- Email: [email protected]
Bartholin's, vulval and perineal abscesses
Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
Contents lists available at ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
7
Bartholin’s, vulval and perineal abscesses Shabana A. Bora, MBBS, Specialist Registrar a, *, George Condous, MRCOG, FRANZCOG, Associate Professor b a
Department of Obstetrics and Gynaecology, Imperial College Healthcare, St Mary’s Hospital, Praed Street, London, UK Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Sydney, Australia b
Keywords: Bartholin’s abscess Vulval abscess Perineal abscess
Perineal infections are a common presenting complaint in women attending acutely to a gynaecology department. Specifically, Bartholin’s abscesses can occur in approximately 2% of women. Conservative versus surgical approaches to manage these infections aims to reduce the need for hospital admission. We summarise the literature on the diagnosis and management of Bartholin’s and other types of perineal infections and abscesses specific to gynaecology. Crown Copyright Ó 2009 Published by Elsevier Ltd. All rights reserved.
Bartholin’s abscess The Bartholin’s glands (or greater vestibular glands) are two glands located slightly below and to the left and right of the entrance to the vagina (Fig. 1). They were first described in 1677 by the Danish anatomist, Casper Bartholin. Each gland is approximately 1 cm in diameter with a narrow 2.5 cm duct to the surface. The glands produce small amounts of mucous and their function was thought to be to provide lubrication during sexual intercourse and maintain the normally moist surface of the vulva.1 However, removal of the gland does not seem to compromise the vestibular epithelium or sexual function.2 The Bartholin’s glands are prone to obstruction at their orifice into the vestibule, commonly associated with friction from intercourse causing oedema.3 This can result in cyst and/or abscess formation, which occurs in approximately 2% of women.2,4 Bartholin’s abscesses are commoner in single women and those of lower socio-economic backgrounds.5 Symptoms and aetiology Bartholin’s cysts are associated with accumulation of sterile, mucoid fluid, while an abscess is associated with an acute inflammatory reaction within the stroma in the duct and contains purulent * Corresponding author. E-mail address: [email protected] (S.A. Bora). 1521-6934/$ – see front matter Crown Copyright Ó 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bpobgyn.2009.05.002
662
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
Fig. 1 Anatomical position of Bartholin’s glands and abscess.
exudate.3 In the majority of cases (around 80%) the causative organisms are mixed vaginal flora (Bacteroides, Escherichia coli, Staphylococcus Aureus)6; however, Neisseria gonorrhoea and rarely Chlamydia can also be responsible for causing infection.7 Therefore, a full sexual screen should be recommended in these women.6,7 Women with Bartholin’s cysts may be asymptomatic and such lesions can go unnoticed. Symptoms at presentation of Bartholin’s abscess include pain, redness and may be associated with the presence of discharging pus. Women can also present with dyspareunia.3 Examination reveals a unilateral, tender, inflamed posterior labial mass. The abscess occurs in the lower third of the introitus, between the vestibule and the labia majora, but may expand extensively anteriorly3,8 and can become as large as 8 cm in diameter.2 Management The management of Bartholin’s abscesses is generally surgical in the UK and Europe, involving incision, drainage and marsupialisation. You will recall that an animal with a pouch, such as a kangaroo, is a marsupial. Marsupialisation creates a surgical pouch and is associated with a 5–15% recurrence rate.9 Marsupialisation was first described by Jacobson in 1950; a small incision is made over the medial aspect of the abscess to minimise scarring and to allow drainage of gland secretions into the vagina. The incision should be distal to the hymeneal ring. The abscess is then drained. Recurrent or chronic abscesses may need loculations broken down, and large abscess cavities may require temporary packing with ribbon gauze for haemostasis. Suturing of the cyst capsule edges to the external incision edges prevents closure of the incision and reformation of the abscess, and to