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Volume 64, Number 6
OBSTETRICAL AND GYNECOLOGICAL SURVEY
Copyright © 2009
by Lippincott Williams & Wilkins       CME REVIEWARTICLE                                                                                    16
               CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total
               of 36 AMA/PRA Category 1 CreditsTM can be earned in 2009. Instructions for how CME credits can be earned appear on the
               last page of the Table of Contents.




             Management of Bartholin Duct Cysts
                      and Abscesses
                                         A Systematic Review
                  Mary Ellen Wechter, MD, MPH,* Jennifer M. Wu, MD, MPH,†
                        David Marzano, MD,‡ and Hope Haefner, MD§¶
           *Senior Associate Consultant, Department of Gynecology, Mayo Clinic Florida, Jacksonville, Florida;
         †Assistant Professor, Department of Obstetrics and Gynecology, Division of Urology, Duke Medical Center,
         Durham, North Carolina; and ‡Clinical Instructor, §Professor, Department of Obstetrics and Gynecology,
        ¶Co-director of the University of Michigan Center for Vulvar Disease, University of Michigan Health System,
                                                   Ann Arbor, Michigan

            Objective. To review systematically the literature, published in English, on recurrence and healing after
         treatment of Bartholin duct cysts and abscesses.
            Data Sources. We searched PubMed, EMBASE, CINAHL, LILACS, Web-of-science, the Cochrane data-
         base, and POPLINE from 1982 until May 2008. We searched the internet, hand-searched reference lists, and
         contacted experts and authors of relevant papers to detect all published and unpublished studies.
            Methods of Study Selection. We included any study with at least 10 participants, addressing either
         frequency of recurrence or healing time after treatment of Bartholin duct cyst or abscess. We followed
         MOOSE (meta-analysis of observational studies in epidemiology) guidelines. Of 532 articles identified, 24
         studies (5 controlled trials, 2 cohort studies, and 17 case series) met all inclusion criteria. Study size
         ranged between 14 and 200 patients.
            Tabulation, Integration, and Results. The interventions included: (1) Silver nitrate gland ablation, (2)
         cyst or abscess fenestration, ablation, or excision using carbon dioxide (CO2) laser, (3) marsupialization,
         (4) needle aspiration with or without alcohol sclerotherapy, (5) fistulization using a Word catheter, Foley
         catheter, or Jacobi ring, (6) gland excision, and (7) incision and drainage followed by primary suture
         closure. The reported frequency of recurrence varied from 0% to 38%. There was no recurrence after
         marsupialization in available studies. Recurrence after other treatments varied, and was most common
         after aspiration alone. Healing generally occurred in 2 weeks or less.
            Conclusion. There are multiple treatments for Bartholin duct cysts and abscesses. A review of the
         literature failed to identify a best treatment approach.
            Target Audience: Obstetricians & Gynecologists, Family Physicians
            Learning Objectives: After completion of this article, the reader should be able to identify seven
         different treatments for Bartholin duct cysts or abscesses, contrast treatment choice complications and
         recurrence risks for the different options for treatment of Bartholin duct cysts or abscesses, and point out
         the limited quality and quantity of data upon which to choose best practices.



  Symptomatic enlargement of Bartholin ducts, most                      this number, its context, and recent estimates of prevalence
commonly due to cyst or abscess formation, represents                   are difficult to find. Clearly defined risk factors are simi-
a common management dilemma in gynecology. Al-                          larly elusive; however, the risk profile is similar to those of
though a prevalence of 2% is often quoted, the origin of                women at risk for sexually transmitted diseases (1).
                                                      www.obgynsurvey.com | 395
396                                         Obstetrical and Gynecological Survey

   Treatment of the symptomatic Bartholin duct cyst or                  “Bartholin glands” with an inclusive key word, “bar-
abscess also may prove challenging, demanding time,                     tholin*,” combined with MESH headings “cysts” and
anesthesia, and exposure. There are many options for                    “abscess” as well as the key words “cyst” or “cysts” or
treatment, including antibiotics and soaks, simple                      “abscess*” or “gland*” or “duct*.” We combined these
drainage, fistulization to create a new duct opening,                   results with a search for key words pertaining to treat-
marsupialization, and excision of the gland. Destruc-                   ment: (“treatment*” or “therapy” or “technique*” or
tion of the cyst or abscess base with silver nitrate or                 “management”) along with the related articles feature
alcohol has also been used. Some providers favor the                    in PubMed and hand-searched reference lists of ob-
use of a carbon dioxide (CO2) laser to accomplish                       tained full-text articles and reviews. We contacted
cyst ablation or fenestration or gland excision. De-                    authors of relevant papers and experts on vulvar
spite the available treatment options, reported recur-                  pathology to detect unpublished studies, and searched
rences are common (2,3), and prolonged healing                          the internet for additional studies.
interrupts daily activities and intercourse. The choice
of treatment for Bartholin duct cysts and abscesses
                                                                                       STUDY SELECTION
remains difficult.
   Our intent with this systematic review is to clarify                    We included any study with the outcomes of inter-
the existing evidence on which to base treatment of                     est related to the treatment of a Bartholin duct cyst or
symptomatic Bartholin duct cysts and abscesses. We                      abscess that included at least 10 participants and was
performed a thorough, transparent search for all                        published in English within the last 26 years. We
available literature published in English in the last 26                excluded case reports and studies on non-Bartholin
years. Specifically, our research questions were: (1)                   vulvar pathology, Bartholin gland malignancy, or
what percentage of treated Bartholin duct cysts or                      Bartholin disorders other than cysts or abscesses
abscesses recurs, according to treatment method;                        (e.g., leiomyoma, hyperplasia, or endometriosis of
and, (2) what is the duration of time to accomplish                     the Bartholin gland).
healing, according to the treatment method. We also                        The authors worked together independently and col-
sought answers to secondary questions including:                        lectively to evaluate and qualify the articles identified.
what is the approximate procedure time for each                         A “quality” designation was based on criteria includ-
treatment; which treatments are accomplished as out-                    ing study design, study size, randomization method
patients; and what complications are associated with                    and concealment of allocation, defined intervention
the different therapies.                                                and outcome, follow up, and the potential for bias.
                                                                        “Quality” was described in prose, guided by a 5-tier
                                                                        scale (1 being a well-done randomized controlled
                          SOURCES                                       trial with allocation concealment and 5 being a small,
  The first author and a university-employed librar-                    descriptive study with little available data.) Compar-
ian independently performed the literature search for                   ative studies were evaluated for similarities that
this review. We searched the following databases from                   might allow inclusion in a meta-analysis. We fol-
1982 (or the earliest available from 1982 forward) until                lowed MOOSE guidelines for observational studies
May 2008: PubMed, EMBASE, CINAHL, LILACS,                               in completing this review and used descriptive sta-
Web-of-science, the Cochrane database, and POPLINE.                     tistics to describe findings (4).
For the PubMED search, we used the MESH heading
                                                                                              RESULTS
   Dr. Wu has disclosed that she was a recipient of a grant from
ACOG/Wyeth and she was/is the recipient of a grant from Pfizer.           Our combined search of databases yielded a total
All other authors have disclosed that they have no financial rela-      of 569 article titles. We scanned the first 400 head-
tionships with or interests in any commercial companies pertain-        ings from our internet search and identified 1 dupli-
ing to this educational activity.
   The Faculty and Staff in a position to control the content of this
                                                                        cate study (5). We identified no unpublished studies
CME activity have disclosed that they have no financial relationships   and no additional studies from contact with experts
with, or financial interests in, any commercial companies pertain-      and authors. We limited identified titles by excluding
ing to this educational activity.                                       duplicates, studies published before 1982, and case
   Lippincott Continuing Medical Education Institute, Inc. has          reports or studies of Bartholin gland malignancy or
identified and resolved all faculty conflicts of interest regarding
this educational activity.
