;)
Figure: Do not access the abscess through a skin incision. The Word catheter is inserted into the middle of the Bartholin abscess cavity (A, B) via a small puncture in the labial mucosa made with a #11 blade and a small hemostat. The balloon is filled with 3-4 ml of fluid, not air (C). If the balloon is painful, remove a small amount of fluid. The inflated balloon keeps the device in the abscess cavity, and the catheter shaft creates a fistula to the skin. Ideally the catheter should be left in place for four weeks to form a fistula, but it may fall out sooner. It is reasonable to eschew replacement if the abscess has been cured, but it should be replaced if infection is still present.
FigureThe Bartholin gland abscess is a bacterial felon that is fodder for treatment in the ED. It often prompts an ED visit when a Bartholin gland becomes cystic and then infected. Recurrent abscesses require a bit more finesse, and may require a specialist for more definitive care. Traditional Bartholin abscess drainage with a specialized catheter rather than standard incision and packing, however, is garden-variety emergency medicine. An ED visit for a Bartholin gland abscess usually results in a good outcome, at least temporarily.
Office Management of Bartholin Gland Cyst and Abscesses
Hill D, et al
Am Fam Physician
1998;57(7):1611
Many women with a Bartholin gland abscess seek out emergency care, but this infection also appears to be a common complaint in the general practitioner's office, and it presents pathology that is quite applicable to outpatient therapy. This review is one of a number of articles in the primary care literature, and represents an overview of this rather annoying and relatively common cutaneous infection. Bartholin gland abscess is a relatively easy diagnosis. The Bartholin glands are bilateral vulvovaginal bodies in the labia minora at approximately the 4 and 8 o'clock positions. Normally nondescript and only the size of a pea, the glands secrete fluid via small ducts to provide moisture for the vulva and vaginal area.
A Bartholin gland abscess is to be differentiated from a sebaceous cyst, hematoma, lipoma, or occasionally a cancerous growth, but this is not particularly challenging. Normally the glands cannot be palpated, but the gland quickly enlarges when the duct is blocked, resulting in a noticeable lump in the labia. A cyst is bothersome, but remains relatively asymptomatic unless it becomes infected. Large cysts may require intervention, but they are usually merely annoying sterile collections. One might be concerned about an apparent Bartholin gland cyst in an older patient because of the possibility of cancer.
These authors promulgate a rather standard prohibition for the treatment of a Bartholin gland abscess. Simply stated, incising, packing, and open drainage of a Bartholin gland abscess is strongly discouraged. The standard treatment is the placement of a Word catheter, a simple procedure that can be used to treat an asymptomatic cyst and a full-blown abscess.
The Word catheter has been around for years, and it is easily placed in the office or ED. It looks like a miniature Foley catheter, but it does not have a drainage port. The catheter shaft itself functions as a drain in the soft tissue, and provides egress for the pus. The catheter is inserted into the cyst cavity by making a stab incision in the vaginal mucosa just inside the hymenal ring. Importantly, the stab is in the mucosa, not in the skin. Don't try to reach the abscess cavity with the scalpel blade itself. The stab incision is the pathway and landmark for a hemostat to locate the abscess cavity, and the hemostat puncture subsequently creates a path for insertion of the drainage catheter. The purpose of the catheter is to create a permanent fistula, in lieu of a blocked duct, that will hopefully prevent further gland occlusion or subsequent infection.
Figure: Equipment required to place the Word catheter (#11 scalpel not shown). Do not perform a traditional I&D and packing of a Bartholin gland abscess. Instead, use Word catheter drainage. Once the catheter tip is in the abscess cavity, inflate the balloon with sterile water or saline infused by a needle that punctures the proximal catheter hub. Pus drains through the space between the soft tissue and the catheter shaft, not through the catheter itself. To painlessly remove the catheter, insert a needle and withdraw the fluid.
The Word catheter is a short, rubber balloon-tip catheter. The Word catheter is advanced in a deflated position to its full depth once inside the cavity, and the balloon is filled with water or saline once the tip is inside the cavity. The inflated balloon will maintain the catheter inside the abscess cavity. The aim is to keep the abscess open, and enhance drainage around (not through) the catheter and to develop a fistula tract. To accomplish the tract formation, the Word catheter should remain in place for two to four weeks to allow epithelialization. Deflating the balloon and withdrawing the catheter is a simple and relatively painless endeavor once the infection has cleared.
Formal marsupialization can be performed for more recurrent abscesses or problematic cysts. The actual cyst can be removed in recalcitrant cases.
A Bartholin gland abscess is not a subtle condition. It elicits pain while walking or sitting, and few women can handle the discomfort for long. The abscess can become remarkably large. Occasionally they will rupture and drain on their own, but this is not definitive therapy. This is a bacterial infection but a polymicrobial one whose growth mimics the natural flora of the area. Once thought to be caused primarily by gonococcal or chlamydial infection, Brook et al reported 67 different bacterial isolates in a series of Bartholin gland abscess cultures. (Surg Gynecol Obstet 1989;169[1]:32.) A Bartholin gland abscess is one infection that should be considered a candidate for culture, but do not culture the abscess pus. Standard vaginal techniques to isolate GC and Chlamydia are suggested.
