Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

asymptomatic Bartholin cyst

1st line – conservative management

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ACUTE
|
asymptomatic Bartholin cyst
1st line – 

conservative management

A small, quiescent, asymptomatic cyst can be managed with sitz baths or warm compresses to aid drainage.[23]

symptomatic Bartholin cyst

1st line – marsupialization

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ACUTE
|
symptomatic Bartholin cyst
1st line – 

marsupialization

Large cysts are more likely to be symptomatic and require treatment. The objectives of marsupialization are to construct a new mucocutaneous junction between the wall of the cyst and the skin of the labia, and to place it in approximately the normal position.[10][26] This allows for patency of the gland to be maintained so that secretory function is not lost. However, if infection is present, accompanied by marked inflammation and necrosis, sutures will pull through the friable tissue and marsupialization will not be possible. It can be performed under pudendal nerve block or local anesthetic.[12]

Variations on this technique have been described, including use of carbon dioxide laser to create a hemostatic cyst defect without use of suture, packing with an iodoform gauze that is removed after 1 week, using rubber drains after placing a linear incision into the cyst cavity, or removing an oval-shaped section of tissue (the window technique).[12][25][27][28][29] One small study found that use of a carbon dioxide laser was associated with a more favorable sexual health recovery than surgical incision.[30] Twice-daily sitz baths are recommended postoperatively.

Complications of marsupialization include moderate pain, hematoma formation, prolonged healing, and dyspareunia due to scarring.[1][18] The recurrence rate is between 2% and 25%.[1][12]

Consider – broad-spectrum antibiotics

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ACUTE
|
symptomatic Bartholin cyst
Consider – 

broad-spectrum antibiotics

Treatment recommended for SOME patients in selected patient group

In the absence of cellulitis, antibiotic therapy is unnecessary.[1][18] More than 70% of cultures from cysts and about 33% of cultures from abscesses are sterile.[13][14]

If cellulitis is present, broad-spectrum antibiotics are recommended, as infection is often polymicrobial. A 1-week course usually suffices. However, the ideal choice of empiric antibiotics remains unclear.[14] Coverage for staphylococcal (including MRSA) and streptococcal species, as well as for enteric gram-negative aerobes, specifically Escherichia coli, is suggested.

Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotizing infection, and admission to the hospital may be considered. Intravenous antibiotic therapy may then be given for the first 48 hours, followed by conversion to oral therapy. There is no evidence to support a particular antibiotic regimen.

Treatment should be modified as necessary once culture results are available.

Primary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily for 7 days

More

Secondary options

amoxicillin/clavulanate: 875 mg orally twice daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

OR

cefixime: 400 mg orally once daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

1st line – catheter drainage

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ACUTE
|
symptomatic Bartholin cyst
1st line – 

catheter drainage

The Word catheter is a safe, simple, and effective outpatient treatment and is a reasonable alternative to marsupialization.[17] The incision for the catheter should be placed just exterior to the hymen ring within the introitus in the region of the normal duct opening. If the cyst is too deep, placing the catheter is difficult and may not be possible. Clinical use is limited by its availability and tendency to dislodge.[32]

The catheter should be left in place for 4-6 weeks to allow epithelialization of a tract.[2][6] Continuous pain or discomfort 24 hours after insertion indicates the bulb is too large. This can be easily corrected by withdrawing some of the fluid in the bulb.

One study looked at quality of life and sexual activity of 30 women with Bartholin cyst or abscess during treatment with a Word catheter, and found discomfort and pain during sexual activity decreased significantly from initial presentation to end of treatment.[33] While this is currently the only study to address quality of life and sexual activity during treatment of Bartholin cyst, the findings are limited by the methodology, including lack of a control group. Another trial reported similar recurrence rates among women with Bartholin gland abscess or recurrent cyst who were randomized to treatment with a Word catheter or marsupialization (12% vs. 10%, respectively within 1 year of treatment, P = 0.70).[34] Treatment with a Word catheter was associated with less pain during the 24-hour postprocedural period, and reduced time from diagnosis to intervention.[34]

A Jacobi ring catheter creates 2 drainage tracts rather than 1 and is thought to be as effective as a Word catheter.[35]

Consider – broad-spectrum antibiotics

Back
ACUTE
|
symptomatic Bartholin cyst
Consider – 

broad-spectrum antibiotics

Treatment recommended for SOME patients in selected patient group

In the absence of cellulitis, antibiotic therapy is unnecessary.[1][18] More than 70% of cultures from cysts and about 33% of cultures from abscesses are sterile.[13][14]

If cellulitis is present, broad-spectrum antibiotics are recommended, as infection is often polymicrobial. A 1-week course usually suffices. However, the ideal choice of empiric antibiotics remains unclear.[14] Coverage for staphylococcal (including MRSA) and streptococcal species, as well as for enteric gram-negative aerobes, specifically Escherichia coli, is suggested.

Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotizing infection, and admission to the hospital may be considered. Intravenous antibiotic therapy may then be given for the first 48 hours, followed by conversion to oral therapy. There is no evidence to support a particular antibiotic regimen.

Treatment should be modified as necessary once culture results are available.

