السلام عليكم

أخي د. نبيل..

فتاة غير متزوجة , ظهرت معها الأعراض التالية

1- Swellling between the clitoris and rt. labia majora
2- Swelling @ the rt. labia majora
الانتفاخ بسيط و هو من الناحية الخارجية يعني مو من ناحية الـ vagina , مع وجود ألم اذا ضغطت عليهم حتى لو ضغط بسيط
3- pain @ rt. groin & rt. pubic area اذا ضغطت على هذه المنطقة
4- Slight swelling @ the rt. pubic area


هذه الأعراض لها يومين فقط و ظهرت فجأة مو تدريجياً

سؤالي: هذه الأعراض مالها علاقه بـ Bartholin's Gland Abscess صح؟
هل ممكن تكون هذه أعراض inguinal hernia ? و اذا لا ايش ممكن تكون؟

و أعتذر عن استخدامي للكلمات الانجليزية , فهي تسهل علي عرض المشكلة منعاً للإحراج

و جزاك الله خيراً..

اختي الفاضله
نعم هو اقرب شيئ الي ما تصفي و لا اعتقد انها فتق اربي لان يومين قليل ان تظهر هكذا و الالم المصاحب اعلي المنطقة يمشي مع التهاب الغدد الليمفاوية نتيج هذا الخراج و اليكي نبذه بسيطة عنه مع العلاج و عليا اخد مضاد حيوي في اسرع وقت

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.
تمنياتي بالشفاء العاجل و لا داعي للاسف و ان اردتي استفسار انا موجود لمدة ساعة الان
د.نبيل

دكتور هل تقصد أنها أقرب لأن تكون Bartholin's Gland Abscess ؟

مع العلم أنه لا توجد أي أعراض من ناحية الـvagina أو الـ labia minora

و اذا كان كذلك , هل يمكن لغير المتزوجة أن تصاب بها؟

و شكراً على ردك السريع

نعم اقصد ذلك و يؤيد انه التهاب الالم و الزمن القصير للشكوي و احمرار المنطقه و كذلك التهاب الغدد الليمفاوية و يأتي ايضا بعض الالتهابات الاخري التي لا يمكن تفريقها الا بالكشف الدقيق
علي اي حال هو التهاب و يجب اخد 3 مضاد حيوي كما ذكرت عالية لتغطية كل البكتريا و سوف تلاحظ التحسن السريع .
هل انتي طالبة طب او طبيبه و هل قراتي المقال اعلاه جميعه ?
ان اردتي احط المقال كامل عن امراض هذه الغدد المختلفة

أخي هل تقصد أن Bartholin's Gland Abscess هو مجرد differential diagnosis ؟

نعم قرأت كل المقال

نعم اجدهم و هناك الكثير DD of Valvovaginal masses
تحبي انزل كل المقال ?

ياريت اذا مافي كلافة

هل علي مراجعة الطبيبة بأسرع وقت؟

الافضل تزوري طبيبة او تبدئي مضاد حيوي ان ده ما سيفعلة الان
لحظة هنزل كل الموضوع

Disorders of Bartholin's gland

Katherine T Chen, MD, MPH


UpToDate performs a continuous review of over 350 journals and other resources. Updates are added as important new information is published. The literature review for version 14.2 is current through April 2006; this topic was last changed on May 4, 2005. The next version of UpToDate (14.3) will be released in October 2006.

INTRODUCTION — The two Bartholin's glands secrete mucus to provide moisture for the vulva; they are the homologue of the bulbourethral glands in the male. These glands are located bilaterally in the vulvovaginal area at approximately the four and eight o'clock positions on the posterior-lateral aspect of the vaginal orifice (show figure 1). Each gland is approximately one-half centimeter (cm) in size and drains into a duct 2.5 cm long. The ducts emerge onto the vestibule, one at each side of the vaginal orifice, just below the hymenal ring. A normal Bartholin's gland is not palpable, except possibly in very thin women.