The use of antibiotics for a drained Bartholin gland abscess has not been prospectively studied, and recommendations vary. Some but not all reviews suggest the use of empiric antibiotics for the abscess itself, but as with other drainable cutaneous pus collections, they are of no proven value. These authors (as of 1998) suggested broad-spectrum antibiotics for the abscess itself and cultures for GC and Chlamydia, but they do not commit to a specific antimicrobial regimen. Treatment in the operating room or admission for IV antibiotics would be warranted in cases with severe cellulitis for exceptionally large abscesses, but that's a clinical call, and it is rarely required.
Comment: Diagnosing and treating a Bartholin gland abscess in the ED is straightforward, but a few caveats should be highlighted. First, avoid formal incision, drainage, and open packing because the purpose is to maintain the function of the Bartholin gland. The ideal therapy is to create a sinus tract rather than a large and painful scar in the vaginal mucosa. Word catheters are easily placed, and the procedure box highlights a few tricks of the trade. Mistakes that I see being made are trying to penetrate the abscess with the scalpel rather than a hemostat, making too large of an incision for catheter passage, and filling the balloon with air instead of saline. The actual infection will dissipate in a few days, but premature catheter removal defeats the purpose of the Word catheter. Most Word catheters will fall out in one to two weeks, and a cure is usually achieved by then. If it falls out in a few days, it is probably best to replace the balloon for two to four weeks if the patient will tolerate it. Usually, however, patients are bacteriologically cured within a few days, and do not require further manipulation, at least not for the first event.
Figure: See One, Do One: Watch a video of a patient receiving a Word catheter for Bartholin's gland abscess and read more about this topic in Dr. Larry Mellick's blog, on the
EMN website, at
http://bit.ly/12pBoC8.
Bartholin gland abscesses tend to recur, but simple Word catheter placement would seem appropriate for at least the first few infections. It's important to avoid incising the skin. Instead, puncture the mucosal surface of the abscess for a point of entry for the catheter. This requires some eversion of the labial tissue to expose the mucosal surface, often a painful procedure that is helped immensely by some judicious intravenous analgesia before any definitive treatment.
E. coli is the most frequently isolated bacterium, and Bacteroides species is the most common of the anaerobes. Many cultures yield polymicrobial infections and no single antibiotic is appropriate, but it seems logical that the only organisms worth searching for are GC and Chlamydia. Less than a third of Bartholin gland abscesses are now caused by sexually transmitted organisms, so be quite careful what you tell your patient. A Bartholin gland abscess does not appear to be a problem of MRSA or ESBL organisms yet. Again, standard GC and Chlamydia probes used in the vagina, rather than a cotton tip applicator filled with abscess pus and sent in a culture tube, appears to be the way to go if one is hunting for organisms. The nucleic acid amplification swabs are the standard devices to ferret out GC and Chlamydia.
Figure: Step-by-step procedure for draining a Bartholin abscess with a Word catheter.
Some authors suggest analgesics and warm soaks to the area for abscesses that have spontaneously ruptured. This will often cure the extant abscess, and some may eschew a Word catheter if drainage has commenced spontaneously. I would search for the point of rupture and try to use that area as an entrance point for a Word catheter, even though the abscess has been partially evacuated.
The UpToDate.com version of Bartholin gland abscess treatment suggests that antibiotic treatment should be limited to those with a GC or Chlamydia infection, extensive cellulitis, immunosuppression, risk for MRSA, or systemic signs of infection. Necrotizing fasciitis and sepsis have been rarely reported. It doesn't make sense to me to use antibiotics to cover MRSA, or try to figure out the correct multiple antibiotics required for multiple organisms recovered by pus culture. I can drain frank pus, but I do not prescribe antibiotics for the abscess itself.
Of course, identifying GC and Chlamydia takes a few days, so some would treat empirically (overtreatment in some). I suggest empiric treatment for GC and Chlamydia at the time of initial drainage for the run-of-the-mill Bartholin gland abscess in my patient population, but without pronouncement of a not-yet-verified STD being the culprit. Many patients with a Word catheter placed in my ED seem to become lost to follow-up for some reason, so it's more productive to treat empirically than try to track down the patient for culture results. The purist would await STD testing results before antibiotics, a very reasonable alternative. Currently, ceftriaxone 250 mg IM plus azithromycin 1 gram PO is the treatment for isolated GC. A seven-day course of doxycycline would be standard intervention for Chlamydia. Broad-spectrum antibiotics are reasonable for those admitted to the hospital with serious infections. Clindamycin might be a reasonable IV empiric antibiotic, but combinations used for other cutaneous infections active against gram-negatives, gram-positives, and anaerobes might be initiated. The data are sparse and the concept is not addressed adequately in the literature.
