BARTHOLIN'S GLAND ABSCESSES — Bartholin's gland ducts and cysts can become infected and form abscesses (show picture 2).

Etiology — Abscesses of Bartholin's gland are the result of polymicrobial infections, but they are also occasionally associated with sexually transmitted diseases. These relationships are illustrated in the following reports:

Aspirates of 28 Bartholin's gland abscesses were studied for aerobic and anaerobic bacteria [5]. Sixty-seven bacterial isolates (43 anaerobic and 24 aerobic and facultative) were recovered, accounting for 2.6 isolates per specimen (1.7 anaerobic and 0.9 aerobic and facultative). Single bacterial isolates were recovered in six infections. The predominant aerobic and facultative bacteria were Escherichia coli and N. gonorrhoeae; the most common anaerobic bacteria were Bacteroides species.
A study of 62 women with Bartholin's gland abscesses undergoing marsupialization found four N. gonorrhea and one C. trachomatis isolates [6]. In addition, bacteriological examination of the uterine cervix yielded another case of N. gonorrhea and four more of C. trachomatis.
An emergency department-based case-control study to examine demographic risk factors for Bartholin's gland abscess noted that the risk factor profile for this condition is similar to that of most sexually transmitted diseases [7].
In view of these findings, women with a Bartholin's gland abscess should have both routine cultures (for anaerobic and aerobic bacteria) and specialized tests for gonorrhea and chlamydia taken of the abscess in conjunction with surgical therapy. Examination and treatment of their sexual partners or referral of the partners should also be recommended when a sexually transmitted disease is uncovered. (See "Treatment" belowSee "Treatment" belowSee "Treatment" below). (See "Neisseria gonorrhoeae infections in women" and see "Genital Chlamydia trachomatis infections in women")

Clinical manifestations and diagnosis — The diagnosis is based upon characteristic clinical findings. Women usually present with such severe pain and swelling that they are unable to walk, sit, or have sexual intercourse. On examination, the lesion appears as a large, tender, soft or fluctuant mass in the medial labia majora or lower vestibular area, occasionally with erythema, edema, and pointing of the abscess.

Treatment — Immediate pain relief occurs with drainage of pus. Women with abscesses that point and rupture spontaneously may not require broad spectrum antibiotics and may only need sitz baths and pain medication. An unruptured abscess, on the other hand, can be managed by placement of a Word catheter, marsupialization (show figure 2), or silver nitrate insertion plus broad spectrum antibiotics (see "Treatment" abovesee "Treatment" abovesee "Treatment" above, section on Bartholin's cysts).

Antibiotic regimens which we use are one dose of ceftriaxone (125 mg intramuscularly) or cefixime (400 mg orally) to cover E. coli and N. gonorrhoeae plus clindamycin (300 mg orally four times per day for seven days) to cover anaerobic organisms. The regimen may have to be modified based upon culture results (eg, if C. trachomatis is present, administer azithromycin [1 g orally as a single dose]).

A chronic Bartholin's abscess with loss of mucus secretion rarely results in vaginal dryness or dyspareunia. However, a scar or mass that exists after the acute infection has subsided may cause discomfort. It may be necessary to excise the entire gland in these cases.

BARTHOLIN'S GLAND CARCINOMA — Primary carcinoma of the Bartholin's gland is rare, accounting for less than 5 percent of all vulvar malignancies. Most cancers arising from the Bartholin's gland and duct are adenocarcinomas or squamous cell carcinomas; adenoid cystic carcinoma, transitional cell carcinomas and adenosquamous make up the remainder. The incidence is highest among women in their 60s. Most affected women do not have a history of a prior diagnosis of other Bartholin's gland disorders.

Clinical manifestations — Bartholin's gland cancers can present in a variety of ways.