                                                                        non-Bartholin vulvar pathology. An additional 12 stud-
   Reprint requests to: Mary Ellen Wechter, MD, MPH, 4500 San           ies, published in foreign languages were excluded, 5 of
Pablo Rd., Jacksonville, FL 32224. E-mail: Wechter.Mary@mayo.edu.       which, by abstract, would have been appropriate for
Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article                             397

full-text review if available in English (6–10). Of the 87   25). Patients’ mean age was between 28 and 34 years.
remaining studies, we evaluated abstracts, when              Treatment was almost universally outpatient (18), and
available, and excluded narrative reviews, patient           local anesthesia was used for all but select patients in
handouts, tutorials, commentaries, presentation of           1 study (24). Antibiotics were given for abscesses
the same study group (within 10 participants) (5,11),        only. Following a 1- to 2-cm linear incision in the
study size less than 10 (12), and any study not              vulvar skin and cyst wall, the Bartholin duct cyst or
evaluating a treatment for Bartholin duct cyst or            abscess was penetrated and evacuated. A 0.5          0.5
abscess or not presenting at least one of the primary        cm stick of crystalloid silver nitrate was then inserted
outcomes of interest (13). We excluded 2 abstracts,          into the cavity. The residual silver nitrate and coag-
presented at scientific meetings, for which a full-text      ulated cyst capsule were commonly removed or
was not available and which either did not describe          spontaneously expelled (22), at 2 to 3 days. Silver
our primary outcomes (14) or did not present healing         nitrate treatment generally took 15 minutes or less.
time nor a reliable denominator for determining re-             Healing after silver nitrate was usually accom-
currence frequency (15).                                     plished within 10 days. With 143 patients repre-
   From the remaining 35 full-text articles, we se-          sented and follow-up of at least a year in all 6 studies,
lected the 24 that met all inclusion criteria. Studies       4 studies reported no recurrence. In each of 2 case
eligible for this review included 5 controlled trials, 2     series, 4% of women had recurrent gland pathology
cohort studies, and 17 case series. Study size ranged        within the first 2 months of treatment. The most
from 14 to 200. The interventions were: (1) silver           common adverse effects were vulvar burning on the
nitrate gland ablation; (2) gland or duct fenestration,      first postoperative day and labial edema. Inadvertent
ablation, or excision using carbon dioxide (CO2)             cautery of vulvar mucosa occurred in 20% of patients
laser; (3) marsupialization or “window operation”;           in 1 small series (22). Hemorrhage was reported in
(4) needle aspiration, with or without alcohol sclero-       4% to 5% of patients (23,24). In the controlled trials,
therapy; (5) fistulization using a Word catheter,            silver nitrate gland ablation under local anesthesia
Foley catheter, or a Jacobi ring; (6) gland excision by      was significantly faster than excision with general
traditional technique; and, (7) incision and drainage        anesthesia (7.3      2.0 vs. 20.8     4.7 minutes, P
followed by primary suture closure. The quality of           0.001) with significantly faster healing (6.5 1.3 vs.
the studies ranged from 2 to 5. Randomized con-              11.1      1.8 days, P      0.001) (18). Compared with
trolled trials were too dissimilar in intervention type,     alcohol sclerotherapy under local anesthesia, in 1
study design, population, and pathology distribution         small series, silver nitrate treatment was significantly
to allow meta-analysis (Tables 1–6).                         slower (15 3 vs. 7 2 minutes, P 0.001) with
   The percentage of women who reported a history            slower healing (9.2       2.5 vs. 4.8    1.3 days, P
of previous Bartholin gland disorder or treatment for        0.001) (16) (Table 1).
such was between 13% and 63%. The mean time to
accomplish healing ranged from 4.8 days (16) to 2.2
weeks (17) (Tables 1–6). When provided, the defi-
                                                                            Carbon Dioxide Laser
nition of “healed” included such descriptions as “ces-
sation of secretions and epithelialization of the              Six case series and a retrospective cohort evaluated
wound” (18), “complete regeneration of the vulvar            the outpatient treatment of Bartholin duct cysts and
tissue” (19), and “absence of swelling and discomfort        abscesses using a CO2 laser (17,19,26–30). The larg-
and the appearance of a freely draining duct” (20).          est case series (30) included 48 patients for which
The recurrence after treatment ranged from none to           outcomes had been previously reported (19). Mean
38%, with the highest frequency of recurrence oc-            patient age was between 32 and 37 years with mean
curring after treatment by aspiration (21). No data on       cyst/abscess diameter between 3.5 and 6.3 cm (range,
cost were given. Cultures from the Bartholin ab-             2–15 cm). The laser was used to create an opening in
scesses, when reported, were polymicrobial and an-           the vulvar skin in the area of the duct orifice. The
tibiotic use varied.                                         Bartholin duct cyst was evacuated and then either
                                                             vaporized (17,19,26–30), excised (19), or left intact
                                                             after fenestration (26). Local anesthesia was used in
           Silver Nitrate Gland Ablation
                                                             nearly all patients (97%), and antibiotics were given
   Four case series and 2 controlled trials evaluated        in the setting of abscess or multiloculated cysts
silver nitrate ablation of Bartholin duct cysts and          (26,28,30). Laser procedures averaged 17 minutes or
abscesses measuring between 3 and 8 cm (16,18,22–            less (Table 2).
398




TABLE 1
Silver nitrate gland ablation for treatment of Bartholin duct cysts and abscesses
 Author, yr, Location,   Previously Treated No. Cysts vs.
 Study Design, Study        for Bartholin       No.                                                                                       Time to            Recurrences
         Size                Pathology       Abscesses               Intervention                  Study Characteristics                 Healing (d)*          n/N (%)
Mungan et al (18) 1995 G1: 3/25 (12%);        G1: 18 vs. 7;   G1: silver nitrate gland   Quality (2): small RCT, defined healing and    G1: 6.5 1.3;      G1: 0/25; G2: 0/25;
 Turkey RCT, N 50       G2: 4/25 (16%)         G2: 20 vs.        ablation, n 25;          statistics, unclear validity of randomization   G2: 11.1 1.8,    follow-up: 2 yr
                                               5                 G2: Excision of gland,   or allocation concealment                       P 0.001
                                                                 n 25
Kafali et al (16) 2004   NR                     16 vs. 6      G1: silver nitrate gland   Quality (3): small RCT randomized by cyst      G1: 9.2 2.5;      G1: 0/10; G2: 1/12
  Turkey RCT, N 22                                               ablation, n 10;          diameter, unclear allocation concealment,       G2: 4.8 1.3,     (8%) at 7 mo NS;
                                                                 G2: alcohol sclerother-  describes statistical methods                   P 0.001          follow-up: 2 yr
                                                                 apy, n 12
Yuce et al (25) 1994           7/52(13%)        42 vs. 10     Silver nitrate gland       Quality (4): small case series, defined        10 3.4 (range,    2/52 (4%) in first 2
  Turkey case series,                                            ablation                 healing, long follow-up, excluded bilateral     7–14)             mo follow-up:
  N 52                                                                                    cysts                                                               12 mo
Turan et al (24) 1995         11/25(44%)        17 vs. 8      Silver nitrate gland       Quality (5): small case series with limited     10 in 52%; 20    1/25 (4%) at day 8
  Turkey case series,                                            ablation                 details and undefined healing                   in 100%           follow-up: 2.5 yr
  N 25
Ortac et al (23) 1991          4/19(21%)        13 vs. 6      Silver nitrate gland      Quality (5): small case series, 2 lost to     “An average of 10   0/17 follow-up: 2 yr
  Turkey case series,                                            ablation                follow-up, imprecise data, unclear method      days”
  N 19                                                                                   of follow-up
                                                                                                                                                                                 Obstetrical and Gynecological Survey




Ergeneli (22) 1999       NR                   NR              Silver nitrate gland      Quality (5): small case series, unclear and   By 4 wk (all)       0/14 follow-up: 1 yr
  Turkey case series,                                            ablation                short duration follow-up, undefined
  N 15                                                                                   inclusion and exclusion criteria
  NR indicates not reported; RCT, randomized controlled trial; NS, not statistically significant.
  *Time to healing is mean standard deviation or as specified or stated in the paper (quotations).
TABLE 2
CO2 laser for treatment of Bartholin duct cysts and abscesses
Author, yr, Location      Previously Treated       No.
