Rosen & Barkin's 5-Minute Emergency Medicine Consult (95 page)

• Arterial Gas Embolus
  
• Decompression Sickness
  
• Hyperbaric Oxygen Therapy
  

CODES

• 993.2 Other and unspecified effects of high altitude
  
• 993.3 Caisson disease
  
• 993.9 Unspecified effect of air pressure
  

BASICS

• The Bartholin glands are located inferiorly on either side of vaginal opening:
  
  • Ducts open on sides of labial vestibule.
    
• Obstruction of duct produces a usually painless cyst:
  
  • Infection of cyst results in abscess formation.
    

Most common in women aged 20–40 yr

• Anaerobic and aerobic microflora normally found in vagina:
  
  • Bacteroides species
    
  • Peptostreptococcus
    species
    
  • Escherichia coli
    
  • Other gram-negative organisms
    
• Occasionally
  Neisseria gonorrhoeae and Chlamydia trachomatis
  

DIAGNOSIS

• Swollen, painful labia
  
• Tender, fluctuant mass on posterolateral margin of vestibule of vagina
  
• Warmth, erythema
  

Acute onset:

• Painful, unilateral labial swelling
  
• Pain with sitting, walking
  
• Dyspareunia
  

• Bartholin abscess:
  
  • Tender, fluctuant, unilateral labial mass
    
  • Surrounding erythema, warmth
    
  • Fever uncommon
    
• Bartholin cyst:
  
  • Painless, unilateral labial mass
    

Diagnosis based on findings of tender, localized, fluctuant mass in region of Bartholin gland

• Culture material from abscess for gonorrhea and chlamydia.
  
• Culture cervix for gonorrhea and chlamydia.
  

Generally not indicated

• Bartholin cyst
  
• Carcinoma of Bartholin gland (rare)
  
• Perineal hernia
  

TREATMENT

• Prompt incision and drainage using local anesthesia with patient in lithotomy position
  
• Narcotic analgesia for patient comfort
  
• Alternative approaches include:
  
  • Simple incision and drainage
    
  • Word catheter method
    
  • Marsupialization
    
• Simple incision and drainage:
  
  • After local anesthesia, palpate abscess between thumb and index fingers.
    
  • Spread vulva apart and make stab incision on
    mucosal
    surface of abscess, parallel to hymenal ring.
    
  • When incising abscess, 2 tissue layers must be penetrated:
    
    • 1st the labial mucosa
      
    • Then abscess wall
      
    • Free flow of pus indicates penetration of abscess wall.
      
  • Pack wound with gauze.
    
  • Follow-up in 24–48 hr for removal of packing.
    
  • Start sitz baths after 24 hr.
    
  • Consider referral for marsupialization to avoid recurrence.
    
• Word catheter method:
  
  • Use small, inflatable, bulb-tipped Word catheter to treat abscess.
    
  • May avoid recurrence and make marsupialization unnecessary
    
  • Stab wound is made as with simple incision and drainage:
    
    • It should be just large enough to easily admit catheter so that balloon does not fall out after inflation.
      
  • After inserting bulb tip of catheter, inflate balloon by injecting 2–4 mL water using 25G needle (to minimize size of puncture):
    
    • Overinflation may cause patient discomfort
      
    • Remedied by withdrawing some water from balloon
      
  • Sitz baths may be started after 24 hr.
    
  • Follow-up in 2–4 days.
    
  • Leave catheter in place for 6–8 wk until epithelialization is complete; after device is removed, gland resumes normal function.
    
  • Common for catheter to fall out prematurely:
    
    • If this occurs, catheter may be reinserted or abscess can heal as with simple incision and drainage.
      
• Marsupialization:
  
  • Procedure allows for a permanent fistula by suturing wound edges of abscess cavity to edges of labial mucosa:
    
    • Technically more challenging in ED and better reserved for specialist.
      
  • Excise an ellipse of labial mucosa that overlays cyst cavity.
    
  • Incision and drainage of abscess
    
  • Evert edges of abscess and suture them to labial epithelium using absorbable suture:
    
    • Opening will shrink but remain patent.
      
    • Packing is not needed.
      
  • Start sitz baths in 24–48 hr.
    
  • Follow-up within 1 wk.
    
• Antibiotics not necessary after incision and drainage:
  
  • If mild cellulitis present or patient immunocompromised, broad-spectrum coverage may be started.
    
  • If sexually transmitted disease (STD) suspected, treat with antibiotics.
    

Broad-spectrum coverage:

• Amoxicillin/clavulanic acid: 500–875 mg PO BID for 5 days with metronidazole 500 mg PO q8h for 5 days
  
• Ciprofloxacin: 500 mg PO BID for 5 days with metronidazole 500 mg PO q8h for 5 days
  

Treat for STD if indicated

FOLLOW-UP

• Sepsis
  
• Significant cellulitis
  
• Evidence of necrotizing infection
  

Well-appearing patients may be discharged with designated follow-up plan.

Patients should have gynecologic follow-up:

• Follow-up in 24–48 hr for removal of packing.
  
• Follow-up in 2–4 days after insertion of Word catheter.
  

Continue sitz baths for at least 72 hr.

• Do not mistake a nontender Bartholin cyst, which does not require immediate treatment, for an inflamed abscess.
  
• Consider malignancy as an alternative cause of a mass, particularly in women >40 yr.
  
• Incision should be on mucosal surface of abscess.
  

• Bhide A, Nama V, Patel S, et al. Microbiology of cysts/abscesses of Bartholin’s gland: Review of empirical antibiotic therapy against microbial culture.
  J Obstet Gynaecol
  . 2010;30:701–703.
  
• Patil S, Sultan AH, Thakar R. Bartholin’s cysts and abscesses.
  J Obstet Gynaecol
  . 2007;27:241–245.
  
• Pundir J, Auld BJ. A review of the management of diseases of Bartholin’s gland.
  J Obstet Gynaecol
  . 2008;28:161–165.
  
• Word B. Office treatment of cyst and abscess of Bartholin’s gland duct.
  South Med J
  . 1968;61:514–518.
  

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