Dr Sabita. P .IGMCRI Puducherry

1. Bartholin glands Cyst &
Abscess
1 August 2021 Prof. B.V. Sai Chandran CTVS 1

3. 1 August 2021 Prof. B.V. Sai Chandran CTVS 3
• Introduction
• Anatomy & Embryology
• Function
• Pathological Conditions
• Management

4. 1 August 2021 Prof. B.V. Sai Chandran CTVS 4
• The Bartholin glands are essential organs of the
female reproductive system.
• The glands were first described in the 17th century
by the Danish anatomist, Casper Bartholin
• The Bartholin’s gland corresponds to the
bulbourethral gland of male.
Introduction

5. 1 August 2021 Prof. B.V. Sai Chandran CTVS 5
Anatomy of
Bartholin’s Gland
(Greater Vestibular Gland)

6. 1 August 2021 Prof. B.V. Sai Chandran CTVS 6
Postero- lateral to
vaginal orifice, beneath
the bulbospongiosus
Pea-sized, of
about 0.5 cm and
yellowish-white
@ 4 and 8 O’ clock
in the superficial
Perineal pouch

7. 1 August 2021 Prof. B.V. Sai Chandran CTVS 7
Duct of Bartholins gland

8. 1 August 2021 Prof. B.V. Sai Chandran CTVS 8
Duct of Bartholins gland
Runs downwards & Inwards
to open at the introitus
outside the hymen
@ Jn. of A
2/3
rd and P
1/3
rd
between Hymen & Labium minus

9. 1 August 2021 Prof. B.V. Sai Chandran CTVS 9
Anatomical position of the bulbo-
urethral gland in the male .

10. 1 August 2021 Prof. B.V. Sai Chandran CTVS 10

11. 1 August 2021 Prof. B.V. Sai Chandran CTVS 11
• Bilateral elongated
masses of erectile tissues
• Beneath the mucous
membrane of the
vestibule.
• Each bulb lies on either
side of the vaginal
orifice in front of the
Bartholin’s gland
• Incorporated within
the bulbocavernosus
muscles.

12. 1 August 2021 Prof. B.V. Sai Chandran CTVS 12
Homologous to the Single Bulb of the Penis and
Corpus Spongiosum in the male.

13. Embryology
• Bartholin’s glands and
Skene’s tubules are
developed from outgrowths
the urogenital sinus (UGS)
Supply:
– External pudendal artery
– Pudendal nerve.
– Superficial inguinal and
pelvic nodes.
Future
Bladder
UGS
Anorectal
canal

14. Blood/Nerve/ Lymphatic Supply:
• External and Internal Pudendal vessels.
• Superficial inguinal andAnorectal Lymph
nodes.
• Pudendal nerve.

15. Histology of Bartholin’s
Glanda:
• It is a compound racemose gland.
• The acini are made up of simple columnar
epithelium.
• the duct ,in its beginning made of cuboidal
epithelium and become transitional and near
its termination made of stratified squamous
epithelium.

16. Histology of Bartholin’s
Galnd:
Low
Power
Field

17. Functions of Bartholin’s Glands:
• Their primary function is the production of a
mucoid secretion that aids in vaginal and
vulvar lubrication.
• They are homologous to the bulbourethral
(Cowper’s) glands in males.
• Tiny drops
• Basic pH

18. • Colourless and Mucoid
• CharacteristicOdour.
• Produced mainly in response to
sexual excitement to act as a
lubricant for coitus.
• Limited activity after the menopause
Secretion of Bartholin Glands:

19. 1 August 2021 Prof. B.V. Sai Chandran CTVS 19
Pathology of
Bartholin’s Gland
(Greater Vestibular Gland)

20. Pathology (Lesions) of Bartholin’s Gland
1. Inflammatory cysts/abscess
2. Tumors
Nodular Hyperplasia
Endometriosis
Adenoma & adenomyoma
Papilloma
Mucocele
Squamous cell carcinoma
Lymphoepithelioma-like carcinoma
Vulvar leiomyosarcoma
Endometrialadenocarcima
Merkel cell carcinoma
Mucinous adenocarcinoma
Transitional cell carcinoma
Epithelioid sarcoma
Malignant melanoma
Non-Hodgkin’s lymphoma
Human papillomavirus type 16
Paget’s disease
Small cell neuroendocrine
B
E
N
I
G
N
M
A
L
I
G
N
A
N
T