Study Design, Study          for Bartholin     Cysts vs. No.                                                                                                Recurrences
        Size                  Pathology         Abscesses                Intervention                 Study Characteristics         Time to Healing           n/N (%)
Penna et al (19) 2002            NR                NR           G1: CO2 laser gland excision,   Quality (3): moderate size cohort   By 1 mo in all      2/111 (2%) follow-up:
  Italy retrospective                                            n 63; G2: CO2 laser             study, limited data                                      mean 28 mo (4 –72)
  cohort, N 111                                                  gland vaporization, n 48
Fabrini (30) 2008 Italy        0 (Excluded)     200 vs. 0       CO2 laser gland vaporization    Quality (4): moderate size case     By 3 mo in all      9/200 (5%) at median
  case series,                                                                                   series, lost 1.5% to 12 follow-                          12 mo (4 –24)
  N 200                                                                                          up, many exclusion criteria                              follow-up: median
                                                                                                                                                          42 mo (6 –96)
Heinonen (28) 1990        36/64 (56.3%)          15 vs. 49      CO2 laser gland vaporization    Quality (4): small size case        NR                  13/64 (20%) at mean
  Finland case series,                                                                           series, unclear follow-up in all                         6.5 mo (0.5–22)
  N 64                                                                                           patients                                                 follow-up: mean 18
                                                                                                                                                          mo (5– 48)
Lashgari et al (29)              NR              28 vs. 0       CO2 laser gland vaporization    Quality (5): small case series, 7   By 4 wk in all      2/21 (10%) follow-up:
  1989 US case                                                                                   lost to follow-up                                        9 yr
  series, N 28
de Gois Speck et al              NR              22 vs. 0       CO2 laser gland vaporization    Quality (5): small case series,     By 3– 4 wk in all   2/22 (9%) follow-up:
  (27) 2007 Brazil                                                                               undefined complete healing,                              NR
  case series,                                                                                   unclear follow-up
  N 22
Benedetti Panici et al         0 (Excluded)      10 vs. 9       CO2 laser fenestration          Quality (4): small case series,     By 8 wk in all      2/19 (11%) at 13, 16
  (26) 2007 Italy                                                                                same surgeon for all                                     mo follow-up:
  case series,                                                                                                                                            median 32 mo
  N 19                                                                                                                                                    (2–58)
Davis (17) 1985 US          6/14 (43%)           14 vs. 0       CO2 laser gland vaporization    Quality (4): small case series,     Mean 2.2 wk         2/14 (14%) follow-up:
  case series,                                                                                   unclear follow-up, well-                                 NR
  N 14                                                                                           described outcomes
                                                                                                                                                                                Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article
                                                                                                                                                                                399
TABLE 3                                                                                                                                                                                    400
Marsupialization for treatment of Bartholin duct cysts and abscesses
Author, yr, Location,      Previously Treated
Study Design, Study           for Bartholin   No. Cysts vs. No.                                                                                                        Recurrences
        Size                   Pathology         Abscesses               Intervention                     Study Characteristics             Time to Healing (d)*         n/N (%)
Andersen et al (31)        G1: 3/14 (21%);     G1: 4 vs. 10;       G1: marsupialization, n  Quality (2): small RCT, defined healing,   G1: 13 (1–21) in 11/         G1: 0/11; G2: 2/18
  1992 Denmark               G2: 5/18 (28%)     G2: 5 vs. 13         14; G2: incision and    described statistics, post-randomization   14; G2: 8 (3–11) in          (11%) at 3 mo,
  RCT, N 32                                                          drainage, then primary  exclusion for incorrect diagnosis in 4     14/18, P 0.05                P 0.05; follow-
                                                                     suture closure, n 18    patients, 7 lost to follow-up                                           up: 6 mo
Haider et al (33)    NR                             0 vs. 58       G1: fistulization, word  Quality (3): small retrospective cohort,   NR                           G1: 1/27 (4%) at 6
  2007 England ret-                                                  catheter, n 35;         questionnaires to assess outcome; 5                                     mo; G2: 0/14
  rospective cohort,                                                 G2: marsupialization,   different surgeons; recurrence assessed                                 follow-up: 6 mo
  N 58                                                               n 23                    by phone; 9 of marsupialization group
                                                                                             lost to follow-up
Cho et al (32) 1990 NR                             25 vs. 22       “Window operation”       Quality (5): small case series, 31 lost to NR                           0/27 at 6 mo 0/16
  Korea case series,                                                                         follow-up at 1 yr                                                        at 1 yr follow-up:
  N 47                                                                                                                                                                1 yr
Downs and Randall      12/19 (63%)                  5 vs. 14       Marsupialization            Quality (5): small cases series, short       NR                      0/18 follow-up:
  (2) 1989 US case                                                                              follow-up by phone; one lost to                                       1–5 mo
  series, N 19                                                                                  follow-up
  *Time to healing presented as median (range).




TABLE 4
Needle aspiration for treatment of Bartholin duct cysts and abscesses
 Author, yr, Location,        Previously Treated   No. Cysts
 Study Design, Study             for Bartholin      vs. No.                                                                                                         Recurrences
         Size                     Pathology        Abscesses             Intervention                    Study Characteristics            Time to Healing             n/N (%)
                                                                                                                                                                                           Obstetrical and Gynecological Survey




Cobellis (21) 2006 Italy             NR               NR          G1: alcohol sclerotherapy,    Quality (3): small controlled             G1: By 1 wk (all);   G1: 1/10 (10%) at 7
  controlled trial,                                                n 10; G2: needle              trial, unclear if randomization or        G2: NR                mo; G2: 3/8 (38%) at
  N 18                                                             aspiration, n 8               concealment of allocation, no                                   24 mo follow-up: 24
                                                                                                 definition of healing, limited data                             mo
van Bogaert (36) 1999                NR             0 vs. 36      Needle aspiration             Quality (5): small case series,           NR                   0/24 follow-up: 6 mo
  South Africa case                                                                              consecutive patients; 33% lost to
  series, N 36                                                                                   follow-up; limited data
Poma (35) 1982 US                    NR             0 vs. 35      Needle aspiration             Quality (5): small case series, unclear   NR                   0/35 follow-up: 1 yr
  case series, N 35                                                                              inclusion/exclusion criteria, limited
                                                                                                 data, unclear means of follow-up
Cheetham (20)1985                    NR            13 vs. 21      Needle aspiration             Quality (5): small case series, defined   NR                   Recurrence/failure to
  England                                                                                        success; lost 4 to follow-up                                    resolve: 5/30 (17%)
Case series, N 34                                                                                                                                              Follow-up: mean 10 mo
TABLE 5
Fistulization for treatment of Bartholin duct cysts and abscesses
   Author, yr,
 Location, Study    Previously Treated     No. Cysts
  Design, Study        for Bartholin        vs. No.                                                                                                Time to          Recurrences
      Size              Pathology          Abscesses               Intervention                         Study Characteristics                      Healing            n/N (%)
Gennis et al (37)            NR              0 vs. 38   G1: fistulization, Jacobi ring,    Quality (2): small RCT, proper randomization        By 3 wk (all)   G1: 0/25 at 6 mo; 1/25
 2004 US RCT,                                            n 25; G2: fistulization,           and allocation concealment, recurrence                              (4%) at 1 yr;
 N 38                                                    Word catheter, n 13                determined by telephone, described                                  G2: 0/13 at 6 mo;
                                                                                            statistical process                                                 1/13 (8%) at 1 yr NS
                                                                                                                                                                follow-up: 1 yr
Haider et al (33)            NR              0 vs. 58   G1: fistulization, Word            Quality (3): small retrospective cohort, no         NR              G1: 1/27 (4%) at 6 mo;
  2007 England                                           catheter, n 35;                    exclusion criteria, questionnaires to assess                        G2: 0/14 at 6 mo
  retrospective                                          G2: marsupialization, n     23     outcome; 5 different surgeons; recurrence                           follow-up: 6 mo
  cohort, N 58                                                                              assessed by phone call; 9 of marsupialization
                                                                                            group lost to follow-up
Yavetz et al (38)            NR                NR       Fistulization, Foley               Quality (4): small case series, defined success,    NR              8/46 (17%) at mean 9
  1987 Israel                                                                               anesthesia not specified, limited data                               mo (range, 5– 42)
  case series,                                                                                                                                                   follow-up: mean 46
  N 46                                                                                                                                                           mo (range, 6 –140)




TABLE 6
Gland excision for treatment of Bartholin duct cysts and abscesses
Author, yr, Location,   Previously Treated
Study Design, Study        for Bartholin       No. Cysts vs. No.                                                                                 Time to              Recurrences
        Size                Pathology             Abscesses                 Intervention                  Study Characteristics                 Healing (d)*            n/N (%)
Mungan et al (18)       G1: 3/25 (12%);        G1: 18 vs. 7;          G1: silver nitrate gland   Quality (2): small RCT, defined healing      G1: 6.5 1.3;         G1: 0/25; G2: 0/25
 1995 Turkey RCT,        G2: 4/25 (16%)         G2: 20 vs. 5            ablation, n 25;           and statistics, unclear validity of          G2: 11.1             follow-up: 2 yr
 N 50                                                                   G2: excision of           randomization method or allocation           1.8, P 0.001
                                                                        gland, n 25               concealment
Penna et al (19)        NR                     NR                     G1: CO2 laser gland        Quality (3): moderate size cohort            By 1 mo (all)        2/111 (2%) follow-
  2002 Italy retro-                                                     excision, n 63;           study, limited data                                                up: mean 28 mo
  spective cohort, N                                                    G2: CO2 laser gland                                                                          (4 –72)
    111                                                                 vaporization, n 48
                                                                                                                                                                                        Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article




Rouzier et al (40)           19/32 (59%)       NR                     Gland excision             Quality (4): small case series, single       NR                   0/32 follow-up:
  2005 France case                                                                                surgeon; series focused on cysts                                   median 36 mo
  series, N 32                                                                                    with anterior expansions (between
                                                                                                  urethra and fourchette)
  *Time to healing is presented as mean      standard deviation or as specified.
