Bartholinitis: Etiology, Classification, Diagnosis and Treatment

Bartholinitis is an inflammatory process of the bartholin glands, which can manifest in various clinical forms.

In clinical practice, several forms of pathology of the bartoline glands are distinguished:

1. A bartholin gland cyst is the result of obstruction of the outlet duct with accumulation of sterile secretion.
2. Acute bartolinitis is an inflammatory process without a purulent component.
3. Bartholin gland abscess – purulent inflammation with cavity formation.

The states can be either successive stages of a single process or develop independently of each other.

Anatomy

The Bartholin glands, also known as the large vestibular glands, are a pair of glands connected to ducts that are located between the labia minora and the edge of the hymenium at the 4 and 8 o’clock positions of the conventional dial. The main function of the glands is to secrete a secretion necessary for moisturizing the mucosa during sexual intercourse.

Etiology

A bartholin gland cyst is a benign obstruction of the gland with impaired secretion, which is often unilateral and asymptomatic.

Secretion accumulation can occur after trauma, episiotomy, or childbirth, but most cases occur without an identifiable cause in women of reproductive age.

Anatomophysiologically, the bartholin glands are highly susceptible to polymicrobial infection from the perianal area, with pathogens colonizing the vagina and glands. With this in mind, a bartholin gland cyst may be complicated by acute bartholinitis or abscess.

Acute bartholinitis and abscess can occur without a cyst of the bartholin gland duct. In addition to perianal flora, sexually transmitted infections can cause inflammation of the gland.

Clinical picture

Bartholin gland cyst of small size, which is not inflamed, can be asymptomatic. Nevertheless, during gynecologic examination it is possible to observe and palpate a soft-elastic formation with smooth contours, not adherent to the surrounding tissues in the area of the gland.

Large cysts, bartholinitis and abscesses usually cause severe pain and swelling of the vulva, and the patient has difficulty walking, sitting and sexual intercourse (dyspareunia). The abscess on examination presents as a mass in the lower vestibular region surrounded by erythema and edema, often with regional lymphadenitis. Enlargement of the abscess and its spread to the labia, may lead to spontaneous drainage. The patient experiences sudden relief after the discharge of purulent contents.

In neonates, bartholin gland duct cyst is associated with hydroureteronephrosis and contralateral renal cyst, which may cause urinary retention.

Involution of the gland begins by the age of 30. Formation in the area of the bartolin gland in women over 40 years of age, may have a malignant nature. In such cases, the neoplasm is painless and adherent to the surrounding tissues, it is often possible to detect an increase in the sentinel lymph node.

Diagnosis of bartholinitis

Differential diagnosis at any age includes the exclusion of the following diseases and conditions:

• Other cysts (Gartner’s passage, Skeen’s duct, Nuka’s canal);
• Vaginal prolapse;
• Vulvar angiomyofibroblastoma;
• Endometriosis;
• Choriocarcinoma;
• Myeloid sarcoma;
• Myxoid leiomyosarcoma;
• Fibroma;
• Angiomyxoma;
• Hematoma;
• Myoblastoma;
• Ischiorectal abscess;
• Folliculitis;
• Fibroadenoma;
• Lipoma;
• Papillary hidradenoma;
• Siringoma;
• Adenocarcinoma;
• Squamous cell carcinoma.

Methods of differential diagnosis used to clarify the diagnosis:

History and physical examination

Collection of complaints, history, examination and palpation of the pelvis and perineum to detect voluminous or inflammatory changes.

Visualization methods

• Ultrasound (USG) is the primary method of evaluating cysts, tumors, and abscesses.
• Magnetic resonance imaging (MRI) – to clarify the structure and prevalence of processes.
• Computed tomography (CT) – in cases of suspected spread of malignant tumors.

Laboratory tests

• General and biochemical blood tests – to detect inflammatory and other systemic changes.
• Examination of cancer markers (e.g., CA-125).
• Microbiologic cultures in suspected infectious processes.

Cytologic and histologic methods

• Smear for cytology (Pap test) – to detect malignant and precancerous changes.
• Biopsy – to confirm and clarify the diagnosis of tumors and endometriosis.

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Treatment for bartholinitis

Asymptomatic cysts do not require active treatment.

If the cyst is enlarged or suppurative, management depends on the possibility of self-drainage. In these circumstances, conservative management with sitz baths and administration of non-steroidal anti-inflammatory drugs for a few days may be considered.

A first-time cyst or abscess can be treated by incision and drainage with a Word catheter. The advantage of this method is the simplicity and effectiveness of the treatment. It is important to clarify the patient’s allergic history, as the Word catheter is made of latex. Installation of drainage is carried out under local anesthesia.

A 3 mm vertical incision should be made with a scalpel along the surface of the labia minora mucosa to avoid scarring and reduce the risk of catheter dislodgement.

The evacuated secretions may be sent to a laboratory for bacteriologic examination, and a biopsy may be performed at the same time.

The balloon-end catheter is then inserted into the cavity and filled with 3-5 ml of hypertonic solution. The outer part of the catheter is placed in the vagina for comfort and to reduce the likelihood of displacement. The catheter is placed for 4-6 weeks for appropriate drainage and epithelialization of the outlet, resulting in the formation of a new outlet.

Catheter placement may be possible in recurrent cysts and abscesses in combination with antibacterial drugs.

Antibiotic therapy should cover:

• Staphylococcal infection, particularly methicillin-resistant Staphylococcus aureus and Streptococcus aureus;
• Enteric gram-negative aerobes, including Escherichia coli.

Antibiotic therapy should be mandatory for patients with systemic symptoms including fever, patients with suspected sepsis, and those at high risk of recurrence.

In addition to the Word catheter, there is a ring catheter.

The advantage of the ring catheter is:

• Reducing the risk of spontaneous prolapse;
• Creation of two drainage ways.

The disadvantage of the method is the lack of commercially available ready-made catheters, only independent individual manufacturing is possible.

In case of impossibility of catheter placement, marsupialization of the cyst is possible. Marsupialization is performed in the operating room by creating a 2-cm incision and suturing the edges of the cyst capsule to the edges of the incision with interrupted sutures. In order to prevent premature closure of the opening, a drain is placed in the first two days.

Treatment of cysts and abscesses with traditional surgery is characterized by some disadvantages and complications such as:

• Bleeding;
• Postoperative dyspareunia;
• Infectious complications;
• The need for general anesthesia.

Laser surgery can be less invasive and more effective because it addresses many of the problems of traditional surgery.

Non-surgical treatment is sclerotherapy using ethanol or silver nitrate, but this treatment still carries a high risk of recurrence.

Needle aspiration of cyst contents is a fairly simple procedure, but it has a higher recurrence rate than the previously discussed office manipulations and is not recommended.

It is worth noting that the removal of the bartolin gland is performed in case of ineffectiveness of other treatment options and remains the only radical method.

Pregnant women diagnosed with a cyst or abscess of the bartholin gland duct should be treated in the same way as non-pregnant women, except for gland excision due to the high risk of bleeding.