Bartholin Gland Cyst

author : AMSSM

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How long did it take to heal, also did it come back? I've got a race in three weeks, which is only a B race, but it looks like I will miss it as it is just too painful to ride.

Member Question

A week ago after a ride I noticed a lump appear in the nether regions and it has since grown and become quite painful. I've since done some research online and it appears that I have a Bartholin cyst. I've made an appointment to see my GP to have it dealt with, which will apparently mean getting it lanced and drained (not something I'm looking forward too!).

Answer from Sean Robinson, MD
Member AMSSM

I am sorry to hear about your groin pain. There are a few potential possibilities to explain the lump in your vaginal area. The more common issue seen is indeed a Bartholin gland cyst. There could be other possibilities including abscess or solid lesions or masses. It is important to remember that both cancerous and non-cancerous masses in this region are extremely uncommon.  However, women over the age of 40 with a concern for bartholin cyst or abscess should have the lesion biopsied to exclude the possibility of cancer.¹ Cysts and abscess are the most common disorders of the bartholin glands however many vulvar and vaginal lesions mimic these disorders thus it is recommended that you always follow up with your sports medicine doctor for a complete evaluation. ²

Bartholin glands function to provide moisture and lubrication for the skin of the vaginal opening.¹ It is important to note that these glands do not provide the lubrication for sexual intercourse, this will become important when discussing treatment options. The glands are located at the 4 o’clock and 8 o’clock of the base of the labia minora (inner vaginal lips) and drain through 2-2.5 cm long ducts (tubes).¹ The glands are usually pea sized (approximately 5 mm in diameter) and cannot be felt or seen normally.  

Bartholin duct cyst is the most common cystic growth in the vulva.^1,2 It is thought that 2% of women will develop duct cyst or gland abscess at some time in her life.¹ A Bartholin gland abscess is an infection of this gland and is even more common than the duct cysts.¹ It is not been studied if cycling increases the risk of developing either Bartholin duct cysts or abscesses.

A Bartholin duct cyst or abscess is formed after obstruction of the ducts, which results in retention of secretions followed by dilation (ballooning) of the duct and formation of a cyst (pocket of fluid). An abscess is thought to form after this retained fluid gets infected, although abscesses have been seen in the setting without a bartholin duct cyst first present.  It was once thought that the abscess was secondary to a sexually transmitted infection, but this is not true.¹ The Bartholin cyst can be symptomatic or asymptomatic. Abscesses are typically symptomatic with vaginal pain with walking, sitting, and/or sexual intercourse.

Treatment depends on the presence of symptoms. If there are no symptoms then there is no reason to treat the lump aggressively. Cysts will sometimes go away on its own if you put a warm moist cloth over the lesion or soak in a warm bath.¹ It is thought that the moist heat helps unblock the duct and allow for drainage.  It is important to note that abscess (infection) rarely get better without further intervention.

Most procedures to treat bartholin gland cysts or abscess can be preformed in the office under local anesthetic. Research is poor regarding the following decisions for which specific treatment is superior to another. Treatments range from warm compresses (as mentioned above) to surgical removal of the gland (most aggressive). The following treatment options will be discussed: incision and drainage, incision followed by word catheter placement (a rubber tube with a small balloon on the end), marsupialization (described below), incision and drainage followed by silver nitrate application, laser treatment and excision of the gland.    

Incision and drainage is the simplest procedure and has minimal risk of complications, but carries highest risk of recurrence (return of the cyst or abscess).¹ The procedure is performed in the office and will provide immediate relief of the pressure.  The procedure requires local anesthetic and a small incision is made in the top of the lesion followed by drainage of the contents. Again, this is not recommended to perform this procedure in isolation, as there is a high tendency for the cyst to recur.

