 Cysts can vary from one to eight cm in diameter, and are usually tense, unilateral and nonpainful. 20 If the cyst becomes infected, an abscess develops in the gland. Abscess formation in the Bartholin’s gland is suspected when the classically located mass is large, tender, erythematous, edematous and fluctuant. There may be regional lymphadenopathy. The well-developed abscess may have an attenuated epithelial lining at the introitus, a sign of a pointing abscess. The abscess can dissect into the labium majus, especially if the abscess is multilocular. Bartholin gland abscesses typically develop over two to four days and can become larger than 8cm. Without treatment, they tend to rupture and drain after four to five days. There may be associated cellulitis with surrounding tenderness, erythema, inflammation and induration. Bartholin’s gland cysts and abscesses may be unilateral or bilateral and recurrent. 7,15,20,22
The differential diagnosis includes cystic and solid vulvar conditions, including: sebaceous cyst, labial abscess, hematoma, fibroma, lipoma, hidradenoma, syringoma, endometriosis, myoblastoma, accessory breast tissue, leiomyoma, acrochordon, Von Recklinghausen’s tumor (neurofibroma), squamous cell carcinoma, adenocarcinoma, Skene’s duct cyst, epidermal inclusion cyst, Gartner’s duct cyst, and inguinal hernia. 15, 19, 22 Cystic lesions can also occur in the vagina and are usually distinguished from Bartholin gland cysts by their anatomic location. 7
There should be no concern for malignancy. Typically, Bartholin’s glands shrink during menopause, thus, a vulvar lesion in a postmenopausal woman should be evaluated for malignancy. Some sources advocate excision of all Bartholin gland cysts in patients over forty years of age because of the possibility of cancer. 6, 20 The mean age of discovery of Bartholin’s gland carcinoma is fifty. 10,20 However, surgical excision is associated with considerable morbidity due to intraoperative hemorrhage (due to vascularity of underlying vestibular bulb and venous plexus), hematoma formation, secondary infection and adhesion formation with resultant postoperative dyspareunia. 19,20 Some investigators have advocated that surgical excision is unnecessary because of the low risk of Bartholin’s gland cancer (0.023 per 100,000 woman-years in premenopausal women and 0.114 cancers per 100,000 woman-years in postmenopausal women). Instead women in this age group may benefit from drainage (marsupialization or Word catheter placement) with selective biopsy. 21 Suspicion for carcinoma should be raised if cyst appears nodular, irregular, is fixed to underlying tissue or is persistently indurated, particularly in patients older than forty. 5,22 If there is concern for malignancy by examination findings, refer the patient to a specialist for biopsy or possible excision and do not proceed with Word catheter placement. 19 |