                                                                                                                                                                                        401
402                                  Obstetrical and Gynecological Survey

  Healing occurred in an average of 2.2 weeks. Re-            Neisseria gonorrhoeae was the most commonly iso-
currences ranged from 2% (excision or vaporization)           lated bacteria from abscess aspirate, reported in 28%
to 20% in the 451 patients represented, with mini-            and 52% of patients. Compared with alcohol sclero-
mum follow-up of 2 months. Major bleeding oc-                 therapy, needle aspiration was associated with over
curred in 2% to 8% after laser gland ablation (28,30).        twice the frequency of recurrence, with no statistical
                                                              analysis reported (Table 4) (21).
                   Marsupialization
                                                                             Alcohol Sclerotherapy
  Four studies reported on the marsupialization of
Bartholin duct cysts and abscesses. These included 2             In addition to the trial mentioned previously, an-
case series, a retrospective cohort, and a randomized         other small trial reported alcohol sclerotherapy in 12
controlled trial comparing marsupialization of ab-            patients, which demonstrated a faster procedure with
scesses to incision and drainage before primary clo-          faster healing when compared to silver nitrate gland
sure (2,31–33). One of the case series reports on the         ablation (Table 1) (16). After evacuation, cyst cavi-
“window operation” (32) which, by description, was            ties were irrigated with 70% alcohol for 5 minutes
similar to traditional marsupialization: excising an          and then re-evacuated. Recurrence was seen in 8%
elliptical portion of vestibular skin and cyst wall,          and 10% of patients in the 2 studies, both at 7 months
emptying the cyst, and preserving the new osteum by           (16,21). All patients healed by 1 week. Transient hy-
suturing the cyst wall to the skin incision edges (34).       peremia was reported in 20% and 100% of patients. The
Local anesthesia or pudendal block was used in all            same 20% had a hematoma (21). Seventeen percent of
but 1 study which employed general anesthesia (31).           patients in the other study experienced tissue necrosis
Antibiotics were not given routinely, and mean proce-         and scar (Tables 1 and 4) (16).
dure duration was 25 minutes, including anesthesia.
Patients were treated in both inpatient and outpatient
                                                                                  Fistulization
settings. Cyst diameter ranged from 3 to 8 cm (2).
Mean patient age was 29 to 37 years.                             A case series, a retrospective cohort, and a ran-
  Median healing occurred in less than 2 weeks. With          domized controlled trial reported outcomes after
70 patients represented and followed for at least 1           fistulization of Bartholin duct cysts or abscesses
month after treatment, there were 0 reported recur-           (33,37,38). The technique for creating a new, epithe-
rences after marsupialization in these studies. Bleed-        lialized outflow tract for an obstructed Bartholin duct
ing was reported in 11% of patients in 1 study (2).           was by placing either a 14-French Foley catheter, a
When compared with patients treated by incision and           Jacobi ring, or a Word catheter. Word catheters are
drainage before primary closure, patients with mar-           placed through a 5-mm stab incision on the inner
supialization healed significantly more slowly (me-           labium minus (just external to the hymen) in the
dian: 13 [range, 1–21 days] vs. median: 8 [range,             region of the Bartholin gland duct. The bulb of the
3–11 days], P 0.05) with no significant difference            catheter is inflated with up to 3 mL of sterile saline,
in recurrence (Table 3) (31).                                 and the catheter is left in place for 4 to 6 weeks (39).
                                                              The Jacobi ring is a rubber catheter, fashioned into a
                                                              ring from an 8-French T tube threaded over a 2-0 silk
                  Needle Aspiration
                                                              suture that enters and leaves the cyst or abscess
   Four studies, including 3 case series and a con-           through 2 separate incisions (37) (Table 5). The
trolled trial, examined the outpatient treatment of           Jacobi ring was placed in the emergency department
Bartholin duct cysts and abscesses by needle aspira-          (5), and no procedure duration was reported for any
tion (20,21,35,36). Procedure duration was not re-            study. Fistulization was performed under local an-
ported; anesthesia consisted of local ethyl chloride          esthesia in some (5,38) or all (33) patients; antibi-
spray in 2 studies, was not given in 1 study, and was         otic use was not reported. Mean age was 30 (range,
not specified in the other. Antibiotics were given for        16–51) (33).
abscess in 3 of 4 studies (35). Patients were aged               Recurrent Bartholin gland pathology was noted in
between 16 and 45 years, with mean abscess diam-              4% to 17% of patients after fistulization, with fol-
eter of 5 cm (35).                                            low-up of at least 6 months in 111 patients repre-
   Healing occurred by 1 week, as reported in 1 study (21).   sented. Premature loss of the Word catheter was the
Recurrences ranged from 0% to 38% with follow-up              most commonly reported adverse event. In a random-
of 6 months or greater in the 97 patients represented.        ized trial comparing the Word catheter to the Jacobi
Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article                                  403

ring for symptomatic Bartholin duct abscesses, healing       numbers of patients. We identified only 5 trials, and
was accomplished by 3 weeks and patients were                comparative studies were small and too heterogeneous
highly satisfied in both groups. A single patient in         for meta-analysis. Limiting our search to English-
each group had a recurrence at 1 year (Table 5) (5).         language eliminated 12 articles. In general, limiting
                                                             studies to those published in English has not been
                                                             noted to dramatically change the summarized treat-
                   Gland Excision
                                                             ment effect estimate (42–44). We limited our search
   Excision of Bartholin duct cysts and abscesses was        to the past 25 years (extended to 26 years when
evaluated in 3 studies: a randomized controlled trial        updated before submission). Before 1982, neither
comparing inpatient treatment by excision to silver          electronic abstracts nor full-text articles are com-
nitrate (18), a retrospective cohort comparing outpa-        monly available, dramatically increasing the com-
tient laser gland excision to gland vaporization (19),       plexity and expense, and decreasing the feasibility of
and a case series describing excision of Bartholin           completing this review. Given the range of treat-
duct cysts with “anterior expansion” (between the            ments for Bartholin pathology still practiced today,
urethra and fourchette) (Table 6) (40). Reported             we argue that we are unlikely to have missed defin-
mean procedure duration was 20 and 60 minutes,               itive studies or to have compromised our conclusion
including bilateral excisions. Patients were a mean          by excluding earlier years.
28 years old (18). Cysts were between 2 and 7 cm.               An ideal treatment for symptomatic Bartholin duct
Anesthesia varied, and antibiotics were reported in 1        cysts and abscesses is fast and safe, performed as an
study, given only for abscess (18). With at least 2          outpatient under local anesthesia, with uncommon re-
years follow-up and 168 patients represented, recur-         currence and rapid healing. Existing literature to guide
rence ranged from 0% to 3%, at the most. Healing             treatment choice is lacking, and the optimal treatment
was accomplished in 11.1        1.8 days. Bleeding or        for Bartholin duct cysts and abscesses is still unclear. In
hematoma was reported in 2% to 8%, fever in 24%,             light of the current literature, and without clearly dem-
and persistent dyspareunia in 8% and 16% (Table 6).          onstrated superiority, each of the described treatments
                                                             could be an appropriate option, depending on patient
                                                             characteristics and provider resources and experience.