maintain duct patency (Fig. 2). Over time, the newly created tract shrinks and re-epithelialises. The procedure is normally conducted under general anaesthetic; however this can be done under local anaesthetic or with a pudendal nerve block.10 The most common postoperative complications include pain, haematoma formation, prolonged healing, scarring and dyspareunia. Conservative management of Bartholin’s abscess reduce the need for a general anaesthetic and therefore hospital admission and include usage of the Word catheter, insertion of Jacobi ring, carbon dioxide (CO2) laser vaporisation, silver nitrate and alcohol sclerotherapy.11–18 The Word catheter is a short rubber tube measuring around 6 cm, the tip of which has a small balloon, which holds 3 ml of saline (Fig. 3). This was described by Buford Word in 1964.11 A 5 mm incision is made within the introitus, external to the hymenal ring in the area of the duct orifice, the abscess is drained and a catheter inserted12 under local anaesthetic infiltration. The balloon is inflated with 2–3 ml of saline and the free end can be tucked into the vagina for comfort.13 It is left in place for 4–6 weeks whilst under follow-up. It is a simple, safe and effective outpatient procedure, which is well tolerated, and an alternative to marsupialisation. Reported problems with the procedure include pain post-insertion, the catheter falling out before follow-up and recurrence.13 In 1698, Word described only two cases of recurrence out of 68 up to 5 years11 and, more recently, Haider found one case of recurrence in 35 women (3%) in a non-randomised prospective study comparing the Word catheter to marsupialisation.
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
663
Fig. 2 Marsupialisation of Bartholin’s abscess: The cyst capsule edges sutured to the external incision site.
The Jacobi ring is a rubber ring catheter made from a 7-cm length of an 8-French T-tube threaded with a 20-cm length of 2/0 silk suture. The catheter enters the abscess through two separate incisions to form a closed rubber ring, and the suture ends are tied. In a randomised controlled trial, the Word catheter was compared to the Jacobi ring. No difference in recurrence of Bartholin’s abscess was found; however, the authors postulated there may be better patient satisfaction with the Jacobi ring.14 CO2 laser vaporisation has been described in several case series.15–17 It involves incision of the vaginal mucosa, drainage and laser vaporisation of the inner cyst wall. A less expensive alternative is
Fig. 3 Word catheter.
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S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
the use of silver nitrate sticks; however, this has been found to be associated with postoperative pain secondary to chemical burns, oedema formation, ecchymosis and scar formation.18 Antibiotics should be advocated only in women with cellulitis, otherwise they have no place in the treatment of Bartholin’s abscess.19 Incision and drainage, although simple and effective in the short term, are associated with a high recurrence rate and are not recommended.3 Excision of the gland at the time of abscess drainage is technically difficult and not recommended. Unless marsupialisation and conservative attempts have failed in women with recurrences1, elective excision can be performed in the absence of infection.20 It can be associated with vaginal dryness and dyspareunia and is generally reserved as a last resort. Vulval abscess Abscesses occurring between urethra and the fourchette may be of uncertain origin. However, a surgical and histological study has shown that the majority of these do in fact represent anterior extensions of Bartholin’s cysts or abscesses.8 Sebaceous cysts are common in the labia majora and tend to be superficial. If infected it is recommended that sebaceous cysts should be incised and drained as for any abscess. Folliculitis is commonly found around the mons and vulva, usually associated with Staphylococcus aureus infection. However, pustules are more common than abscesses and usually only antibiotics are needed with occasional incision of an enlarged pustule under a local anaesthetic. Urethral diverticulae are rare but if present are found in the anterior midline of the vagina over the ventral portion of the mid-urethra, approximately 2–3 cm from the introitus. The