Word catheter placement is another common procedure that is used in conjunction with incision and drainage. This is another procedure that can be preformed in the office. After the incision and drainage procedure a balloon-tipped device (word catheter) is placed through the incision and inflated and left in place to allow further drainage and formation of a wider opening for the gland. The balloon-tipped device is typically left in place for 4-6 weeks to allow for full healing, though it commonly dislodged.  Since the device is left in place, patients can have more discomfort than other procedures. Activity is typically based on presence of symptoms, though to avoid dislodging the device, pelvic rest for the 4-6 weeks is recommended. The recurrence rate is quoted to be 3% with this procedure.

Marsupialization involves removal of part of the skin and cyst lining followed by suturing (sewing) the edges together to form a pouch. This creates a new larger duct and allows for continued drainage. This too can be performed under local or a regional nerve block in an office setting. This procedure does take longer and is more invasive than the Word catheter placement procedure described above. Generally this is reserved after a patient has failed one to two word catheter treatments. The post-procedure issues associated with this procedure include pain, infection, scarring, pain with intercourse, hematoma (pocket of blood under the skin). Patient’s who have undergone this procedure typically take 2-3 weeks to heal and activity can resume with resolution of discomfort. 

Word catheter and marsupialization are similarly effective and have low risk of complications and relatively low risk of cyst recurrence (less than 20%)

Marsupialization procedure is somewhat more complicated however patients have less post procedure discomfort. 

Incision and drainage followed by silver nitrate (a substance that is antibacterial and promotes clotting) application is simple and possibly more effective than either word catherization or marsupialization, but data on effectiveness is limited. Post procedure discomfort is the major disadvantage. This procedure is like the incision and drainage procedure described above but a silver nitrate stick (0.5 cm) is placed in the cavity after. The silver nitrate promotes better wound healing and is thought to keep the cavity open for further drainage. The patient then returns 48 hours later for the incision site to be cleaned.  A small study showed complete healing within 15 days, and a small number had recurrence.² Side effects reported for this procedure include: pain, chemical burns of nearby tissue, labial edema, bruising, increased vaginal discharge and scarring. There are new studies that show use of alcohol (to replace the silver nitrate) might be just as effective but with less post procedure side effects.³

Laser treatment has been shown to be an effective form of treatment, but due to the cost and requirement of expertise in laser surgery this option is not readily available.² With this technique can be preformed under local anesthetic in the office, the post-procedures issue include minimal bleeding and scarring being reported.  Healing time is thought to be shorter than the above procedures but again will ultimately be driven by symptoms.

Excision (complete removal of gland) is a definitive treatment.¹ This procedure requires a gynecological surgeon and is preformed in an operating room. This procedure is usually considered when multiple attempts of more conservative treatments (as mentioned above) have failed. This procedure carries a higher risk of postoperative complications, which include hematoma formation, local soft tissue infection of the surrounding area, scarring, disfigurement, and pain with intercourse.

As you can see there are multiple treatment options all with various pros/cons and healing times. The typical treatment plan is to start with the most conservative approach and in a stepwise fashion increase the intervention needed. If infection is present you will also require a course of antibiotic therapy.

Prevention of Bartholin gland cysts or abscess include making sure you keep good vaginal hygiene with soap and water. As a cyclist, it is important to maintain clean clothing. If possible, avoiding hard or deep rubbing in the area of the opening of the vagina, this may include adjusting a bicycle seat positioning or determine the selection of the seat. The thought is to increase the cushioning in this area.

It sounds like you are on the right track with following up with your doctor for diagnosis and to address your treatment options.  

Best wishes for a quick recovery,

Sean Robinson, MD

Oregon Health and Science University

References:

1. Omole F, Simmons BJ, Hacker Y. Management of Bartholin duct cyst and gland abscess. Am Fam Physician. Jul 1 2003;68(1):135–140
      
2. Chen, K. (2012). Discorders of Bartholin gland. In R. Barbieri (Ed.),UpToDate. Available from http://www.uptodateonline.com.
      
3. Kafali, H, Yurtseven, S. Ozardali I. Aspiration and alcohol sclerotherapy: a novel method for management of Bartholin’s cyst or abscess. Eur J Obstet Gynecol Reprod Biol. 2004 Jan 15;112(1):98-101.

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date: June 11, 2013