                   CONCLUSION
                                                             Large, randomized controlled trials comparing common
   All of the available treatments for Bartholin duct        therapeutic strategies are needed to establish the best
cysts and abscesses have been performed, at least by         available therapy for this painful condition.
some authors, as outpatient procedures under local              Note: At the time of final proof review in April of
anesthesia, usually in 20 minutes or less. Patients          2009, the authors repeated a search of the listed data-
heal in 2 weeks or less, and reported adverse events         bases and identified a single additional study that
are generally uncommon and non–life-threatening,             would have qualified for inclusion in this systematic
regardless of the treatment. Recurrences are reported        review. This randomized controlled trial of 212 partic-
in 20% or less of patients, with few exceptions. The         ipants (159 completed the study) compared marsupial-
highest frequency of recurrence in this review was           ization to silver nitrate application for treatment of
after treatment by aspiration only. There was no recur-      Bartholin duct cysts and abscesses. Excluding post-
rence after marsupialization but in comparatively few        menopausal women and those with recurrent or bilat-
patients over short follow-up. With longer procedure         eral gland pathology, this study reported 24.1% and
times, treatment by excision was associated with infre-      26% recurrences at six months with no significant dif-
quent recurrence over extended follow-up. Treatment          ference between groups in recurrence or treatment du-
with silver nitrate, reported only in Turkey, had uncom-     ration. All patients received antibiotics, and time to
mon recurrence and was fast and amenable to local            healing was not reported. Ozdegirmenci O, Kayikcioglu F,
anesthesia, with serious complications (vulvar mucosal       Haberal A. Prospective Randomized Study of Marsupi-
cauterization) reported in only 1 study.                     alization versus Silver Nitrate Application in the Man-
   This review has both strengths and weaknesses. A          agement of Bartholin Gland Cysts and Abscesses. J
strength lies in its transparent search strategy, rigorous   Minim Invasive Gynecol 2009;16:149–152.
efforts to include all relevant published and unpublished
studies, strict inclusion and exclusion criteria (41), and                        REFERENCES
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Bartholine´s disease

  • 1. Volume 64, Number 6 OBSTETRICAL AND GYNECOLOGICAL SURVEY Copyright © 2009 by Lippincott Williams & Wilkins CME REVIEWARTICLE 16 CHIEF EDITOR’S NOTE: This article is part of a series of continuing education activities in this Journal through which a total of 36 AMA/PRA Category 1 CreditsTM can be earned in 2009. Instructions for how CME credits can be earned appear on the last page of the Table of Contents. Management of Bartholin Duct Cysts and Abscesses A Systematic Review Mary Ellen Wechter, MD, MPH,* Jennifer M. Wu, MD, MPH,† David Marzano, MD,‡ and Hope Haefner, MD§¶ *Senior Associate Consultant, Department of Gynecology, Mayo Clinic Florida, Jacksonville, Florida; †Assistant Professor, Department of Obstetrics and Gynecology, Division of Urology, Duke Medical Center, Durham, North Carolina; and ‡Clinical Instructor, §Professor, Department of Obstetrics and Gynecology, ¶Co-director of the University of Michigan Center for Vulvar Disease, University of Michigan Health System, Ann Arbor, Michigan Objective. To review systematically the literature, published in English, on recurrence and healing after treatment of Bartholin duct cysts and abscesses. Data Sources. We searched PubMed, EMBASE, CINAHL, LILACS, Web-of-science, the Cochrane data- base, and POPLINE from 1982 until May 2008. We searched the internet, hand-searched reference lists, and contacted experts and authors of relevant papers to detect all published and unpublished studies. Methods of Study Selection. We included any study with at least 10 participants, addressing either frequency of recurrence or healing time after treatment of Bartholin duct cyst or abscess. We followed MOOSE (meta-analysis of observational studies in epidemiology) guidelines. Of 532 articles identified, 24 studies (5 controlled trials, 2 cohort studies, and 17 case series) met all inclusion criteria. Study size ranged between 14 and 200 patients. Tabulation, Integration, and Results. The interventions included: (1) Silver nitrate gland ablation, (2) cyst or abscess fenestration, ablation, or excision using carbon dioxide (CO2) laser, (3) marsupialization, (4) needle aspiration with or without alcohol sclerotherapy, (5) fistulization using a Word catheter, Foley catheter, or Jacobi ring, (6) gland excision, and (7) incision and drainage followed by primary suture closure. The reported frequency of recurrence varied from 0% to 38%. There was no recurrence after marsupialization in available studies. Recurrence after other treatments varied, and was most common after aspiration alone. Healing generally occurred in 2 weeks or less. Conclusion. There are multiple treatments for Bartholin duct cysts and abscesses. A review of the literature failed to identify a best treatment approach. Target Audience: Obstetricians & Gynecologists, Family Physicians Learning Objectives: After completion of this article, the reader should be able to identify seven different treatments for Bartholin duct cysts or abscesses, contrast treatment choice complications and recurrence risks for the different options for treatment of Bartholin duct cysts or abscesses, and point out the limited quality and quantity of data upon which to choose best practices. Symptomatic enlargement of Bartholin ducts, most this number, its context, and recent estimates of prevalence commonly due to cyst or abscess formation, represents are difficult to find. Clearly defined risk factors are simi- a common management dilemma in gynecology. Al- larly elusive; however, the risk profile is similar to those of though a prevalence of 2% is often quoted, the origin of women at risk for sexually transmitted diseases (1). www.obgynsurvey.com | 395
  • 2. 396 Obstetrical and Gynecological Survey Treatment of the symptomatic Bartholin duct cyst or “Bartholin glands” with an inclusive key word, “bar- abscess also may prove challenging, demanding time, tholin*,” combined with MESH headings “cysts” and anesthesia, and exposure. There are many options for “abscess” as well as the key words “cyst” or “cysts” or treatment, including antibiotics and soaks, simple “abscess*” or “gland*” or “duct*.” We combined these drainage, fistulization to create a new duct opening, results with a search for key words pertaining to treat- marsupialization, and excision of the gland. Destruc- ment: (“treatment*” or “therapy” or “technique*” or tion of the cyst or abscess base with silver nitrate or “management”) along with the related articles feature alcohol has also been used. Some providers favor the in PubMed and hand-searched reference lists of ob- use of a carbon dioxide (CO2) laser to accomplish tained full-text articles and reviews. We contacted cyst ablation or fenestration or gland excision. De- authors of relevant papers and experts on vulvar spite the available treatment options, reported recur- pathology to detect unpublished studies, and searched rences are common (2,3), and prolonged healing the internet for additional studies. interrupts daily activities and intercourse. The choice of treatment for Bartholin duct cysts and abscesses STUDY SELECTION remains difficult. Our intent with this systematic review is to clarify We included any study with the outcomes of inter- the existing evidence on which to base treatment of est related to the treatment of a Bartholin duct cyst or symptomatic Bartholin duct cysts and abscesses. We abscess that included at least 10 participants and was performed a thorough, transparent search for all published in English within the last 26 years. We available literature published in English in the last 26 excluded case reports and studies on non-Bartholin years. Specifically, our research questions were: (1) vulvar pathology, Bartholin gland malignancy, or what percentage of treated Bartholin duct cysts or Bartholin disorders other than cysts or abscesses abscesses recurs, according to treatment method; (e.g., leiomyoma, hyperplasia, or endometriosis of and, (2) what is the duration of time to accomplish the Bartholin gland). healing, according to the treatment method. We also The authors worked together independently and col- sought answers to secondary questions including: lectively to evaluate and qualify the articles identified. what is the approximate procedure time for each A “quality” designation was based on criteria includ- treatment; which treatments are accomplished as out- ing study design, study size, randomization method patients; and what complications are associated with and concealment of allocation, defined intervention the different therapies. and outcome, follow up, and the potential for bias. “Quality” was described in prose, guided by a 5-tier scale (1 being a well-done randomized