Recurrent Bartholin Abscess

A recurrent Bartholin abscess is a Bartholin abscess that forms again after drainage, with two or more episodes, usually in the same gland.

• Incomplete drainage, premature closure of the incision and chronic gland infection drive recurrence.
• Treatment needs a definitive procedure after the acute infection has settled.
• Women above 40 years need histology.

Repeated acute painful swelling at the posterior introitus over weeks to months.

• Hot, red, tender fluctuant swelling with surrounding cellulitis, an old scar, and sometimes a sinus discharging pus.
• Fever, dyspareunia, difficulty walking and sitting.
• Differential diagnosis: infected Bartholin cyst, Skene gland abscess, vulval furuncle, hidradenitis suppurativa of the vulva, Crohn disease of the vulva, vulval tuberculosis, Bartholin gland carcinoma.
• Complications: cellulitis, necrotising fasciitis, sepsis, fistula, scarring and dyspareunia.

Diagnosis is clinical, with microbiology.

• Pus for Gram stain, culture and sensitivity, and Ziehl-Neelsen stain or Xpert MTB/RIF when the sinus is chronic.
• Endocervical swabs for gonorrhoea and chlamydia.
• Random blood glucose, HIV and syphilis tests.
• Biopsy of the cyst wall or any indurated tissue, especially above 40 years.

Drain the acute abscess, then perform a definitive procedure.

• Supportive: warm sitz baths 10 to 15 minutes, 3 to 4 times daily; loose cotton underwear; rest.
• Pharmacological: 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. Antibiotics guided by culture; start amoxicillin-clavulanate 625 mg oral 8-hourly for 7 days. MRSA or penicillin allergy: clindamycin 300 mg oral 8-hourly for 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.
• Procedures: incision and drainage with a Word catheter for 4 to 6 weeks under 1 percent lignocaine (maximum 3 mg/kg, absolute maximum 200 mg plain). After the infection has settled (at least 6 weeks), marsupialisation. If recurrence follows marsupialisation, excise the gland in theatre under general or regional anaesthesia.
• Special groups: in pregnancy use amoxicillin-clavulanate or clindamycin, avoid doxycycline and ibuprofen from 28 weeks, and defer excision to the postpartum period. In diabetes control blood glucose to 6 to 10 mmol/L with insulin as needed.
• Red flags: spreading erythema, crepitus, pain out of proportion, hypotension, skin necrosis, a hard mass, rapid recurrence.
• Follow-up: review at 48 hours, 2 weeks and 6 weeks; arrange definitive surgery; follow up at 3 months.