21. 1 August 2021 Prof. B.V. Sai Chandran CTVS 21
Bartholin’s gland Cysts & Abscess

22. Bartholin’s gland Cysts &
Abscess
2% of the women develop in their life time

23. Bartholin’s Gland Cysts &
Abscess
• Trauma
• Episiotomy
• Child birth
• No identifiable cause
They are common in occurrence.
Obstruction of the duct
Cystic dilation of the duct
Build-up of mucus
Cyst formation
Infection
Abscess

24. Bartholin’s Gland : CystVs Abscess
Bartholin's abscess
Cultures often show
Polymicrobial infection
Duct cyst is not
required for the
development of
abscess.
The abscesses are
almost 3 times
more common
than duct cysts

25. Brucella melitensis
Chlamydia trachomatis
Escherichia coli
Klebsiella pneumonia
Neisseria gonorrhea & sicca
Aerobes
Pseudomonas aeruginosa
Bacteroides species
Pasteurella bettii
Salmonella panama
Staphylococcus aureus -Panton-Valentine-Leucocidin production
Streptococcus species
Gram Negative
Gram Positive
Bacteriology

26. Childbearing age :
• Onset of puberty (mostly) and increases with age
Clinical Manifestations and Symptoms

27. • May be asymptomatic if the
cyst is small and not
inflamed.
• Incidental finding of small
mass by the physicians in
the gland region
• Larger cyst / cyst with
inflamation
Bartholin’s Duct Cyst – Clinical
Abscesses commonly
present with cellulitis
and lymphangitis.
- severe vulvar pain
- swelling
- difficulty in walking,
sitting and engaging
in sexual intercourse
(dyspareunia).
- Fever may

28. Clinical Presentation
• Tender mass in the lower vestibular region surrounded
by erythema and edema. Grows large enough to
extend to the upper labia
• Skin rupture and spontaneous drain – may happen
• Presenting in the form of inguinal hernia

29. Differential diagnosis

30. • Culture sensitivity
• s/o STD

31. IMAGING STUDIES
 MRI and CT Scan may be utilized to examine large
Bartholin’s duct cysts in addition to a physical examination
 Asymptomatic cysts may also be examined through MRI
scans
 High definition USG is also used to reveal presence of
Bartholin's cyst

32. • Age
• Size
• Symptoms
• Infection+/_
• History of Recurrence

33. 1. Expectant management
2. Conservative.
3. Curative
4. Office/ inpatient
The goal of management is to preserve the
gland and its function

34. • Marsupialization should NOT be used to
treat a gland ABSCESS.
• Broad-spectrum Antibiotic therapy is
warranted only when cellulitis is present.
• Excisional biopsy is only in menopausal or
perimenopausal women with an irregular,
nodular Bartholin's gland mass –to R/O
Adenocarcinoma

35. • ASYMPTOMATIC
• < 40 YEARS
• Small
• Incidentally Found
EXPECTANT MANAGEMENT ( SMALL CYSTS )

36. • Medication and Antibiotics for
abscesses.
• Antibiotic may not be necessary
for healthy women with
uncomplicated abscesses.
• Ceftriaxone, Ciprofloxacin,
Doxycycline & Azithromycin.
• This treatment option should be
restricted to women who have
high risk of complicated infection
such as,
Indications :
• Recurrence
• pregnancy,
• Immunosuppression,
• MRSA risk,
• Widespread cellulitis
• Gonorrhea or chlamydia.
Topical or local anesthetics
such as lidocaine and
bupivacaine are also used to
treat abscesses
CONSERVATIVE MEDICAL

37. MANAGEMENT OF LARGE CYSTS & ABSCESS
Spontaneous rupture: Sitz bath, Anti inflammatory / Antibiotics SOS
Available treatment options
1. Incision and drainage - simple, office procedure, high recurrence rate
2. Needle aspiration - not recommended
3. Ablative therapy - Alcohol / Silver Nitrate
4. Catheter placement – Word catheter / Jacobi Ring Catheter
5. Marsupialization
6. CO2 Laser

38. • Should it be a OT procedure (or) office
procedure such as Word catheter placement?
• Is it strictly a Cyst (or ) Abscess?
• What are the organisms (in case of Abscess) &
wheter the Antibioctics are adequate?
• Is the patient immunocompromised?
• Are there comorbidities delaying postoperative
healing?
• Whether any chance of malignancy?