controlled SOURCES trial with allocation concealment and 5 being a small, The first author and a university-employed librar- descriptive study with little available data.) Compar- ian independently performed the literature search for ative studies were evaluated for similarities that this review. We searched the following databases from might allow inclusion in a meta-analysis. We fol- 1982 (or the earliest available from 1982 forward) until lowed MOOSE guidelines for observational studies May 2008: PubMed, EMBASE, CINAHL, LILACS, in completing this review and used descriptive sta- Web-of-science, the Cochrane database, and POPLINE. tistics to describe findings (4). For the PubMED search, we used the MESH heading RESULTS Dr. Wu has disclosed that she was a recipient of a grant from ACOG/Wyeth and she was/is the recipient of a grant from Pfizer. Our combined search of databases yielded a total All other authors have disclosed that they have no financial rela- of 569 article titles. We scanned the first 400 head- tionships with or interests in any commercial companies pertain- ings from our internet search and identified 1 dupli- ing to this educational activity. The Faculty and Staff in a position to control the content of this cate study (5). We identified no unpublished studies CME activity have disclosed that they have no financial relationships and no additional studies from contact with experts with, or financial interests in, any commercial companies pertain- and authors. We limited identified titles by excluding ing to this educational activity. duplicates, studies published before 1982, and case Lippincott Continuing Medical Education Institute, Inc. has reports or studies of Bartholin gland malignancy or identified and resolved all faculty conflicts of interest regarding this educational activity. non-Bartholin vulvar pathology. An additional 12 stud- Reprint requests to: Mary Ellen Wechter, MD, MPH, 4500 San ies, published in foreign languages were excluded, 5 of Pablo Rd., Jacksonville, FL 32224. E-mail: Wechter.Mary@mayo.edu. which, by abstract, would have been appropriate for
  • 3. Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article 397 full-text review if available in English (6–10). Of the 87 25). Patients’ mean age was between 28 and 34 years. remaining studies, we evaluated abstracts, when Treatment was almost universally outpatient (18), and available, and excluded narrative reviews, patient local anesthesia was used for all but select patients in handouts, tutorials, commentaries, presentation of 1 study (24). Antibiotics were given for abscesses the same study group (within 10 participants) (5,11), only. Following a 1- to 2-cm linear incision in the study size less than 10 (12), and any study not vulvar skin and cyst wall, the Bartholin duct cyst or evaluating a treatment for Bartholin duct cyst or abscess was penetrated and evacuated. A 0.5 0.5 abscess or not presenting at least one of the primary cm stick of crystalloid silver nitrate was then inserted outcomes of interest (13). We excluded 2 abstracts, into the cavity. The residual silver nitrate and coag- presented at scientific meetings, for which a full-text ulated cyst capsule were commonly removed or was not available and which either did not describe spontaneously expelled (22), at 2 to 3 days. Silver our primary outcomes (14) or did not present healing nitrate treatment generally took 15 minutes or less. time nor a reliable denominator for determining re- Healing after silver nitrate was usually accom- currence frequency (15). plished within 10 days. With 143 patients repre- From the remaining 35 full-text articles, we se- sented and follow-up of at least a year in all 6 studies, lected the 24 that met all inclusion criteria. Studies 4 studies reported no recurrence. In each of 2 case eligible for this review included 5 controlled trials, 2 series, 4% of women had recurrent gland pathology cohort studies, and 17 case series. Study size ranged within the first 2 months of treatment. The most from 14 to 200. The interventions were: (1) silver common adverse effects were vulvar burning on the nitrate gland ablation; (2) gland or duct fenestration, first postoperative day and labial edema. Inadvertent ablation, or excision using carbon dioxide (CO2) cautery of vulvar mucosa occurred in 20% of patients laser; (3) marsupialization or “window operation”; in 1 small series (22). Hemorrhage was reported in (4) needle aspiration, with or without alcohol sclero- 4% to 5% of patients (23,24). In the controlled trials, therapy; (5) fistulization using a Word catheter, silver nitrate gland ablation under local anesthesia Foley catheter, or a Jacobi ring; (6) gland excision by was significantly faster than excision with general traditional technique; and, (7) incision and drainage anesthesia (7.3 2.0 vs. 20.8 4.7 minutes, P followed by primary suture closure. The quality of 0.001) with significantly faster healing (6.5 1.3 vs. the studies ranged from 2 to 5. Randomized con- 11.1 1.8 days, P 0.001) (18). Compared with trolled trials were too dissimilar in intervention type, alcohol sclerotherapy under local anesthesia, in 1 study design, population, and pathology distribution small series, silver nitrate treatment was significantly to allow meta-analysis (Tables 1–6). slower (15 3 vs. 7 2 minutes, P 0.001) with The percentage of women who reported a history slower healing (9.2 2.5 vs. 4.8 1.3 days, P of previous Bartholin gland disorder or treatment for 0.001) (16) (Table 1). such was between 13% and 63%. The mean time to accomplish healing ranged from 4.8 days (16) to 2.2 weeks (17) (Tables 1–6). When provided, the defi- Carbon Dioxide Laser nition of “healed” included such descriptions as “ces- sation of secretions and epithelialization of the Six case series and a retrospective cohort evaluated wound” (18), “complete regeneration of the vulvar the outpatient treatment of Bartholin duct cysts and tissue” (19), and “absence of swelling and discomfort abscesses using a CO2 laser (17,19,26–30). The larg- and the appearance of a freely draining duct” (20). est case series (30) included 48 patients for which The recurrence after treatment ranged from none to outcomes had been previously reported (19). Mean 38%, with the highest frequency of recurrence oc- patient age was between 32 and 37 years with mean curring after treatment by aspiration (21). No data on cyst/abscess diameter between 3.5 and 6.3 cm (range, cost were given. Cultures from the Bartholin ab- 2–15 cm). The laser was used to create an opening in scesses, when reported, were polymicrobial and an- the vulvar skin in the area of the duct orifice. The tibiotic use varied. Bartholin duct cyst was evacuated and then either vaporized (17,19,26–30), excised (19), or left intact after fenestration (26). Local anesthesia was used in Silver Nitrate Gland Ablation nearly all patients (97%), and antibiotics were given Four case series and 2 controlled trials evaluated in the setting of abscess or multiloculated cysts silver nitrate ablation of Bartholin duct cysts and (26,28,30). Laser procedures averaged 17 minutes or abscesses measuring between 3 and 8 cm (16,18,22– less (Table 2).
  • 4. 398 TABLE 1 Silver nitrate gland ablation for treatment of Bartholin duct cysts and abscesses Author, yr, Location, Previously Treated No. Cysts vs. Study Design, Study for Bartholin No. Time to Recurrences Size Pathology Abscesses Intervention Study Characteristics Healing (d)* n/N (%) Mungan et al (18) 1995 G1: 3/25 (12%); G1: 18 vs. 7; G1: silver nitrate gland Quality (2): small RCT, defined healing and G1: 6.5 1.3; G1: 0/25; G2: 0/25; Turkey RCT, N 50 G2: 4/25 (16%) G2: 20 vs. ablation, n 25; statistics, unclear validity of randomization G2: 11.1 1.8, follow-up: 2 yr 5 G2: Excision of gland, or allocation concealment P 0.001 n 25 Kafali et al (16) 2004 NR 16 vs. 6 G1: silver nitrate gland Quality (3): small RCT randomized by cyst G1: 9.2 2.5; G1: 0/10; G2: 1/12 Turkey RCT, N 22 ablation, n 10; diameter, unclear allocation concealment, G2: 4.8 1.3, (8%) at 7 mo NS; G2: alcohol sclerother- describes statistical methods P 0.001 follow-up: 2 yr apy, n 12 Yuce et al (25) 1994 7/52(13%) 42 vs. 10 Silver nitrate gland Quality (4): small case series, defined 10 3.4 (range, 2/52 (4%) in first 2 Turkey case series, ablation healing, long follow-up, excluded bilateral 7–14) mo follow-up: N 52 cysts 12 mo Turan et al (24) 1995 11/25(44%) 17 vs. 8 Silver nitrate gland Quality (5): small case series with limited 10 in 52%; 20 1/25 (4%) at day 8 Turkey case series, ablation details and undefined healing in 100% follow-up: 2.5 yr N 25 Ortac et al (23) 1991 4/19(21%) 13 vs. 6 Silver nitrate gland Quality (5): small case series, 2 lost to “An average of 10 0/17 follow-up: 2 yr Turkey case series, ablation follow-up, imprecise data, unclear method days” N 19 of follow-up Obstetrical and Gynecological Survey Ergeneli (22) 1999 NR NR Silver nitrate gland Quality (5): small case series, unclear and By 4 wk (all) 0/14 follow-up: 1 yr Turkey case series, ablation short duration follow-up, undefined N 15 inclusion and exclusion criteria NR indicates not reported; RCT, randomized controlled trial; NS, not statistically significant. *Time to healing is mean standard deviation or as specified or stated in the paper (quotations).
