Bartholin Cyst

A Bartholin cyst is a fluid-filled swelling of the Bartholin gland or duct. It forms when the duct opening at the posterior vestibule blocks. It is a common vulval cyst in women of reproductive age.

• The duct blocks from inflammation, mucus plugging, trauma or scarring, and the gland fills with mucus.
• Most cysts are sterile and painless until they enlarge or become infected.
• A new Bartholin swelling in a woman above 40 years needs tissue diagnosis, because Bartholin gland carcinoma presents as a cyst or mass.

Typical presentation is a unilateral, tense, painless swelling at the posterior introitus (5 or 7 o'clock position), 1 to 4 cm in size.

• Vulval fullness, discomfort when sitting, walking or cycling, and dyspareunia when large.
• The swelling is smooth, fluctuant and non-tender, with no surrounding erythema.
• Differential diagnosis: Bartholin abscess, epidermal inclusion cyst, Skene gland cyst, mucous cyst of the vestibule, vulval lipoma, cyst of the canal of Nuck, Gartner duct cyst, Bartholin gland carcinoma.
• Complications: abscess formation, recurrence, dyspareunia, obstruction of the introitus during vaginal delivery when large.

Diagnosis is clinical, by inspection and palpation of the vulva.

• Measure the cyst and record the side, consistency and tenderness.
• Take endocervical and high vaginal swabs for gonorrhoea and chlamydia (NAAT or Gram stain) when there is discharge or sexual risk.
• Offer HIV and syphilis tests.
• Biopsy or excise for histology when age is above 40 years, the woman is postmenopausal, or the mass is solid, irregular, ulcerated or fixed.
• Pelvic ultrasound when a solid component or a canal of Nuck cyst is suspected.

Management depends on symptoms and size.

• Supportive: warm sitz baths in clean warm water for 10 to 15 minutes, 3 to 4 times daily; loose cotton underwear; avoid soaps, wipes and douches; reassure that small asymptomatic cysts need no treatment.
• Pharmacological: asymptomatic cyst needs no drug. For pain give paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) with or without ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days (maximum 1.2 g in 24 hours). Antibiotics only when infection or a positive swab is present: ceftriaxone 500 mg IM single dose plus doxycycline 100 mg oral 12-hourly for 7 days.
• Procedures: for a symptomatic cyst, Word catheter insertion under local anaesthesia with 1 percent lignocaine (maximum 3 mg/kg, absolute maximum 200 mg plain). Make a 5 mm stab incision on the inner labium minus mucosa at the hymenal ring, drain the cyst, insert the catheter, inflate the balloon with 2 to 3 mL sterile water, and leave in place for 4 to 6 weeks. Alternative is marsupialisation with absorbable 3-0 sutures. Excise the cyst wall for histology when malignancy is suspected.
• Special groups: in pregnancy use paracetamol only and avoid ibuprofen from 28 weeks; replace doxycycline with azithromycin 1 g oral single dose for chlamydia.
• Red flags: rapid enlargement, fever, severe pain (abscess), hard fixed mass, ulceration, bleeding, new mass above 40 years.
• Follow-up: review at 2 weeks after catheter insertion and remove the catheter at 4 to 6 weeks; review 6 weeks after marsupialisation; refer for gland excision or specialist care if the cyst recurs.