Primary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily for 7 days

More

Secondary options

amoxicillin/clavulanate: 875 mg orally twice daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

OR

cefixime: 400 mg orally once daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

2nd line – surgical excision

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ACUTE
|
symptomatic Bartholin cyst
2nd line – 

surgical excision

Excising the cyst duct or gland was standard primary treatment of a Bartholin cyst until the late 1960s.[1] It is no longer the preferred treatment for primary surgery but may be required for recurrent cysts. However, the absence of a Bartholin gland may lead to dryness of the vulva, with severe itching, burning, and dyspareunia.[10][19][26][36]

It should be performed by an experienced gynecologic surgeon under general anesthesia because of the possibility of excessive bleeding from the underlying venous plexus.[1][12][16][19] Excision can be difficult if multiple previous attempts have been made to drain a cyst or abscess, and adhesions have formed. It should not be attempted in the presence of active infection.[12] Liquid paraffin may aid dissection.[16]

Complications of excision include hemorrhage, hematoma formation, cellulitis, sepsis, damage to the rectum, cosmetic disfigurement, and formation of scar tissue.[12][16][19][22]

3rd line – silver nitrate cauterization

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ACUTE
|
symptomatic Bartholin cyst
3rd line – 

silver nitrate cauterization

Silver nitrate is a simple, cost-effective germicide and a chemical sclerosing agent. Its use has been described in the outpatient treatment of both cysts and abscesses.[12][37] Benefits of silver nitrate application include low rate of early and late morbidity, low recurrence rate, and avoiding sutures.[37] A prospective randomized controlled trial found that using silver nitrate and marsupialization were equally effective, with less scar formation noted with the use of silver nitrate.[38] Complications include chemical burns of the labial or surrounding mucosa, labial edema, hemorrhagic or purulent discharge, and cyst recurrence.[12]

Primary options

silver nitrate topical: consult specialist for guidance on dose

3rd line – alcohol sclerotherapy

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ACUTE
|
symptomatic Bartholin cyst
3rd line – 

alcohol sclerotherapy

Compared with aspiration, instillation of alcohol for sclerotherapy reduced treatment time, with a low recurrence rate.[21] Complete evacuation of the injected alcohol is essential to avoid necrosis of the cyst wall. Compared with silver nitrate, alcohol sclerotherapy was as effective, with fewer complications and a faster healing time. There were no recurrences at 24-month follow-up.

Bartholin abscess

1st line – conservative management ± incision and drainage

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ACUTE
|
Bartholin abscess
1st line – 

conservative management ± incision and drainage

If an abscess points and ruptures spontaneously, conservative management with regular sitz baths and analgesia is usually all that is required.[19]

Small unruptured abscesses can also be treated with local application of warm, wet dressings or regular sitz baths to promote spontaneous drainage or development to a stage suitable for incision and drainage.[6][19]

Incision and drainage may be required if spontaneous drainage does not occur. Packing the cavity may reduce the risk of recurrence.[32] Abscess after incision and drainage recurs in up to 15% of cases.

Primary options

acetaminophen: 325-1000 mg orally every 4-6 hours when required, maximum 4000 mg/day

Plus – broad-spectrum antibiotics

Back
ACUTE
|
Bartholin abscess
Plus – 

broad-spectrum antibiotics

Treatment recommended for ALL patients in selected patient group

If an abscess points and ruptures spontaneously or surgically, broad-spectrum antibiotics should be given.[19] A 1-week course usually suffices. While there is no evidence to support a particular antibiotic regimen, coverage for staphylococcal (including MRSA) and streptococcal species, as well as for enteric gram-negative aerobes, specifically Escherichia coli, are suggested.

Primary options

sulfamethoxazole/trimethoprim: 160 mg orally twice daily for 7 days

More

Secondary options

amoxicillin/clavulanate: 875 mg orally twice daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

OR

cefixime: 400 mg orally once daily for 7 days

and

clindamycin: 300 mg orally four times daily for 7 days

Consider – marsupialization or catheter insertion

Back
ACUTE
|
Bartholin abscess
|
after resolution of infection/inflammation
Consider – 

marsupialization or catheter insertion

Treatment recommended for SOME patients in selected patient group

Definitive surgical methods are preferably deferred until active infection and inflammation have resolved. There is a lack of evidence to support a particular management strategy. A catheter left in situ after drainage may reduce the risk of recurrence.[32]

Marsupialization can be carried out in the presence of infection, but sutures may pull though due to inflammation of the tissues. If larger sutures are not effective, the procedure should be postponed. The objectives of marsupialization are to construct a new mucocutaneous junction between the wall of the cyst and the skin of the labia, and to place it in approximately the normal position.[10][26] This allows for patency of the gland to be maintained so that secretory function is not lost.

The Word catheter is a safe, simple, and effective outpatient treatment and is a reasonable alternative to marsupialization.[17] The incision for the catheter should be placed just exterior to the hymen ring within the introitus in the region of the normal duct opening. If the cyst is too deep, placing the catheter is difficult and may not be possible. Clinical use is limited by its availability and tendency to dislodge.[32]

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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