  • 5. TABLE 2 CO2 laser for treatment of Bartholin duct cysts and abscesses Author, yr, Location Previously Treated No. Study Design, Study for Bartholin Cysts vs. No. Recurrences Size Pathology Abscesses Intervention Study Characteristics Time to Healing n/N (%) Penna et al (19) 2002 NR NR G1: CO2 laser gland excision, Quality (3): moderate size cohort By 1 mo in all 2/111 (2%) follow-up: Italy retrospective n 63; G2: CO2 laser study, limited data mean 28 mo (4 –72) cohort, N 111 gland vaporization, n 48 Fabrini (30) 2008 Italy 0 (Excluded) 200 vs. 0 CO2 laser gland vaporization Quality (4): moderate size case By 3 mo in all 9/200 (5%) at median case series, series, lost 1.5% to 12 follow- 12 mo (4 –24) N 200 up, many exclusion criteria follow-up: median 42 mo (6 –96) Heinonen (28) 1990 36/64 (56.3%) 15 vs. 49 CO2 laser gland vaporization Quality (4): small size case NR 13/64 (20%) at mean Finland case series, series, unclear follow-up in all 6.5 mo (0.5–22) N 64 patients follow-up: mean 18 mo (5– 48) Lashgari et al (29) NR 28 vs. 0 CO2 laser gland vaporization Quality (5): small case series, 7 By 4 wk in all 2/21 (10%) follow-up: 1989 US case lost to follow-up 9 yr series, N 28 de Gois Speck et al NR 22 vs. 0 CO2 laser gland vaporization Quality (5): small case series, By 3– 4 wk in all 2/22 (9%) follow-up: (27) 2007 Brazil undefined complete healing, NR case series, unclear follow-up N 22 Benedetti Panici et al 0 (Excluded) 10 vs. 9 CO2 laser fenestration Quality (4): small case series, By 8 wk in all 2/19 (11%) at 13, 16 (26) 2007 Italy same surgeon for all mo follow-up: case series, median 32 mo N 19 (2–58) Davis (17) 1985 US 6/14 (43%) 14 vs. 0 CO2 laser gland vaporization Quality (4): small case series, Mean 2.2 wk 2/14 (14%) follow-up: case series, unclear follow-up, well- NR N 14 described outcomes Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article 399
  • 6. TABLE 3 400 Marsupialization for treatment of Bartholin duct cysts and abscesses Author, yr, Location, Previously Treated Study Design, Study for Bartholin No. Cysts vs. No. Recurrences Size Pathology Abscesses Intervention Study Characteristics Time to Healing (d)* n/N (%) Andersen et al (31) G1: 3/14 (21%); G1: 4 vs. 10; G1: marsupialization, n Quality (2): small RCT, defined healing, G1: 13 (1–21) in 11/ G1: 0/11; G2: 2/18 1992 Denmark G2: 5/18 (28%) G2: 5 vs. 13 14; G2: incision and described statistics, post-randomization 14; G2: 8 (3–11) in (11%) at 3 mo, RCT, N 32 drainage, then primary exclusion for incorrect diagnosis in 4 14/18, P 0.05 P 0.05; follow- suture closure, n 18 patients, 7 lost to follow-up up: 6 mo Haider et al (33) NR 0 vs. 58 G1: fistulization, word Quality (3): small retrospective cohort, NR G1: 1/27 (4%) at 6 2007 England ret- catheter, n 35; questionnaires to assess outcome; 5 mo; G2: 0/14 rospective cohort, G2: marsupialization, different surgeons; recurrence assessed follow-up: 6 mo N 58 n 23 by phone; 9 of marsupialization group lost to follow-up Cho et al (32) 1990 NR 25 vs. 22 “Window operation” Quality (5): small case series, 31 lost to NR 0/27 at 6 mo 0/16 Korea case series, follow-up at 1 yr at 1 yr follow-up: N 47 1 yr Downs and Randall 12/19 (63%) 5 vs. 14 Marsupialization Quality (5): small cases series, short NR 0/18 follow-up: (2) 1989 US case follow-up by phone; one lost to 1–5 mo series, N 19 follow-up *Time to healing presented as median (range). TABLE 4 Needle aspiration for treatment of Bartholin duct cysts and abscesses Author, yr, Location, Previously Treated No. Cysts Study Design, Study for Bartholin vs. No. Recurrences Size Pathology Abscesses Intervention Study Characteristics Time to Healing n/N (%) Obstetrical and Gynecological Survey Cobellis (21) 2006 Italy NR NR G1: alcohol sclerotherapy, Quality (3): small controlled G1: By 1 wk (all); G1: 1/10 (10%) at 7 controlled trial, n 10; G2: needle trial, unclear if randomization or G2: NR mo; G2: 3/8 (38%) at N 18 aspiration, n 8 concealment of allocation, no 24 mo follow-up: 24 definition of healing, limited data mo van Bogaert (36) 1999 NR 0 vs. 36 Needle aspiration Quality (5): small case series, NR 0/24 follow-up: 6 mo South Africa case consecutive patients; 33% lost to series, N 36 follow-up; limited data Poma (35) 1982 US NR 0 vs. 35 Needle aspiration Quality (5): small case series, unclear NR 0/35 follow-up: 1 yr case series, N 35 inclusion/exclusion criteria, limited data, unclear means of follow-up Cheetham (20)1985 NR 13 vs. 21 Needle aspiration Quality (5): small case series, defined NR Recurrence/failure to England success; lost 4 to follow-up resolve: 5/30 (17%) Case series, N 34 Follow-up: mean 10 mo
  • 7. TABLE 5 Fistulization for treatment of Bartholin duct cysts and abscesses Author, yr, Location, Study Previously Treated No. Cysts Design, Study for Bartholin vs. No. Time to Recurrences Size Pathology Abscesses Intervention Study Characteristics Healing n/N (%) Gennis et al (37) NR 0 vs. 38 G1: fistulization, Jacobi ring, Quality (2): small RCT, proper randomization By 3 wk (all) G1: 0/25 at 6 mo; 1/25 2004 US RCT, n 25; G2: fistulization, and allocation concealment, recurrence (4%) at 1 yr; N 38 Word catheter, n 13 determined by telephone, described G2: 0/13 at 6 mo; statistical process 1/13 (8%) at 1 yr NS follow-up: 1 yr Haider et al (33) NR 0 vs. 58 G1: fistulization, Word Quality (3): small retrospective cohort, no NR G1: 1/27 (4%) at 6 mo; 2007 England catheter, n 35; exclusion criteria, questionnaires to assess G2: 0/14 at 6 mo retrospective G2: marsupialization, n 23 outcome; 5 different surgeons; recurrence follow-up: 6 mo cohort, N 58 assessed by phone call; 9 of marsupialization group lost to follow-up Yavetz et al (38) NR NR Fistulization, Foley Quality (4): small case series, defined success, NR 8/46 (17%) at mean 9 1987 Israel anesthesia not specified, limited data mo (range, 5– 42) case series, follow-up: mean 46 N 46 mo (range, 6 –140) TABLE 6 Gland excision for treatment of Bartholin duct cysts and abscesses Author, yr, Location, Previously Treated Study Design, Study for Bartholin No. Cysts vs. No. Time to Recurrences Size Pathology Abscesses Intervention Study Characteristics Healing (d)* n/N (%) Mungan et al (18) G1: 3/25 (12%); G1: 18 vs. 7; G1: silver nitrate gland Quality (2): small RCT, defined healing G1: 6.5 1.3; G1: 0/25; G2: 0/25 1995 Turkey RCT, G2: 4/25 (16%) G2: 20 vs. 5 ablation, n 25; and statistics, unclear validity of G2: 11.1 follow-up: 2 yr N 50 G2: excision of randomization method or allocation 1.8, P 0.001 gland, n 25 concealment Penna et al (19) NR NR G1: CO2 laser gland Quality (3): moderate size cohort By 1 mo (all) 2/111 (2%) follow- 2002 Italy retro- excision, n 63; study, limited data up: mean 28 mo spective cohort, N G2: CO2 laser gland (4 –72) 111 vaporization, n 48 Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article Rouzier et al (40) 19/32 (59%) NR Gland excision Quality (4): small case series, single NR 0/32 follow-up: 2005 France case surgeon; series focused on cysts median 36 mo series, N 32 with anterior expansions (between urethra and fourchette) *Time to healing is presented as mean standard deviation or as specified. 401
  • 8. 402 Obstetrical and Gynecological Survey Healing occurred in an average of 2.2 weeks. Re- Neisseria gonorrhoeae was the most commonly iso- currences ranged from 2% (excision or vaporization) lated bacteria from abscess aspirate, reported in 28% to 20% in the 451 patients represented, with mini- and 52% of patients. Compared with alcohol sclero- mum follow-up of 2 months. Major bleeding oc- therapy, needle aspiration was associated with over curred in 2% to 8% after laser gland ablation (28,30). twice the frequency of recurrence, with no statistical analysis reported (Table 4) (21). Marsupialization Alcohol Sclerotherapy Four studies reported on the marsupialization of Bartholin duct cysts and abscesses. These included 2 In addition to the trial mentioned previously, an- case series, a retrospective cohort, and a randomized other small trial reported alcohol sclerotherapy in 12 controlled trial comparing marsupialization of ab- patients, which demonstrated a faster procedure with scesses to incision and drainage before primary clo- faster healing when compared to silver nitrate gland sure (2,31–33). One of the case series reports on the ablation (Table 1) (16). After evacuation, cyst cavi- “window operation” (32) which, by description, was ties were irrigated with 70% alcohol for 5 minutes similar to traditional marsupialization: excising an and then re-evacuated. Recurrence was seen in 8% elliptical portion of vestibular skin and cyst