39. ABLATIVE TREATMENT
Chemical destruction of epithelial lining of a
duct cyst or gland abscess
Sclerosant Therapy : Alcohol / Silver nitrate

40. 18- to 20-G needle
Inserted into the cyst at the point of maximal fluctuation
Aspirated until the cyst walls collapse.
Alcohol (70%) - similar volume as the cyst content -injected
- Injected into the cyst
- Left for five minutes, then aspirated.
Healing usually occurs within one week.

41. A clamp is placed into the cyst/abscess,
and the contents are fully drained.
A 5-mm diameter silver nitrate stick,
trimmed to a length of 5 mm is
inserted into the cavity.
A single suture is applied to the skin to
fix the stick in the cavity for continued
drainage.
After 3 days, the stick is removed with
the necrotized tissue using a clamp
Healing time is approximately 2 weeks

42. Results of Alcohol vs. Silver Nitrate Sclerotherapy
Effectiveness and safety almost similar despite
the minor risks of tissue necrosis and scar
formation.

43. Prospective Randomized Study of Marsupialization versus Silver Nitrate
Application in the Management of Bartholin Gland Cysts and Abscesses J Minim
Invasive Gynecol Mar-Apr 2009;16(2):149-52
Conclusion: Marsupialization and silver nitrate application seem to be equally
effective management methods in Bartholin cyst and abscesses, however, silver
nitrate favors complete healing with less scar formation.
•. Mar-Apr 2009;16(2):149-52
•. Mar-Apr 2009;16(2):149-52

44. CATHETER PLACEMENT
Draining the contents of the cyst or abscess and
placement of a catheter for few days.
2 Types of Catheters :
Word Cattheter Jacobi Ring Catheter

45. First described by
Buford Word, in 1964

46. Careful
incision
length
because the
catheters
are often
prematurely
expelled.
A suture
may be
used to
close the
incision to
help keep
the catheter
in place

47. 7-cm long 8F T tube threaded
20-cm long 2-0 silk suture
5-cm piece of tubing from a
butterfly blood collection set is
threaded with absorbable sutures
(Vicryl) through the lumen

48. An incision is made into
the mucosal surface of the
Bartholin duct abscess.
Adhesions are lysed, and
the abscess can drain.
A hemostat is tunneled
into the abscess cavity and
a second incision is made.
The hemostat is used to
grasp one end of the
Jacobi ring.
The Jacobi ring is pulled
through the abscess
cavity with care that the
suture is not pulled out
of the catheter.
The two ends of the
suture are tied, forming
the closed ring.
… Jacobi Ring Catheter

49. Merits :
• No risk premature expulsion
• Creating 2 drainage tracts.
Ring catheter is left in place up to 4 weeks
Removal is done in the physician’s office by cutting
the suture, then removing the entire tube.
…..JACOBI Ring:

50. The primary outcome: of the study were
successful placement of the catheter and
resolution of the abscess
• Patient satisfaction was higher
with ring Catheter
• No significant clinical or statistical differences
regarding :
― Catheter placement success
(The ease of insertion was
similar for the 2 devices
― Abscess resolution, or
― Recurrence. No recurrence at 6
6months
Secondary outcomes included ease of
insertion, patient satisfaction and
recurrence at 6 months.
Ring Catheter Vs Word Catheter – RCT reports

51. In 1950, Jacobson was the first to describe the technique
MARSUPIALIZATION

52. Indications
1. H/o Recurrence
2. Significant pain or discomfort
3. Failure of other modes of treatment (unresolving or
extremely prolonged delay in resolving )
4. Unable to tolerate Word catheter placement in an office
setting
Complications:
• Scarring due to the removed tissue  Lack of Lubrication &
Dyspareunia

54. The WoMan-trial (WOrd versus MArsupialisation) was a
multicentre, open label, randomised controlled trial performed
in 4 university, 12 teaching and two general hospitals
in the Netherlands and in one teaching hospital in England.
in women with a Bartholin duct cyst or gland
abscess, demonstrated similar recurrence rates with both
procedures
.
Word Catheter Vs Marsupialization

55. • Treatment for a symptomatic cyst or abscess of the
• Bartholin gland by both Word catheter and
marsupialisation
• resulted in similar 1-year recurrence rates. Outpatient
• placement of a Word catheter is also well tolerated by
• patients. In our opinion, our data favours treatment of a
• Bartholin cyst or abscess with a Word catheter as this is
• the fastest procedure, relieving pain sooner after
diagnoses,
• with lower costs than when marsupialisation is performed.