Figure: Locating and entering the center of the abscess cavity can be tricky and not as easy as it may appear. Stabilize the abscess with the thumb and index finger, and guide the stab incision onto the hemostat, pushing until a distinct puncture is felt and pus comes out. Do not break up loculations or irrigate the cavity. Do not enlarge the puncture tract, or the Word catheter will more easily fall out.
Finding the abscess cavity is not always as easy as it appears on a technical level. The pus-filled cavity should be your only target if the abscess can be palpitated. You're in the wrong spot if your stab incision or hemostat forage does not yield copious pus. Trying to break up the loculations with a hemostat or irrigating the cavity tends to enlarge the stab incision, and can promote spontaneous explosion of the Word catheter. I would put at least 3-4 ml of saline into the catheter by injecting the hub with a 20-gauge needle. That recreates a large lump in the labia. Excessive pain when inflating the balloon calls for the removal of a small amount of fluid.
Failure of the Word catheter to remain in place for the recommended two to four weeks is common. It's a standard axiom to attempt to keep it in place for that time period, but I am not convinced that this is a strict requirement, at least for a first-time cure. A series investigating the retention of a Word catheter found that 27 of 35 (77%) women retained the catheter for four weeks. Three catheters fell out within 24 hours of insertion, three fell out within one week, and one fell out after 11 days. (Aust N Z J Obstet Gynaecol 2007;47[2]:137.) Those who return for a wound check in four to five days with a catheter out generally seem to have an initial cure in my experience.
For the iconoclast who wants to be fancy, the Word catheter may seem a bit dated, albeit generally quite effective. Gennis et al (Am J Emerg Med 2005;23[3]:414) described a novel technique that appears to simulate a loop drainage technique called the Jacobi ring catheter (after the New York hospital) that I discussed in earlier columns. (See FastLinks.) It provides a long-term loop catheter rather than a Word catheter, and this will not fall out. It seems a bit complicated for the ED, and the loop drainage seems much easier and more readily adaptable to the ED. I'm waiting for my first case to give the loop drainage technique its maiden voyage.
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Bacterial Isolates from Bartholin Gland Abscesses
Aerobic Organisms
- Neisseria gonorrhoeae
- Staphylococcus aureus
- Streptococcus faecalis
- Escherichia coli
- Pseudomonas aeruginosa
- Chlamydia trachomatis
Anaerobic Organisms
- Bacteroides fragilis
- Clostridium perfringens
- Peptostreptococcus species
- Fusobacterium species
Source: Surg Gynecol Obstet 1989;169(1):32.
FastLinks
- Read The Procedural Pause, EMN's newest blog by Dr. Roberts and his daughter, Martha Roberts, ACNP, CEN, at http://bit.ly/ProceduralPause.
- Dr. Roberts' column on loop drainage is available at http://bit.ly/12n4IpU.
- Read all of Dr. Roberts' past columns at http://bit.ly/RobertsInFocus.
- Comments about this article? Write to EMN at [email protected].
Reader Feedback:Readers are invited to ask specific questions and offer personal experiences, comments, or observations on InFocus topics. Literature references are appreciated. Pertinent responses will be published in a future issue. Please send comments to[email protected].
Dr. Roberts:While on vacation, I took my son, a healthy 30-year-old with a 3 cm painful, tender, warm anterior cervical triangle cutaneous abscess, to the Accident & Emergency Room at St. Mary's Hospital in London. The abscess was well defined, and had a 3 cm halo of erythema.
The 40-year-old emergency medicine-boarded physician there insisted on a cephalosporin and penicillin. I so wished that I had brought along an I&D kit and opened the abscess in our flat. The physician cited the British “Roberts Rules” of dealing with such abscesses and would not open it.
The halo receded, and the pain of the abscess improved after significantly after 72 hours. My son was followed up in Senegal where he is a Peace Corps volunteer; the entire infection pretty much resolved without complication after two weeks of antibiotics. I am not sure what to take away from this experience in Britain. — Tristram C. Dammin, MD, Danvers, MA
Dr. Roberts responds:I am not sure what to make of this either, but it does seem that this Brit had a jolly different approach from the United States. Perhaps an English-trained EP who is an EMN reader can chime in. I would not argue too much with success, albeit protracted therapy, courting C. diff.
Failure to drain pus in a true abscess would certainly have upset Hippocrates, and seems counterintuitive to our current thinking. It probably did save your offspring from a neck scar, a dating turnoff for sure. One wonders if this were a true abscess or just a very indurated cervical lymph node or reactive bug bite. Both can mimic an abscess and go away with time and antibiotics.
In my experience, an abscess would not take two weeks to resolve if it had been drained. The penicillin/cephalosporin combination is a bit odd; I have not seen that regimen quoted by the Infectious Diseases Society of America. It would seem that this was not MRSA, or at least not treated as such. Hopefully, he did not misquote “Jim Roberts' Rules;” those would take a contrary stance, and I did not think that parliamentary rules of order were applicable to an abscess. I think I would have stuck a pin in it back at the hotel.