history of dysuria, post-void dribbling and dyspareunia aid the diagnosis. Urethral diverticulae need careful investigation and specialist repair, but the presence of an abscess is an indication for incision and drainage, prior to definitive surgery.21 Enlargements of Gartner’s duct cysts and Skene’s gland cysts, located on the lateral and anterior walls of the vulva, respectively, can also present with abscess in the form of a peri-urethral swelling. When severe, if adjacent to the urethral orifice, the abscess can cause urethral obstruction and urinary retention.2 Hidradenitis suppurativa may involve apocrine glands anywhere within the milk-line running from the labia majora to the axilla, with a predilection for genital skin. It is found more commonly in darkerpigmented individuals, begins after menarche, and improves after menopause. Mild cases may present as recurrent isolated nodules, while severe instances of the disease with chronic inflammation may lead to scarring, functional impairment and, rarely, squamous cell carcinoma.22,23 Early surgical intervention reduces the risk of abscess, sinus tract infection, fistulae and scarring.24 Pilonidal sinuses, although more common in men and traditionally originating from the natal cleft25, have been reported as unusual causes of vulval infection and abscess formation.26,27 Perianal infections can also extend to the perineal area of women, the more common of which are anorectal abscesses.28 These are superficial collections of purulent material located beneath the skin of the anal canal and do not transverse the external sphincter. Other ano-rectal abcesses include ischiorectal, intersphincteric and supralevator and as fistula formation can occur in 25–50% of cases definitive treatment is timely surgical incision and drainage to prevent further complications.28 In presence of doubt, it is important to confer with general surgical colleagues with the aim of appropriately managing perineal abscesses if the origin of infection is indistinct. Carcinoma Four in a series of 17 women diagnosed with vulval malignancies had an initial misdiagnosis of Bartholin’s cyst or abscess. Therefore, careful examination should be performed with consideration of alternative diagnoses if the appearance is atypical.29 Biopsy or referral to a gynaecological oncologist should be carried out if the abscess shows suspicious features or fails to heal. Carcinoma of the Bartholin’s gland accounts for only 1% of female genital malignancies, with a peak incidence in women between 40 and 70 years of age.30 Because the gland shrinks in postmenopausal women, any enlargement of the gland in these women that appears to be irregular, solid or fixed to the underlying structures should be investigated with excisional biopsy.2
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
665
Summary Perineal infections are a common presenting complaint in women attending acutely to a gynaecology department. The mainstay of treatment of Bartholin’s abscesses is incision and drainage; however, newer conservative methods are replacing the need for hospital admission and surgery, with similar long-term outcome and patient satisfaction. Carcinoma should be considered if the appearance of any vulval lesion is atypical; under these circumstances, biopsy and histological analysis are mandatory. If the origin of a labial or perineal infection or abscess is indistinct, an opinion from surgical colleagues should be sought in order to provide the optimal method of treatment.
Practice points Bartholin’s abcesses is a common gynaecological complaint for women presenting to an emergency department. The mainstay of treatment of Bartholin’s abcesses is incision and drainage. There is no place for antibiotics in the management of these infections unless cellulitis is present. The outpatient management of Bartholin’s abscesses by use of conservative procedures may be an effective alternative to surgical treatment. Other perineal abscesses are often found to represent anterior extensions of Bartholin’s abscesses. Communication with general surgical colleagues is important if the origin of a perineal infection is indistinct.
Research agenda A randomised trial of the usage of the Word catheter versus marsupialisation will demonstrate whether there is a difference in healing, recurrence rates and patient satisfaction.
