EM@3AM: Bartholin’s Abscess

Welcome to EM@3AM, an emDOCs series designed to foster your working knowledge by providing an expedited review of clinical basics. We’ll keep it short, while you keep that EM brain sharp.

Answer: Bartholin’s Abscess

Background:

• Bartholin’s glands^[1]
  • Pea-sized glands located bilaterally at the 4 o’clock and 8 o’clock positions of the posterior introitus
  • Provide lubrication to the vagina by secreting mucus via ducts into the introitus
  • If normal, usually cannot be felt by simple palpation

Epidemiology:

• 2% of women have a lifetime incidence of a Bartholin’s cyst or abscess^[3]
• Much more common in reproductive-age women

Pathogenesis:

• When a Bartholin’s duct is obstructed, mucoid secretions cannot be released^[3,4]
• Secretions build up inside the duct and eventually form a Bartholin’s cyst^[4]
• If the cyst becomes infected, it develops into a Bartholin’s abscess
  • However, an abscess does not always need a cyst to precede it
• Initially thought to be caused solely by STI organisms, but that is no longer the case^[3]

History:

• Important points to consider^[4,5]

• • How long have symptoms been occurring?
  • What is the extent of the patient’s pain? Is it occurring with simple movements such as walking or intercourse?
  • History of prior Bartholin’s cyst or abscess?
  • Obtain a thorough sexual history to differentiate various genital lesions

Physical Exam:^[3,5]

• Perform both an external and internal exam to determine extent of patient’s symptoms
• Important points to consider during your exam:

• • Are there multiple lesions?
  • Is the lesion painful?
  • Are there any overlying skin changes?
  • Are there systemic symptoms?
  • If there is vaginal discharge or cervical motion tenderness, an STI etiology may be more likely

Clinical Presentation:^[5]

• Usually painful, unilateral, and located at the 4 o’clock or 8 o’clock position
  • A Bartholin’s cyst, while located in the same position, is usually not painful
• Fluctuant mass with possible induration/erythema on overlying skin
• May already be draining purulent fluid

Differential Diagnosis:

• Soft Lesion: Bartholin’s cyst, Bartholin’s abscess, Skene’s duct cyst, Epidermal inclusion cyst^[3,5]
• Firm Lesion: Leiomyoma, Lipoma, Squamous cell carcinoma^[3,5]

Management:

• Rarely resolves on its own. If a patient has pain, intervention will likely be needed^[6]
• Treatment begins with an incision and drainage. Afterwards, a Word catheter or Jacobi ring must be used
• I&D: This step will be like any other I&D
• Anesthetize the area with lidocaine
• Using a #11 blade, make a vertical incision posterior to the labia minora. This location will prevent notable scarring
• Break up loculations with a hemostat to allow proper drainage
• Send off a culture after collecting purulent fluid on a culture swab
• However, a Bartholin’s abscess I&D is not a definitive treatment^[7]
  • ~13% of patients will have recurrent abscess
  • This is due to premature closure of the tract which prevents further drainage
• To allow continued drainage and thereby prevent recurrence, a Word catheter or Jacobi ring should be placed
  • Word catheter: Short, rubber catheter with a balloon tip^[8]

• Word catheter provides a tract for continued drainage of the abscess^[10]
  • Pus does not flow out through the catheter itself. It drains from the space between the mucosa and rubber catheter
• Steps to place a Word catheter^[11,12]
  • Once the incision is made and fluid is drained, place the catheter through the opening
  • After the catheter is placed, inflate the balloon with saline. This will prevent it from being dislodged when the patient goes home
  • The Word catheter stays in place for 2-4 weeks until it is removed
  • For removal: Balloon is deflated, and the catheter is simply pulled from the abscess cavity

• To place a Jacobi ring:^[13]
  • Inject lidocaine
  • Make an initial stab into the mucosa
  • Break up loculations with a hemostat
  • Create a tract with the hemostat and make another stab incision into the other end of the tract
  • Take tubing from a butterfly catheter (cut off the needle end) and pass it through the tract you created
  • Tie the two ends of the tubing, but be sure not to tie too tightly

• Antibiotics^[11]
  • Should only be given if a patient has a recurrent Bartholin’s abscess or if there is overlying cellulitis
  • Should cover Gram-positive organisms, including MRSA
  • Choices include Bactrim 800mg/160mg BID x7 days or Doxycycline 100mg BID x7 days
  • Consider IV antibiotics for immunocompromised patients or those with poorly controlled diabetes
• For further care at home, the patient should do Sitz baths and refrain from intercourse^[8]
• Patient should follow up with an OB/GYN after discharge due to risk of recurrence

Take Home Points:

• If a patient presents with a painful fluctuant mass near the introitus and you suspect a Bartholin’s abscess, intervention is almost always needed
• A simple I&D is usually not a definitive treatment for a Bartholin’s abscess
• A Word catheter or Jacobi ring can prevent recurrence of a Bartholin’s abscess
• Antibiotics are needed for recurrent abscesses, overlying cellulitis, or an immunocompromised patient

Further Reading: