# Bartholins Cyst or Abscess Drainage

## Overview

This module describes how to manage a Bartholin’s cyst/abscess where incision and drainage is indicated.

## Indications

1. Symptomatic (painful) Bartholin gland cysts or abscesses

2. Marsupialisation
   Marsupialisation

   Where the edges of the skin are sutured open after incision; must be performed in theatre under general anaesthesia.

   is indicated for an infected cyst or abscess

3. Complete excision
   Complete excision

   To be performed by a gynaecologist under general anaesthetic in theatre.

   is indicated for chronically infected glands or abcesses/cysts in peri- or postmenopausal woman, because there is a small risk of malignancy

## Contraindications

1. None

## Patient information and consent

Always verify your patient’s identity and obtain informed consent before proceeding.

### How do I explain this procedure?

“The swelling that has formed on the inner lip of your vagina is a cyst or abscess that has formed in a normal gland. It’s not clear why this happens. I need to make a small cut to drain the pus, then place a short piece of tubing that will remain in place for a month.”

### What can my patient expect?

“This is a relatively quick procedure. I will give you an injection that will numb the area before I make the cut and place the tubing. You may feel pressure and tugging when I work there, and this will be uncomfortable.”

### What is my patient’s role?

“Let me know if you have any allergies, a heart condition, a bleeding tendency, or use blood thinners. Fearing blood or needles is normal, but tell me if you have fainted from it. Keep as still as possible. If you feel strange sensations like tingling or severe pain, tell me immediately. Afterwards you will need to sit in a bath of warm salt water a few times a day to assist with the healing. Come back in a month to have the tubing removed, and while it is in, abstain from sexual intercourse.”

## Preparation

###

### Documentation

1. Patient notes

### Equipment

1. Non-sterile and

   sterile
   sterile

   Although it is considered best practice to use sterile gloves to perform minor procedures, there is mounting evidence that infection rates are similar for sterile and non-sterile glove use.

   gloves

2. Alcohol-based hand rub

3. Sharps container
   Sharps container

   If a sharps container is not within arm's length, use a kidney dish or other hard container to temporarily hold used sharps and to carry them to the sharps container for disposal.

4. Sterile drapes

5. Povidone iodine

6. Supplies for

   anaesthesia:
   anaesthesia:

   Superficial, well-fluctuant abscesses may be sufficiently anaesthetised with ethyl chloride spray.

   1. Lignocaine (usually 1-2% with adrenaline)
   2. Alcohol swab
   3. 5 ml syringe
   4. Aspiration needle (ideally blunt fill) & a small gauge injection needle

7. Suture pack

8. Word catheter or make a

   Jacobi ring
   Jacobi ring

   See Troubleshooting for details.

9. No.11/15 scalpel blade

10. 5 ml syringe & injection needle

11. PPE: Gown, mask and eye protection

## Site & Positioning

Position the patient in lithotomy. This procedure requires strong, focused lighting.

## Procedure

Follow medical asepsis with sterile gloves.

1. Perform hand hygiene and don non-sterile gloves.

2. Draw up approximately 3 ml lignocaine and anaesthetise the area, use ethyl chloride spray for small abscesses, or consider general anaesthesia for large or deep abscesses.

3. Doff non-sterile gloves. Don mask, gown, and eye protection.

4. Open the suture pack to create a sterile field. Pour skin disinfectant into the well. Open the scalpel blade, Word catheter, syringe and needle onto the field.

5. Don sterile gloves.

6. Clean
   Clean

   Clean in a circular fashion from the abscess in the centre outwards.

   and drape the area.

7. Retract the labia majora laterally.

8. Stabilise the cyst with the fingers of your non-dominant hand or by grasping the cyst wall with forceps.

9. Make a 2-3 cm vertical stab incision at the mucocutaneous junction, then extend the incision deeper into the cyst.

10. Apply pressure to the area around the cyst to expel contents.

11. Insert a haemostat or curved forceps. Use blunt dissection to break down loculations inside the cyst.

12. Apply pressure to expel remaining contents.

13. Place the tip of a Word catheter into the cavity and inflate the balloon using a needle and syringe with 2-5 ml normal saline.

14. Tuck the end of the catheter into the vagina.

15. Dispose of medical waste safely.

16. Record the completion of the procedure in patient notes.

### For placement of a Jacobi ring

1. Perform steps 1-12 as above.
2. Tunnel the haemostat or curved forceps through the cyst and make a second incision on the other end of the cyst for the tip of the haemostat or curved forceps to exit.
3. Grasp the one end of the Jacobi ring with the haemostat or curved forceps.
4. Pull the Jacobi ring through the abscess cavity, ensuring that the suture is not pulled out of the catheter.
5. Tie the two ends of the sutures, which forms a closed ring.
6. The Jacobi ring is removed on follow-up after 3 weeks.

### For marsupialization

1. The initial procedure is the same as for incision and drainage.
2. Grasp the edge of the incision with a forceps and evert the edge.
3. Using absorbable interrupted sutures, suture the edges onto the adjacent epithelial surface, starting first with one side of the incision then the other, so that the cavity stays open.
4. Pack the cavity with topical antibiotic cream or iodine soaked gauze.

## Troubleshooting

I do not have stirrups at my disposal.

The patient should be positioned reclining or supine, with their heels drawn up to their buttocks and knees apart.

I want to make a Jacobi ring.

Use a 7cm length of a size 8 French T tube, and thread approximately 20cm of 2-0 silk suture material through the middle of the tube. Alternatively, a 5 cm length of butterfly needle tubing can be used with absorbable (Vicryl) suture material threaded through the lumen.

I do not have theatre facilities available.

If the cyst walls can be identified, marsupialisation in theatre is the preferred treatment. If unable to perform, relieve the abscess first, then electively do the marsupialisation.

The cyst appears to be under high pressure and I’m worried about splash exposure.

Wear appropriate PPE, including eye protection, a facemask, and an apron. You may partially drain the cyst with a needle and syringe prior to excision. Don’t fully drain the cyst as this will make incision more difficult.

## Risks

1. Haemorrhage
2. Postoperative dyspareunia
3. Infections
4. Excessive scarring secondary to marsupialization
5. Sharps injury to healthcare personnel

## References

1. Lee WA, Wittler M. Bartholin Gland Cyst. [Updated 2022 Feb 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK532271/
2. Blitz-Lindeque J. How to treat a bartholin’s cyst or abscess. In: Mash B, Blitz-Lindeque J, eds. South African Family Practice Manual. 2nd ed. Pretoria: Van Schaik Publishers; 2010: 302.
3. Omole F, Kelsey RC, Phillips K, Cunningham K. Bartholin Duct Cyst and Gland Abscess: Office Management. Am Fam Physician. 2019;99(12):760-766. Available from: https://www.aafp.org/afp/2019/0615/p760.html
4. Gennis, Li, S. F., Provataris, J., Shahabuddin, S., Schachtel, A., Lee, E., & Bobby, P. Jacobi ring catheter treatment of Bartholin’s abscesses. The American Journal of Emergency Medicine. 2005;23(3):414–415. https://doi.org/10.1016/j.ajem.2005.02.033