References *1. Patil S, Sultan AH & Thakar R. Bartholin’s cysts and abscesses. J Obstet Gynaecol 2007; 27(3): 241–245. *2. Omole F, Simmons BJ & Hacker Y. Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician Jul 1 2003; 68(1): 135–140. *3. Pundir J & Auld BJ. A review of the management of diseases of the Bartholin’s gland. J Obstet Gynaecol Feb 2008; 28(2): 161–165. *4. Marzano A & Haefner H. The Bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004; 8(3): 195–204. 5. Cheetham DR. Bartholin’s cyst: marsupialization or aspiration? Am J Obstet Gynecol 1985; 152: 569–570. 6. Brook I. Aerobic and anaerobic microbiology of Bartholin’s abscess. Surg Gynecol Obstet 1989; 169: 32–34. 7. Bleker OP, Smalbraak DJ & Schutte MF. Bartholin’s abscess: the role of Chlamydia trachomatis. Genitourin Med Feb 1990; 66(1): 24–25. *8. Rouzier R, Azarian M, Plantier F et al. Unusual presentation of Bartholin’s gland duct cysts: anterior expansions. BJOG 2005; 112(8): 1150–1152. 9. Horowitz IR, Buscema J & Woodruff JD. Surgical conditions of the vulva. In Rock JA & Thompson JD (eds.). Te Linde’s operative gynecology. 8th edn. Philadelphia: Lipincott-Raven, 1997, pp. 890–893. 10. Downs MC & Randall Jr. HW. The ambulatory surgical management of Bartholin duct cysts. J Emerg Med 1990 Jul–Aug; 8(4): 505–506. *11. Word B. Office treatment of cyst and abscess of Bartholin’s gland duct. South Med J 1968; 61: 514–518. 12. Apgar BS. Bartholin’s cyst/abscess: word catheter insertion. In Pfenninger JL & Fowler GC (eds.). Procedures for primary care physicians. St. Louis: Mosby, 1994, pp. 596–600. *13. Haider Z, Condous G & Kirk E. The simple outpatient management of Bartholin’s abscess using the Word catheter: a preliminary study. Aust N Z J Obstet Gynaecol 2007; 47(2): 137–140. 14. Gennis P, Siu Fai L, Provataris J et al. Jacobi ring treatment of Bartholin’s abscesses. Am J Emerg Med 2005; 23(3): 414–415. 15. Lashgari M & Keene M. Excision of Bartholin duct cysts using the CO2 laser. Obstet Gynecol 1986 May; 67(5): 735–737. 16. Davis GD. Management of Bartholin duct cysts with the carbon dioxide laser. Obstet Gynecol 1985 Feb; 65(2): 279–280.
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17. Fambrini M, Penna C, Pieralli A et al. Carbon-dioxide laser vaporization of the Bartholin gland cyst: a retrospective analysis on 200 cases. J Minim Invasive Gynecol 2008 May–Jun; 15(3): 327–331. 18. Kafali H, Yurtseven S & Ozardali I. Aspiration and alcohol sclerotherapy: a novel method for management of Bartholin’s cyst or abscess. Eur J Obstet Gynecol Reprod Biol. 2004 Jan 15; 112(1): 98–101. *19. Stovall TG & Ling FW. Atlas of benign gynaecological and obstetric surgery. London: Mosby-Wolfe, 1995, pp. 6–9. 20. Stenchever MA. Comprehensive gynecology. 4th edn. St. Louis: Mosby, 2001. 482–6,645–6. 21. Patel A, Anand K, Chapple et al. Female urethral diverticula. Curr Opin Urol 2006; 16(4): 248–254. 22. Wiseman MC. Hidradenitis supparative: a review. Dermatol Ther 2004; 17(1): 50–54. 23. Manosilatis T, Biankin S, Jaworski R et al. Vulval squamous cell carcinoma arising in chronic hidradenitis suppurativa. Gynecol Oncol 1999; 75(2): 285–288. 24. Balik E, Eren T, Bulut T et al. Surgical approach to extensive hidradenitis supparative in the perineal/perianal and gluteal regions. World J Surg 2008; 33(3): 481–487. 25. Dwight RW & Maloy JK. Pilonidal sinus: experience with 449 cases. N Engl J Med 1953; 249: 926–930. 26. Baker T, Barclay D & Ballard C. Pilonidal cyst involving the clitoris: a case report. J Low Genit Tract Dis 2008; 12(2): 127–129. *27. Kafali H, Duvan CI, Bayrak R et al. Vulvar pilonidal sinuses: treatment of a rare cause of vulvar pain. Arch Gynecol Obstet 2008 Nov; 278(5): 487–488. 28. Janicke DM & Pundt MR. Anorectal disorders. Emerg Med Clin North Am 1996 Nov; 14(4): 757–788. *29. Behranwala K, Latifa B, Blake P et al. Vulvar soft tissue tumors. Int J Gynecol Cancer 2004; 14(1): 94–99. 30. Visco AG & Del Priore G. Postmenopausal Bartholin gland enlargement: a hospital-based cancer risk assessment. Obstet Gynecol 1996; 87: 286–290.
