Bartholin gland cyst and abscess: Word catheter placement

INTRODUCTION — The Bartholin glands (also called the greater vestibular glands) are located bilaterally in the vulvar vestibule (figure 1), and blockage of the Bartholin ducts is a common etiology of a vulvar mass. The most common Bartholin masses are cysts or abscesses. The mainstay of management of a Bartholin mass is incision and drainage (I&D) with placement of a Word catheter (picture 1). A Word catheter allows the mass contents to drain and, over time, to form a fistulous tract around the catheter from the dilated duct or abscess to the vestibule to allow future drainage.

This topic will review the procedure for I&D and placement of a Word catheter for treatment of a Bartholin cyst or abscess. The anatomy of the Bartholin gland, diagnosis and management of a Bartholin cyst or abscess, and the management of other types of vulvar abscess are discussed in detail separately.

●(See "Bartholin gland masses".)

●(See "Vulvar abscess".)

INDICATIONS AND CONTRAINDICATIONS

●Indications – The indication for incision and drainage (I&D) and Word catheter placement is the presence of a Bartholin cyst or abscess (picture 2). It is generally used for patients with a first or second episode of a large mass (eg, ≥3 cm). (See "Bartholin gland masses", section on 'Management'.)

Patients who have failed one or two placements of a Word catheter are typically treated with marsupialization or gland excision. This is discussed in detail separately. (See 'Recurrence' below and "Bartholin gland masses", section on 'Management of recurrent masses'.)

●Contraindications – The stem of the Word catheter is latex, and thus use of this device is contraindicated in patients with latex allergy.

While not an absolute contraindication, it is often not possible to place a Word catheter in small (eg, <3 cm) masses.

PREPROCEDURE EVALUATION — The patient is evaluated prior to the procedure to confirm that the mass is a Bartholin cyst or abscess (figure 1), rather than another vulvar mass. (See "Bartholin gland masses", section on 'Differential diagnosis'.)

While Bartholin gland carcinoma is rare, patients in whom there is suspicion for malignancy (eg, mass with a solid component, cyst or abscess wall is fixed to surrounding tissue, persistent mass, postmenopausal status) require a biopsy. This is discussed separately. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Bartholin gland carcinoma' and "Bartholin gland masses", section on 'Biopsy'.)

EQUIPMENT AND INSTRUMENTS — Assemble the following supplies [1,2]:

●Sterile gloves.

●Sterilizing solution, such as povidone-iodine swab sticks, to prepare the surgical site.

●Local anesthetic, such as 1 or 2% lidocaine (without epinephrine). Oral or intravenous sedatives or analgesics may also be given if necessary.

●25- or 30-gauge needle and 3 mL syringe to inject the local anesthetic.

●Small forceps, which will be used to hold the cyst or abscess wall.

●Scalpel with a number 11 blade for performing a stab incision.

●Culture swab for sending sample of abscess contents for microbiologic identification and nucleic acid amplification testing of gonorrhea and chlamydia.

●Hemostat to break up loculations.

●Word catheter (picture 1). The balloon-tipped catheter can hold 3 to 5 cc of liquid. The total length of the catheter is typically 5 cm. Test the catheter to confirm there are no leaks when the balloon is filled.

●A small syringe containing 3 mL saline or water and attached to a small-gauge needle, for distending the catheter balloon.

●Gauze pads to control bleeding and effluents.

PROCEDURE — Incision and drainage (I&D) and Word catheter placement includes the following steps [1,2]:

●Position patient in dorsal lithotomy position.

●Prepare the area of the cyst or abscess with sterilizing solution.

●Inject 1 to 3 mL of local anesthetic to infiltrate the site planned for the stab incision. This site is usually at or behind the hymen.

●Immobilize the cyst or abscess by fixing it between the fingers of one hand.

●Incise the cyst or abscess with a number 11 blade to create a 5 mm stab incision, 1.5 cm deep, in the vaginal orifice at or behind the hymen (to prevent vulvar scarring). If the incision is too large, the catheter will fall out.

●Drain the cyst or abscess contents completely by breaking up loculations with the hemostat. Culture abscess contents with a culture swab and send for microbiologic identification. (See 'Equipment and instruments' above and "Bartholin gland masses", section on 'Abscess cultures'.)

●Place the Word catheter through the incision, as deep as possible. Make sure the catheter is in the duct cavity. Holding onto the cyst wall with forceps helps to prevent creation of a false passage separate from the cavity.