57. Merits over the other methods :
CO2 LASER
• Minimal Recurrence,
• No Scar formation - as the Incision on
the cyst is made with CO2 laser and the
wall is vaporized from the inside.
• No Hemorrhage.
• Less chance of persistent drainage
• Vaporizes removes the gland.
• Less discomfort to the patient in the
intra- and postoperative periods
• Simple
• Quick
• As OP Procedure
Demerits Expensive, Facility & skills not available widely
Technical Aspects

58. Procedure with CO2 Laser in the Treatment of a Bartholin Cyst
Exposure of
the cyst to
the right,
with 2%
xylocaine
infiltration
Incision with the
focused laser beam
over the cyst.
Opening
of the
capsule
with
complete
drainage
of the
content
Repair of the
borders with
exposure of the
internal
surface of the
capsule.
Vaporization of the
internal capsule with
unfocussed laser beam

59. Post procedural :
• Sitz-baths with diluted povidone-iodine in water thrice daily,
• Abstain from sexual activity for 2 to 3 weeks.
• Antibiotics and analgesics when signs of infection
• The patients were evaluated 15 and 30 days after procedure
• In the first 2 weeks  continuous drainage of mucus,
at the end of the 1st month  complete healing
….CO2 Laser

60. The gold standard treatment is surgical removal of the
entire cyst. However, this treatment is NOT performed
often since it affects the physiological vaginal lubrication
and is associated with other complications
Bartholinectomy
• Exeresis of Bartholin gland is a surgical treatment -
an elective procedure, performed in the absence of
infection. Usually performed after failure of other
techniques.
• Requires greater operative time.
Cyst Excision

61. • Modern variations are discussed, including
the use of hydrodissection for excision, as well
as the application of MRI use in devising
treatment for recurrent cysts.
….CYST EXCISION

62. Objective: to examine cases with Bartholin gland excision due to
Bartholin cyst or abscess.
Methods: demographic features, obstetric and medical history
of the patients, location and size of the Bartholin cyst or abscess,
complaints, duration of operation and postoperative
complications.
….GLAND EXCISION
Evaluation of 149 Cases who underwent total excision of the
Bartholin gland due to cyst or abscess - @ Istanbul Kanuni
Sultan Suleyman Training and Research Hospital between
January2011 and December 2016 -
A Retrospective Study
European Archives of Medical Research

63. Results :
• The mean age of the patients was 33.33―7.126 years.
• The gravida and parity mean values were 2.11 and 1.56, respectively.
• Of the patients, 35 were nulliparous, and 108 had vaginal delivery.
• The mean diameter of the cyst was found to be 3.18 cm.
• There were 20 patients with recurrent cases of Bartholin abscesses.
• The mean duration of operation was 22.42 min.
• The most common complaint was pain.
….GLAND EXCISION
European Archives of Medical Research

64. 1 August 2021 Prof. B.V. Sai Chandran CTVS 64
Bartholin’s Gland Carcinoma

65. Carcinomas
• Rare type of gynecological tumor that
• Accounts for 2–7% of vulvar carcinomas.
• The median age 57 years old.
• Incidence is highest among women in their 60’s.
• Benign tumors are rarer than carcinomas
1. Adenocarcinoma
2. Squamous cell carcinoma
3.Transitional Carcinoma
4. Adenoid-cystic Carcinoma
5. Undifferentiated carcinomas
Human papilloma
virus is only related to
squamous cell lesions.
80-90%
10-20%

66. When to Suspect ?
• Bartholin gland involution occurs by 30 years of age
• Hence enlargement occurring after 40 years of age should
raise suspicion for malignancy
• Particularly if the gland is firm, fixed, or irregularly shaped
and painless
• First detection of sentinel node may lead to diagnosis of
adenocarcinoma of Bartholin's gland
..Carcinomas

67. • Diagnosis established by histological examination.
• Drainage and biopsy - to eliminate a biopsy is recommended over
excision
• When malignancy suspected , diagnostic criteria :
– The tumor must be primarily located in the labia
– The surrounding skin must remain undamaged,
– There must be at least a small amount of glandular epithelium
present.
• Metastatic disease is likely due to the vulva's extensive vascular and
lymphatic network
• Early recognition is important because of the risk of local invasion and
metastasis.
..Carcinomas

68. • Thank you