Prepare the Patient

Informed consent for procedure should be obtained.

The patient is positioned in the dorsal lithotomy position, preferably in stirrups

The Bartholin’s duct cyst or abscess is stabilized between thumb and forefinger, and is subsequently prepped with iodine solution.

At this point, change to sterile gloves.

Administer local anesthetic (2-5cc of 1% or 2% lidocaine using 25 or 30 gauge needle) superficially in mucosa overlying abscess/duct cyst inside hymenal ring.

Tip: Try to inject under and around cyst/abscess and not directly into it. Injecting directly into the cavity can trap lidocaine within the cavity and result in inadequate anesthesia as well as causing abscess/ cyst rupture. If rupture occurs, try not to drain abscess/cyst completely as this will make Word catheter placement more difficult.

Incise the lesion

Grasp cyst wall or abscess with small forceps (or stabilize abscess/cyst with thumb and forefinger) and using a No. 11 scalpel make a stab incision into the Bartholin’s gland cyst or abscess. Place stab incision preferably inside (internal) or just outside (external) to hymenal ring within the introitus in region of normal gland opening. It is not appropriate to place incision on the external genitalia (outside labia) unless the abscess is pointing in this region and rupture is imminent. Make the stab incision <1cm length (usually 3-4mm) and 1-1.5cm deep into cyst or abscess. If the incision is too small, it will not accommodate the catheter. If the incision is too large, the catheter will fall out prematurely. Proper placement of stab incision may require assistance with traction placed on the lateral aspect of the labia to allow visualization inside the hymenal ring. Entering the abscess cavity will be signaled by a palpable pop or the free flow of pus.

Alternatively, make incision using 4-6mm Keyes-punch biopsy. Using a rotating motion, apply 4mm punch biopsy instrument to cyst/abscess, will need to puncture vaginal mucosa & then cyst wall to enter cyst/abscess cavity. This may also result in tissue specimen for diagnosis

Culture and Irrigate

If abscess- culture abscess cavity for GC/Chlamydia & routine culture for aerobes and anerobes

Consider obtaining cervical cultures for GC and Chlamydia due to association of Bartholin’s abscess with GC and Chlamydia.

Drain and irrigate cyst cavity. After irrigation, probe with q-tip or hemostat to break up loculations, and irrigate again.

Insert the Word Catheter

Check integrity of balloon (using needle attached to syringe, inject saline into balloon through catheter’s sealed-stopper end, be careful not to puncture balloon with needle as inserting into tip of catheter)

Place deflated Word catheter into the incision to base of cyst/abscess cavity.

Tip: If you encounter difficulty inserting catheter into cyst cavity, the incision may be too small or the incision may not be completely through the cyst/abscess wall. One option is to place the 20 to 25 gauge 1 inch needle with attached syringe filled with 3cc of saline into self-sealing injection port of catheter before insertion (leave the balloon deflated). This provides a stylette for insertion (catheter is otherwise very flexible) and can reduce the chance of accidental needle-stick injury. Grasp edge of cyst or abscess wall with hemostat to provide traction & allow for easier passage of catheter. If this fails, would enlarge incision & retry. If incision is too large, then catheter will not remain in place & will require suturing.

Inflate bulb with saline 2-3 cc injected through hub of catheter. The inflated balloon allows the catheter to remain within the cavity of the cyst or abscess. Check to ensure balloon secure within cyst or abscess cavity by gently tugging on catheter with syringe detached or with pressure maintained on the syringe plunger (see below). Persistent pain after the balloon is inflated signals overfilling the balloon and 0.5-1cc should be removed until the patient is comfortable.

Tip: The catheter can fall out when the clinician checks the tightness of balloon by tugging on it with the syringe still attached. This increased pressure on the balloon will push saline back up into the syringe and the balloon deflates to a smaller size. To prevent premature expulsion of catheter, maintain pressure on the syringe plunger while checking the bulb placement or remove syringe.

Suture catheter in place if necessary, one interrupted suture placed on one side of catheter is usually sufficient to close incision, do not place suture through catheter.

Tuck free end of catheter into vagina.

Aftercare

Antibiotics | Discharge Instructions | Follow Up | Catheter Removal

Antibiotics

Noninfected Bartholin gland cysts are usually sterile, routine antibiotic therapy is not necessary.

Initiate broad spectrum oral antibiotics only if surrounding cellulitis is present (erythema, induration, inflammation). Until cultures resulted, antibiotic coverage should also be directed at N. Gonorrhea. One suggested regimen is ceftriaxone (125mg IM as a single dose) or cefixime (400mg PO as a single dose) to cover E. Coli and N. gonorrhea and clindamycin (300mg PO qid for 7 days) to cover anerobic organisms. If the culture result reveals chlamydia trachomatis, azithromycin (1gm PO as a single dose) can also be given. (up to date). Another suggested regimen is cefpodoxime (200mg PO bid for 7 days) or metronidazole (400mg PO bid for 7 days ) with ampicillin (250mg PO qid for 7 days).

Signs of sepsis should prompt intravenous therapy with coverage for coagulase-positive staphylococcal organisms.

Discharge Instructions

Patient instructions: sitz baths 2- 3 times daily will provide comfort & healing during immediate postoperative period. The patient should expect a discharge, as catheter allows for drainage of cyst or abscess. The catheter will ideally remain in place for 4-6 weeks to allow epithelialization of a new tract. Most sources advise pelvic rest (no sexual intercourse, tampon insertion or douching) until removal of catheter, although Word’s original paper stated that sexual intercourse may be resumed after catheter insertion. The concern is for premature catheter expulsion and superinfection.

Follow Up

If the patient has abscess with or without cellulitis, she should be seen asoutpatient within 48 hours to ensure resolution and check culture results.

If Bartholin’s duct cyst, she should be seen within 1 week to ensure resolution of symptoms, check status of catheter, then again at 4-6 weeks to remove catheter or sooner if pain or catheter expulsion.

Catheter removal

Leave should be left in place for 4-6 weeks to allow epithelialized tract to form & drainage of secretions.

Catheter is removed by deflating the balloon by inserting needle into the catheter sealed-stopper end and drawing out the saline. The catheter is then withdrawn from the incision. Over time the resulting orifice will decrease in size and become unnoticeable. Scarring is usually minimal.