The Bartholin glands are two small mucus producing glands in the vagina which unfortunately can become plugged and cause issues. There are two general presentations: painless vaginal bump (usually a cyst) or a very painful vaginal bump (usually an abscess). Treatment is the same – drainage. E. coli, staph, strep species, and STDs are commonly cultured from the abscess, so if you are placing the patient on antibiotics, make sure you are covering for all potential bacterial agents. Rarely the swelling can be caused by malignancy, so have a low threshold to get quick gyn follow up, especially if the patient is older.

Quick anatomy review:

The pair of Bartholin glands are located at the vaginal introitus at the 4 and 8 -o’ clock position with the patient in the lithotomy position. Normally the Bartholin are difficult to find/palpate but are easily visualized and palpated when a cyst/abscess is present.

In general, this can be diagnosed by external examination. There is no need for imaging. You may want to send cultures from the cyst when you drain it, especially if recurrent. Consider sending STD testing as well.

Because of the location, the Bartholin glands often do not drain well and require placement of a catheter (Word catheter) to stent the area open and allow continued drainage until healed. There is a small balloon at the end of the catheter that will need to be inflated with saline once in place. The catheter is about 1 inch long and the same diameter as a 10 Fr foley. These are usually made with latex, so ask your patients about allergies before placing.

Considerations with Consent:

Always have a chaperone when performing procedures on sensitive areas
Risks:
- Infection including cellulitis, bleeding, pain, painful intercourse, scarring, recurrence of the cyst/abscess
Alternatives:
- For mild cases, sitz baths may be sufficient
  - Aspiration/syringe drainage is largely ineffective and not recommended
- For more severe or recurrent cases, marsupialization or more extensive excision by Gyn is required

Things You Need:

Iodine/betadine to clean skin and vaginal introitus (alcohol is not recommended for mucosal surfaces and chlorhexidine may be too irritating)
Lidocaine 1-2% (with or without epi)
- Can place some topical viscous lidocaine or a lidocaine-soaked gauze to the area ~30 min prior to injecting to help with some of the discomfort

Word catheter
Sterile saline for flushing and for filling Word balloon
- Sterile flushes work well
5 ml syringe and 30 ga needle for injecting lidocaine
3 ml syringe and 25 ga needle for inflating the Word catheter
#11 blade
Forceps/pickups for grasping cyst wall when incising and when placing the catheter
Hemostats to break up loculations

How to do it:

Place your patient in the lithotomy position
Clean the vaginal introitus and surrounding skin with iodine/betadine
Anesthetize the area over the cyst – generally this means injecting into the introitus behind the hymenal ring over the area of fluctuance
Once adequately numbed, grab the skin near the cyst to hold it firmly positioned
Make a stab incision in to the cyst – should be <0.5 cm in length to ensure the Word catheter does not fall out
- This should be done inside the vagina to optimize the position of the Word catheter
Express material from the cyst (and culture if indicated/desired)
Use saline flushes to wash out pocket
Break up loculations if present – area should feel soft and well decompressed if adequately drained
Once drained, prep your Word catheter
- Use 25 ga needle and 3 ml syringe filled with saline needle at the wider end to fill with 1-2 ml of saline to ensure balloon intact

- Deflate balloon before placing
Insert tip/deflated balloon into the stab incision and advance the catheter until at least half of it is in the abscess/cyst pocket
Using the same 25 ga needle and 3 ml syringe, inflate the balloon with 2 ml of saline to secure it into place (can put in up to 3 ml but may not need that much)
Gently tug the catheter to make sure it does not dislodge
Tuck the end of the Word catheter into the vagina

The patient will need to leave the catheter in place for 2-4 weeks (some sources say up to 6 weeks) to ensure a good drainage tract/fistula is fully formed. The catheter may fall out on its own before 4 weeks; it does not have to be replaced if this occurs. Sitz baths a few times a day for the first week or so may help with discomfort and to encourage drainage. Pain should be significantly improved after the Word catheter is placed. Patients may ask about sex/tampon use – these are fine as long as the patient is not having any discomfort.

Additional notes:

Make sure you are getting the patient close follow up with gyn for monitoring and removal.
Consider treating for STDs, doxycycline can treat most staph/strep/E coli so may be a good option.
Make sure the needle is straight when injecting into the Word catheter – if you puncture through the side, the balloon will leak
Some sources will tell you to cut on the surface skin, but this is more likely to scar and the Bartholin tract will drain outside rather than into the vagina (a more anatomic location)

Relevant Billing/CPT Codes:

56420 - Incision and drainage of Bartholin's gland abscess, includes the placement and removal of the Word catheter.

Videos:

https://journals.lww.com/em-news/pages/video.aspx?v=2 – longer video, but shows some of the commonly encountered issues like not making the incision large enough or having a leaking catheter

https://www.youtube.com/watch?v=GOyEMuRdR7s