
2. Asymptomatic, but large cysts can be irritating.
3. Interference with sexual intercourse and walking. 
4. Cellulitis with localized erythema. 
5. Abscesses.
6. Severe vulvar pain.
7. Fever.
8. Vaginal discharge may be present
9. Sexually transmitted diseases may coexist.

How are Bartholin Cysts Diagnosed?

• Clinical evaluation

Diagnosis of Bartholin cysts is usually by physical examination. A sample of discharge, if present, may be tested for sexually transmitted infections. Abscess fluid should be cultured and for women above 40 years of age, a biopsy is recommended to exclude vulvar cancer. Cysts that have been present for years and have not changed in appearance do not require biopsy.

Bartholin Cysts Treatment

1. Sitz baths for mild Bartholin cysts

Soaking in a tub filled with a few inches of warm water (sitz bath) several times a day for three or four days may help a small, infected cyst to rupture and drain on its own.

Asymptomatic cysts do not require treatment. Mild symptoms may resolve when sitz baths are used.

2. Surgery for more severe symptoms and for all cysts in women > 40

Abscesses also require surgery because cysts often recur after simple drainage (I & D). Surgery aims to produce a permanent opening from the duct to the exterior. Usually, one of the following is done:

• The balloon catheter technique

A specially designed small flexible balloon-tipped catheter called the word catheter is inserted, inflated, and left in the cyst sac for 4 to 6 weeks- this procedure stimulates fibrosis and produces a permanent opening for future drainage.

Too much fluid used in inflating the catheter balloon causes pain and an unhappy patient who will demand that the catheter be removed immediately while too little fluid (or too large an incision) will allow the catheter to fall out.

• Marsupialization

With marsupialization, your provider cuts a slit into a Bartholin cyst, allowing it to drain. Then, they suture the edges of the cyst to the surrounding tissue to form a tiny pouch. The pouch allows the fluid from your Bartholin gland to drain freely.

Marsupialization has an excellent success rate of resolving Bartholin cysts for good. Bartholin cysts return after marsupialization in only 2% to 13% of cases. Allow two to four weeks for the wound to heal completely.

Plan to avoid the following activities for four weeks unless your provider instructs you differently:

• • Having sexual intercourse.
  • Inserting tampons.
  • Usage of scented soaps, lotions or powders that may irritate your wound.

• Gland excision

Surgery to remove the affected Bartholin’s gland may be recommended if other treatments have not been effective and Bartholin’s cysts or abscesses keep coming back.

This operation is usually carried out under general anaesthetic and takes about an hour to complete. You may need to stay in hospital for 2 or 3 days afterwards.

Risks of this type of surgery include bleeding, bruising and infection of the wound. If the wound does become infected, this can usually be treated with antibiotics prescribed by a GP.

3. Antibiotic therapy

Abscesses are sometimes also treated with oral antibiotic regimens that cover MRSA. Increasing resistance has been reported

• Timethoprin /Sulphamethoxazole(160/800)  800 mg twice a day.
• Amoxicillin/Clavulanate625 mg twice a day for 1 week) plus
• Clindamycin (300 mg 4 times a day for 1 week). 

Oral antibiotics should be used when cellulitis is also present; antibiotics should be chosen based on that region’s antibiogram. Inpatient admission for IV antibiotics should be strongly considered if patients have poorly controlled diabetes mellitus or are immunocompromised.

4. CO₂ laser 

A carbon dioxide laser can be used to create an opening in the skin of the vulva so the cyst can be drained. The cyst can then be removed, destroyed using the laser, or left in place with a small hole to allow fluid to drain from it.

In reported cases, the cysts healed with no scar formation and minimal incidence of recurrence.

5. Silver nitrate gland ablation

Silver nitrate is a mixture of chemicals sometimes used to burn (cauterize) blood vessels to stop bleeding. A small, solid stick of silver nitrate is used in silver nitrate gland ablation. A cut is made in the skin surrounding the vagina and the wall of the cyst or abscess.

The cyst or abscess is then drained and the stick of silver nitrate is inserted into the empty space left after draining the fluid. The silver nitrate causes the cyst cavity to form into a small, solid lump. After 2 or 3 days the silver nitrate and cyst remains are removed or may fall out on their own.

It’s possible for the silver nitrate to burn some of the skin of the vulva when it’s first used. 

6. Laser needle aspiration with or without alcohol sclerotherapy

During needle aspiration, a needle and syringe are used to drain the cyst. It is sometimes combined with a procedure called alcohol sclerotherapy, where the cavity is filled with a 70% alcohol liquid after being drained. This is left in the cyst cavity for 5 minutes and then drained out.

Rare Presentation of Bartholin Cysts

Endometriosis in the Bartholin gland without surgery in the perineal area is a rare presentation of extra-peritoneal endometriosis. So far, only five cases concerning endometriosis in the Bartholin gland have been reported in the literature.

Conclusion

The Bartholin’s glands are a crucial part of the female reproductive system that helps in vaginal lubrication A cyst may not require treatment if it’s small and doesn’t cause any symptoms. If the cyst does cause symptoms, seek treatment.