●Distend the balloon of the Word catheter with 2 to 3 mL of saline or water injected into the catheter hub with a needle and syringe.

●Tuck the end of the Word catheter into the vagina to minimize discomfort (figure 2).

●For selected patients at risk of infection, empiric broad spectrum antibiotics may be given after placement of the Word catheter. (See "Bartholin gland masses", section on 'Role of antibiotics'.)

COMPLICATIONS — Complications are uncommon and include infection, bleeding, and scarring. The latter can result in dyspareunia and distortion of anatomy, although this is rare [3].

In one retrospective study including 64 patients undergoing Word catheterization, postoperative complications were observed in 2 patients (3 percent), all of whom had a postprocedure infection [4].

RECURRENCE — After management with a Word catheter, recurrence occurs in approximately 2 to 15 percent of patients [5-8]. Management of recurrence, with a second incision and drainage (I&D) and Word catheter placement, or another procedure (marsupialization, gland excision) is discussed separately. (See "Bartholin gland masses", section on 'Management of recurrent masses'.)

POSTPROCEDURE CARE

Patient counseling — Patients are counseled to:

●Wear a peripad to absorb discharge.

●Maintain pelvic rest (ie, nothing in the vagina) while the Word catheter is in place.

●Use sitz baths and mild analgesics to treat pain if present during the first postoperative day or two.

●Call to be examined if experiencing increasing swelling, pain, vaginal discharge, or fever.

Clinical course — Clinical course is as follows:

●The catheter is left in place for at least four weeks to promote formation of an epithelialized tract for permanent drainage of glandular secretions. Epithelialization may occur as soon as three weeks.

●In patients with a catheter in place who have persistent discomfort despite analgesics, we remove 0.5 to 1 mL of fluid from the balloon.

●If the catheter falls out, determine further treatment based on examination results. With normal wound healing and no sign of recurrence, no further treatment is necessary [9]. If the catheter falls out before the tract is epithelialized and the cyst or abscess remains, the patient may need a repeat Word catheter placement or another procedure (eg, marsupialization, gland excision). (See "Bartholin gland masses", section on 'Procedure technique'.)

●When the tract appears well epithelialized, remove the catheter by deflating the balloon in the office.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Bartholin gland cyst (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Indications – Management with incision and drainage (I&D) and Word catheter placement is generally used for patients with a first or second episode of a large (eg, ≥3 cm) Bartholin cyst or abscess (picture 2). The choice of Word catheterization compared with other procedures (eg, marsupialization, gland excision) is discussed separately. (See 'Indications and contraindications' above and "Bartholin gland masses", section on 'Initial management'.)

●Contraindications – The stem of the Word catheter is latex, and thus use of this device is contraindicated in patients with latex allergy. (See 'Indications and contraindications' above.)

●Preprocedure evaluation

•The patient is evaluated prior to the procedure to confirm that the mass is a Bartholin cyst or abscess (figure 1), rather than another vulvar mass. (See 'Preprocedure evaluation' above.)

•Patients in whom there is suspicion for malignancy (eg, mass with a solid component, cyst or abscess wall is fixed to surrounding tissue, persistent mass, postmenopausal status) require a biopsy. This is discussed in detail separately. (See "Bartholin gland masses", section on 'Biopsy'.)

●Procedure (see 'Procedure' above)

•Inject 1 to 3 mL of local anesthetic to infiltrate the site planned for the stab incision.

•The cyst or abscess is incised with a number 11 blade to create a 5 mm stab incision, 1.5 cm deep, in the vaginal orifice at or behind the hymen.

•Drain the cyst or abscess contents completely by breaking up loculations with the hemostat.

•Culture abscess contents with a culture swab and send for microbiologic identification.

•A Word catheter is placed in the cavity, its balloon distended with 2 to 3 mL of saline or water, and the end tucked into vagina (figure 2).

●Complications – Complications are uncommon and include bleeding, infection, and scarring. (See 'Complications' above.)

●Follow-up – The catheter is left in place for at least four weeks to promote formation of an epithelialized tract for permanent drainage of glandular secretions, although epithelialization may occur as soon as three weeks. When the tract appears well epithelialized, the catheter is removed. (See 'Clinical course' above.)

●Recurrence – Recurrence occurs in approximately 2 to 15 percent of patients. Management of recurrence with a second I&D and Word catheter placement or another procedure (marsupialization, gland excision) is discussed separately. (See "Bartholin gland masses", section on 'Management of recurrent masses'.)