The gland may appear solid, cystic, or abscessed.
The gland may be fixed to the underlying tissue.
A solid area may be noted within a Bartholin's cyst.
The most common presentation is a painless vulvar mass. Benign solid tumors of Bartholin's gland are even rarer than carcinoma, with only six cases reported in the English language literature since 1966 [8].

Diagnosis — The diagnosis of Bartholin's gland carcinoma is based upon histological examination of a biopsy specimen. It is generally recommended that women over age 40 with a Bartholin's cyst or abscess undergo excision of the gland to exclude the possibility of an underlying carcinoma [1]. Excision should also be considered if a palpable mass persists after drainage of a cyst.

In contrast, a large hospital-based regional tumor registry and medical records from a tertiary hospital over a 24 year period reported that the incidence of Bartholin's gland carcinoma was exceeding rare in all women (0.023 per 100,000 woman-years in premenopausal women and 0.114 per 100,000 woman-years in postmenopausal women) [9]. Of 13 postmenopausal women (mean age 65.4 years) with Bartholin gland enlargement admitted to the tertiary care center, four had excisions and the remainder had drainage or marsupialization. None of the patients treated with drainage or marsupialization were listed subsequently in the tumor registry as developing Bartholin gland cancer during a median surveillance of 10.3 years (range 1.7 to 14.4). Therefore, the authors advocated a drainage procedure and selective biopsy as the initial evaluation of postmenopausal women with Bartholin's gland enlargement. Women with recurrent disease should all undergo excisional biopsy.

In our practice, we drain and biopsy the first Bartholin cyst/abscess in women over age 40 and recommend complete excision for recurrent disease.

Prognosis — Metastatic disease is common in cancers of Bartholin's gland because of the rich vascular and lymphatic network of the vulva. Nevertheless, a study summarizing 30 years' clinical experience and involving 36 patients with Bartholin's carcinoma reported a five-year survival rate of 85 percent [10].

Treatment — Women with Bartholin's gland carcinoma should be referred to a gynecologic oncologist. (See "Treatment and prognosis of vulvar cancer" section on Bartholin's gland).

SUMMARY AND RECOMMENDATIONS

Bartholin's glands are located bilaterally in the vulvovaginal area at approximately the four and eight o'clock positions on the posteriorolateral aspect of the vaginal orifice (show figure 1).
Cysts and abscesses are the most common disorders of the Bartholin's glands; carcinoma is rare. Cysts average from 1 to 3 cm in size and are usually asymptomatic, whereas abscesses are very tender and may be fluctuant. The most common presentation of cancer is a painless vulvar mass in a postmenopausal woman.
No intervention is necessary for asymptomatic Bartholin's cysts, except in women over age 40 in whom a biopsy should be considered to exclude a carcinoma.
We suggest incision and drainage supplemented by placement of a Word catheter for management of symptomatic cysts and abscesses. We try this method first as it can be performed as an outpatient procedure in the office or emergency ward setting under local anesthesia and has a lower rate of recurrence than incision and drainage alone.
In addition, women with a Bartholin's gland abscess should have both routine cultures (for anaerobic and aerobic bacteria) and specialized tests for gonorrhea and chlamydia taken of the abscess in conjunction with surgical therapy. Antibiotic regimens which we use are one dose of ceftriaxone (125 mg intramuscularly) or cefixime (400 mg orally) to cover E. coli and N. gonorrhoeae plus clindamycin (300 mg orally four times per day for seven days) to cover anaerobic organisms. The regimen may have to be modified based upon culture results (eg, if C. trachomatis is present, administer azithromycin [1 g orally as a single dose]).
We perform marsupialization, which is a more invasive procedure, after failure of one or two placements of a Word catheter.
In women over age 40, we drain and biopsy the first Bartholin cyst/abscess and recommend complete excision for recurrent disease. Excision should also be considered if a palpable mass persists after drainage of a cyst. Others have suggested that women over age 40 with a Bartholin's cyst or abscess undergo excision of the gland to exclude the possibility of an underlying carcinoma.