Cysts and abscesses are the most common disorders of the Bartholin's glands, occurring in 2 percent of women; carcinoma is rare [1]. However, many vaginal and vulvar lesions mimic Bartholin's gland disorders and should be considered in the differential diagnosis of a vulvovaginal mass (show table 1).

BARTHOLIN'S GLAND CYSTS — Chronic inflammation can obstruct the orifice of the Bartholin's gland duct. This leads to cystic dilatation of the duct, but not the gland, proximal to the obstruction.

Clinical manifestations and diagnosis — Bartholin's cysts average from 1 to 3 cm in size and are usually asymptomatic. Larger cysts may be associated with vulvar pain, discomfort during sexual intercourse, or difficulty sitting or ambulating.

The diagnosis is clinical and based upon findings of a soft, painless mass in the medial labia majora or lower vestibular area. Most such cysts are detected during a routine pelvic examination or by the woman, herself.

Treatment — 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 (see "Bartholin's gland carcinoma" below). Bartholin's cysts are usually sterile, thus they do not require antibiotic therapy [1].

Cysts that are disfiguring or symptomatic can be treated by the techniques illustrated below. There are no large clinical trials that provide data for guiding therapeutic decisions.

Incision and drainage — Incision and drainage may be performed with or without packing. The cyst should be lanced at or behind the hymenal ring to prevent vulvar scarring. However, we do not recommend this procedure alone since there is a tendency for cysts to recur because outflow is obstructed when the incised tissue ees reapproximate.

Word catheter — Incision and drainage can be supplemented by placement of a Word catheter (show picture 1). This catheter is a balloon-tipped device that can be placed into the cyst cavity immediately after incision and drainage (show figure 2). The bulb of the catheter is then inflated and left in place for at least two to four weeks to promote formation of an epithelialized tract for drainage of glandular secretions; the end of the catheter is tucked into the vagina to minimize discomfort. The catheter can be removed in the office when the tract appears well epithelialized. In our practice, we try this method first as it can be performed as an outpatient procedure in the office or emergency ward setting under local anesthesia. (See "Word catheter placement for treatment of Bartholin's cysts and abscesses").

Marsupialization — Marsupialization refers to a procedure whereby a new ductal orifice is created by excising a 1 to 2 cm oval portion of the vulvar roof of the cyst behind the hymenal ring. The proximal duct wall is then everted onto the introital mucosa with sutures, thus creating a fenestration for egress of glandular secretions. This procedure can often be performed with local anesthesia (show figure 3) [2]. We resort to this method after failure of one or two placements of a Word catheter.

Sclerotherapy — Silver nitrate sticks can be inserted into the cyst cavity to necrotize the cyst wall. After incision and drainage, a crystalloid silver nitrate stick 0.5 cm in length and diameter is placed deep into the cavity. Mild burning may occur. After 48 hours, the patient returns to the office and the vulva is cleansed to reveal the incision site. Necrotized tissue with the remaining silver nitrate particles are removed.

In one report of 52 patients with either a Bartholin's cyst or abscess treated with this procedure, all patients showed complete healing within 15 days, although two women had recurrences within the first two months [3]. One of these patients was treated with excision and the other by repetition of the same method with no recurrences. In addition, a randomized controlled trial found silver nitrate insertion was as effective as excision of Bartholin's cysts or abscesses [4]. Comparison of sclerotherapy with more traditional and less invasive procedures than excision has not been performed. Studies that compare sclerotherapy with incision and drainage and Word catheter insertion and/or with marsupialization will help in deciding the role of sclerotherapy.

Excision — Excision of the entire Bartholin's gland and duct is the definitive procedure for both cysts and abscesses. It is usually considered after other methods have repetitively failed because it is not an office procedure and has higher morbidity, including excessive bleeding, hematoma formation, cellulitis, and dyspareunia.

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.