Bartholin Abscess

A Bartholin abscess is a collection of pus in the Bartholin gland, usually from infection of a blocked duct or an existing cyst. It presents acutely and is painful.

• Causative organisms are mixed skin and gut flora (Escherichia coli, Staphylococcus aureus, anaerobes) and, less often, Neisseria gonorrhoeae and Chlamydia trachomatis.
• It needs drainage; antibiotics alone usually fail.
• Diabetes, HIV infection and sexually transmitted infection raise the risk.

Rapid onset, over 2 to 4 days, of severe unilateral vulval pain and swelling at the posterior introitus.

• Hot, red, exquisitely tender fluctuant swelling, 3 to 8 cm, with surrounding oedema and cellulitis.
• Difficulty walking, sitting and passing urine; fever in some women; spontaneous rupture relieves pain.
• Differential diagnosis: infected Bartholin cyst, vulval furuncle, infected epidermal inclusion cyst, Skene gland abscess, vulval cellulitis, herpes genitalis, Bartholin gland carcinoma.
• Complications: spontaneous rupture, recurrence, cellulitis, necrotising fasciitis, septicaemia, scarring and dyspareunia.

Diagnosis is clinical.

• Send pus for Gram stain, culture and sensitivity.
• Take endocervical swabs for gonorrhoea and chlamydia by NAAT or Gram stain.
• Check random blood glucose, HIV test and syphilis test.
• Full blood count and temperature when systemic features are present.
• Biopsy the cyst wall at drainage or later in women above 40 years or when the wall looks thickened.

Drain promptly.

• Supportive: warm sitz baths 10 to 15 minutes, 3 to 4 times daily; rest; adequate fluids; loose cotton underwear.
• Pharmacological: analgesia with paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food (maximum 1.2 g in 24 hours) for 5 days. Give antibiotics when there is cellulitis, fever, diabetes, HIV infection or STI risk: amoxicillin-clavulanate 625 mg oral 8-hourly for 5 to 7 days. If MRSA is suspected or the woman is allergic to penicillin: co-trimoxazole 960 mg oral 12-hourly for 5 to 7 days (not in the first trimester) or clindamycin 300 mg oral 8-hourly for 5 to 7 days. For gonorrhoea and chlamydia add ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly for 7 days. Severe infection: ceftriaxone 1 g IV daily plus metronidazole 500 mg IV 8-hourly until afebrile for 24 hours, then change to oral.
• Procedures: incision and drainage under 1 percent lignocaine (maximum 3 mg/kg, absolute maximum 200 mg plain) with a 1 to 2 cm incision on the inner mucosa. Break loculi, irrigate with sterile saline, and insert a Word catheter with 2 to 3 mL sterile water in the balloon for 4 to 6 weeks. Use general or regional anaesthesia when the abscess is large or the woman cannot tolerate local anaesthesia.
• Special groups: in pregnancy use amoxicillin-clavulanate or clindamycin, avoid doxycycline, avoid co-trimoxazole in the first trimester and avoid ibuprofen from 28 weeks; use azithromycin 1 g oral single dose for chlamydia. In diabetes target blood glucose 6 to 10 mmol/L with insulin as needed.
• Red flags: pain out of proportion, spreading erythema, crepitus, skin necrosis, hypotension, fever above 38.5 degrees Celsius.
• Follow-up: review at 48 hours and 2 weeks; remove the catheter at 4 to 6 weeks; refer for marsupialisation if the abscess recurs.