Describe bartholin's cyst and abscess — its aetiology, clinical features and management.

Definition

A Bartholin's cyst is a retention cyst formed by obstruction of the Bartholin's (greater vestibular) gland duct, with accumulation of secretion; a Bartholin's abscess is an infected, suppurating cyst.

Cause

Blockage of the duct (by inflammation/inspissated secretion); the abscess is usually caused by E. Coli, gonococcus, staphylococci and anaerobes.

Clinical Features

Cyst — a painless, tense, cystic swelling in the posterolateral part of the introitus (lower third of the labium majus). Abscess — a painful, hot, red, tender swelling with difficulty in sitting/walking, sometimes with fever.

Management

• Small asymptomatic cyst — observation.
• Symptomatic cyst — marsupialisation (creating a permanent new duct opening) to preserve gland function.
• Abscess — incision and drainage (or marsupialisation) with antibiotics; a Word catheter may be placed to keep the cavity draining.

Complications and Recurrence

An untreated abscess may rupture spontaneously or recur; recurrence after simple incision is common (hence marsupialisation is preferred), and a chronic cyst may cause dyspareunia. Cellulitis of the vulva and, rarely, necrotising infection can complicate an abscess.

Anatomy and Differential Diagnosis

The Bartholin's (greater vestibular) glands lie in the posterolateral wall of the lower vagina and secrete lubricating mucus through a duct opening into the vestibule. The swelling is distinguished from a cyst of the canal of Nuck, an inclusion/sebaceous cyst, and — in the elderly — carcinoma of the gland.

A Note on WHY Marsupialisation Is Preferred to Simple Incision

A useful concept is understanding why a Bartholin's abscess must not simply be incised and drained, but marsupialised — and why this apparently fussy distinction matters. The underlying problem is obstruction of the duct of the gland: the gland continues to secrete, the secretion cannot escape, and a cyst forms — which may then become infected and form an abscess. If one simply incises the abscess and lets the pus out, the cavity collapses and the incision heals over — recreating the very obstruction that caused the problem, so the cyst or abscess promptly recurs. Marsupialisation solves this by creating a permanent new opening: after incising the cyst, the cyst wall is everted and its lining is sutured to the overlying vaginal/vulval skin, so that the cavity becomes a pouch (a 'marsupium') that remains open and epithelialises. The gland can then continue to secrete and drain normally — preserving its function (important for lubrication) while preventing recurrence. An alternative is a Word catheter, left in place for several weeks to allow an epithelialised tract to form. One further rule matters: in a woman over 40, the lesion must be biopsied or excised, because a Bartholin's gland carcinoma, though rare, can masquerade as a cyst.

Marsupialisation prevents recurrence better than simple incision.

• Bartholin's cyst: retention cyst from obstruction of the duct of the greater vestibular gland (at the posterior vestibule, 4 and 8 o'clock); abscess if infected.
• Abscess presents with an acutely painful, tender, fluctuant swelling with difficulty in sitting and walking; organisms include E. Coli, staphylococci and gonococcus/chlamydia.
• Simple incision and drainage recurs — the duct re-obstructs; marsupialisation creates a permanent drainage opening and preserves gland function.
• Alternative: a Word catheter left for 4–6 weeks to epithelialise a new tract; add antibiotics if there is cellulitis.
• In a woman over 40, biopsy or excise — to exclude the rare Bartholin's gland carcinoma.

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