wall, and 10% of patients in the 2 studies, both at 7 months emptying the cyst, and preserving the new osteum by (16,21). All patients healed by 1 week. Transient hy- suturing the cyst wall to the skin incision edges (34). peremia was reported in 20% and 100% of patients. The Local anesthesia or pudendal block was used in all same 20% had a hematoma (21). Seventeen percent of but 1 study which employed general anesthesia (31). patients in the other study experienced tissue necrosis Antibiotics were not given routinely, and mean proce- and scar (Tables 1 and 4) (16). dure duration was 25 minutes, including anesthesia. Patients were treated in both inpatient and outpatient Fistulization settings. Cyst diameter ranged from 3 to 8 cm (2). Mean patient age was 29 to 37 years. A case series, a retrospective cohort, and a ran- Median healing occurred in less than 2 weeks. With domized controlled trial reported outcomes after 70 patients represented and followed for at least 1 fistulization of Bartholin duct cysts or abscesses month after treatment, there were 0 reported recur- (33,37,38). The technique for creating a new, epithe- rences after marsupialization in these studies. Bleed- lialized outflow tract for an obstructed Bartholin duct ing was reported in 11% of patients in 1 study (2). was by placing either a 14-French Foley catheter, a When compared with patients treated by incision and Jacobi ring, or a Word catheter. Word catheters are drainage before primary closure, patients with mar- placed through a 5-mm stab incision on the inner supialization healed significantly more slowly (me- labium minus (just external to the hymen) in the dian: 13 [range, 1–21 days] vs. median: 8 [range, region of the Bartholin gland duct. The bulb of the 3–11 days], P 0.05) with no significant difference catheter is inflated with up to 3 mL of sterile saline, in recurrence (Table 3) (31). and the catheter is left in place for 4 to 6 weeks (39). The Jacobi ring is a rubber catheter, fashioned into a ring from an 8-French T tube threaded over a 2-0 silk Needle Aspiration suture that enters and leaves the cyst or abscess Four studies, including 3 case series and a con- through 2 separate incisions (37) (Table 5). The trolled trial, examined the outpatient treatment of Jacobi ring was placed in the emergency department Bartholin duct cysts and abscesses by needle aspira- (5), and no procedure duration was reported for any tion (20,21,35,36). Procedure duration was not re- study. Fistulization was performed under local an- ported; anesthesia consisted of local ethyl chloride esthesia in some (5,38) or all (33) patients; antibi- spray in 2 studies, was not given in 1 study, and was otic use was not reported. Mean age was 30 (range, not specified in the other. Antibiotics were given for 16–51) (33). abscess in 3 of 4 studies (35). Patients were aged Recurrent Bartholin gland pathology was noted in between 16 and 45 years, with mean abscess diam- 4% to 17% of patients after fistulization, with fol- eter of 5 cm (35). low-up of at least 6 months in 111 patients repre- Healing occurred by 1 week, as reported in 1 study (21). sented. Premature loss of the Word catheter was the Recurrences ranged from 0% to 38% with follow-up most commonly reported adverse event. In a random- of 6 months or greater in the 97 patients represented. ized trial comparing the Word catheter to the Jacobi
  • 9. Treatment of Bartholin Duct Cysts and Abscesses Y CME Review Article 403 ring for symptomatic Bartholin duct abscesses, healing numbers of patients. We identified only 5 trials, and was accomplished by 3 weeks and patients were comparative studies were small and too heterogeneous highly satisfied in both groups. A single patient in for meta-analysis. Limiting our search to English- each group had a recurrence at 1 year (Table 5) (5). language eliminated 12 articles. In general, limiting studies to those published in English has not been noted to dramatically change the summarized treat- Gland Excision ment effect estimate (42–44). We limited our search Excision of Bartholin duct cysts and abscesses was to the past 25 years (extended to 26 years when evaluated in 3 studies: a randomized controlled trial updated before submission). Before 1982, neither comparing inpatient treatment by excision to silver electronic abstracts nor full-text articles are com- nitrate (18), a retrospective cohort comparing outpa- monly available, dramatically increasing the com- tient laser gland excision to gland vaporization (19), plexity and expense, and decreasing the feasibility of and a case series describing excision of Bartholin completing this review. Given the range of treat- duct cysts with “anterior expansion” (between the ments for Bartholin pathology still practiced today, urethra and fourchette) (Table 6) (40). Reported we argue that we are unlikely to have missed defin- mean procedure duration was 20 and 60 minutes, itive studies or to have compromised our conclusion including bilateral excisions. Patients were a mean by excluding earlier years. 28 years old (18). Cysts were between 2 and 7 cm. An ideal treatment for symptomatic Bartholin duct Anesthesia varied, and antibiotics were reported in 1 cysts and abscesses is fast and safe, performed as an study, given only for abscess (18). With at least 2 outpatient under local anesthesia, with uncommon re- years follow-up and 168 patients represented, recur- currence and rapid healing. Existing literature to guide rence ranged from 0% to 3%, at the most. Healing treatment choice is lacking, and the optimal treatment was accomplished in 11.1 1.8 days. Bleeding or for Bartholin duct cysts and abscesses is still unclear. In hematoma was reported in 2% to 8%, fever in 24%, light of the current literature, and without clearly dem- and persistent dyspareunia in 8% and 16% (Table 6). onstrated superiority, each of the described treatments could be an appropriate option, depending on patient characteristics and provider resources and experience. CONCLUSION Large, randomized controlled trials comparing common All of the available treatments for Bartholin duct therapeutic strategies are needed to establish the best cysts and abscesses have been performed, at least by available therapy for this painful condition. some authors, as outpatient procedures under local Note: At the time of final proof review in April of anesthesia, usually in 20 minutes or less. Patients 2009, the authors repeated a search of the listed data- heal in 2 weeks or less, and reported adverse events bases and identified a single additional study that are generally uncommon and non–life-threatening, would have qualified for inclusion in this systematic regardless of the treatment. Recurrences are reported review. This randomized controlled trial of 212 partic- in 20% or less of patients, with few exceptions. The ipants (159 completed the study) compared marsupial- highest frequency of recurrence in this review was ization to silver nitrate application for treatment of after treatment by aspiration only. There was no recur- Bartholin duct cysts and abscesses. Excluding post- rence after marsupialization but in comparatively few menopausal women and those with recurrent or bilat- patients over short follow-up. With longer procedure eral gland pathology, this study reported 24.1% and times, treatment by excision was associated with infre- 26% recurrences at six months with no significant dif- quent recurrence over extended follow-up. Treatment ference between groups in recurrence or treatment du- with silver nitrate, reported only in Turkey, had uncom- ration. All patients received antibiotics, and time to mon recurrence and was fast and amenable to local healing was not reported. Ozdegirmenci O, Kayikcioglu F, anesthesia, with serious complications (vulvar mucosal Haberal A. Prospective Randomized Study of Marsupi- cauterization) reported in only 1 study. alization versus Silver Nitrate Application in the Man- This review has both strengths and weaknesses. A agement of Bartholin Gland Cysts and Abscesses. J strength lies in its transparent search strategy, rigorous Minim Invasive Gynecol 2009;16:149–152. efforts to include all relevant published and unpublished studies, strict inclusion and exclusion criteria (41), and REFERENCES adherence to MOOSE guidelines (4). A weakness re- 1. Aghajanian A, Bernstein L, Grimes DA. Bartholin’s duct ab- lates to the limited quality and size of the available scess and cyst: a case-control study. South Med J 1994;87: reports, most of which were case series with small 26–29.
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