Recurrent Bartholin Cyst

A recurrent Bartholin cyst is a Bartholin cyst that returns after one or more drainage procedures. It is defined as recurrence within 12 months or two or more episodes.

• Simple incision and drainage often fails because the duct closes again.
• Definitive treatment creates a permanent new duct opening or removes the gland.
• Women above 40 years need histology to exclude carcinoma.

Repeated painless or mildly painful swelling at the posterior introitus on the side of the previous cyst.

• Swelling 2 to 5 cm, tense and non-tender, with a scar from earlier drainage.
• Dyspareunia, discomfort when sitting, and recurrent need for drainage.
• Differential diagnosis: recurrent Bartholin abscess, epidermal inclusion cyst, Skene gland cyst, vestibular mucous cyst, canal of Nuck cyst, Bartholin gland carcinoma.
• Complications: abscess, scarring, dyspareunia, repeated procedures and, rarely, malignancy missed.

Diagnosis is clinical.

• Document the number and dates of earlier episodes and procedures.
• Endocervical swabs for gonorrhoea and chlamydia; HIV and syphilis tests; random blood glucose.
• Send the cyst wall for histology at surgery, and biopsy before surgery if the mass is solid, ulcerated or fixed.
• Pelvic ultrasound when a canal of Nuck cyst or solid component is suspected.

Treatment aims for a durable new duct opening.

• Supportive: warm sitz baths for 10 to 15 minutes, 3 to 4 times daily after the procedure; loose cotton underwear; avoid sexual intercourse for 2 to 4 weeks.
• Pharmacological: paracetamol 1 g oral 6-hourly (maximum 4 g in 24 hours) and ibuprofen 400 mg oral 8-hourly with food for 3 to 5 days (maximum 1.2 g in 24 hours). Antibiotics only for infection or positive swab: amoxicillin-clavulanate 625 mg oral 8-hourly for 5 days; for gonorrhoea or chlamydia add ceftriaxone 500 mg IM single dose and doxycycline 100 mg oral 12-hourly for 7 days.
• Procedures: marsupialisation is first choice. Under local anaesthesia with 1 percent lignocaine (maximum 3 mg/kg, absolute maximum 200 mg plain) or regional anaesthesia, make a 1.5 to 3 cm elliptical incision on the inner mucosal surface, drain, and suture the cyst wall edges to the vestibular mucosa with interrupted absorbable 3-0 sutures. Alternative: Word catheter for 4 to 6 weeks. If marsupialisation fails twice, gland excision under general or regional anaesthesia, with care for haemorrhage from the vascular bed. Silver nitrate ablation of the cyst wall is an option when facilities for surgery are limited.
• Special groups: in pregnancy defer excision to the postpartum period and use catheter or marsupialisation only if symptomatic; avoid ibuprofen from 28 weeks and doxycycline.
• Red flags: haematoma after surgery, fever, hard or ulcerated mass, new mass in women above 40 years.
• Follow-up: review at 2 and 6 weeks; examine for recurrence at 3 months; refer for gland excision if recurrence follows marsupialisation.