Contents lists available at ScienceDirect
Best Practice & Research Clinical Obstetrics and Gynaecology journal homepage: www.elsevier.com/locate/bpobgyn
7
Bartholin’s, vulval and perineal abscesses Shabana A. Bora, MBBS, Specialist Registrar a, *, George Condous, MRCOG, FRANZCOG, Associate Professor b a
Department of Obstetrics and Gynaecology, Imperial College Healthcare, St Mary’s Hospital, Praed Street, London, UK Acute Gynaecology, Early Pregnancy and Advanced Endosurgery Unit, Nepean Centre for Perinatal Care, Nepean Clinical School, University of Sydney, Sydney, Australia b
Keywords: Bartholin’s abscess Vulval abscess Perineal abscess
Perineal infections are a common presenting complaint in women attending acutely to a gynaecology department. Specifically, Bartholin’s abscesses can occur in approximately 2% of women. Conservative versus surgical approaches to manage these infections aims to reduce the need for hospital admission. We summarise the literature on the diagnosis and management of Bartholin’s and other types of perineal infections and abscesses specific to gynaecology. Crown Copyright Ó 2009 Published by Elsevier Ltd. All rights reserved.
Bartholin’s abscess The Bartholin’s glands (or greater vestibular glands) are two glands located slightly below and to the left and right of the entrance to the vagina (Fig. 1). They were first described in 1677 by the Danish anatomist, Casper Bartholin. Each gland is approximately 1 cm in diameter with a narrow 2.5 cm duct to the surface. The glands produce small amounts of mucous and their function was thought to be to provide lubrication during sexual intercourse and maintain the normally moist surface of the vulva.1 However, removal of the gland does not seem to compromise the vestibular epithelium or sexual function.2 The Bartholin’s glands are prone to obstruction at their orifice into the vestibule, commonly associated with friction from intercourse causing oedema.3 This can result in cyst and/or abscess formation, which occurs in approximately 2% of women.2,4 Bartholin’s abscesses are commoner in single women and those of lower socio-economic backgrounds.5 Symptoms and aetiology Bartholin’s cysts are associated with accumulation of sterile, mucoid fluid, while an abscess is associated with an acute inflammatory reaction within the stroma in the duct and contains purulent * Corresponding author. E-mail address: [email protected] (S.A. Bora). 1521-6934/$ – see front matter Crown Copyright Ó 2009 Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bpobgyn.2009.05.002
662
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
Fig. 1 Anatomical position of Bartholin’s glands and abscess.
exudate.3 In the majority of cases (around 80%) the causative organisms are mixed vaginal flora (Bacteroides, Escherichia coli, Staphylococcus Aureus)6; however, Neisseria gonorrhoea and rarely Chlamydia can also be responsible for causing infection.7 Therefore, a full sexual screen should be recommended in these women.6,7 Women with Bartholin’s cysts may be asymptomatic and such lesions can go unnoticed. Symptoms at presentation of Bartholin’s abscess include pain, redness and may be associated with the presence of discharging pus. Women can also present with dyspareunia.3 Examination reveals a unilateral, tender, inflamed posterior labial mass. The abscess occurs in the lower third of the introitus, between the vestibule and the labia majora, but may expand extensively anteriorly3,8 and can become as large as 8 cm in diameter.2 Management The management of Bartholin’s abscesses is generally surgical in the UK and Europe, involving incision, drainage and marsupialisation. You will recall that an animal with a pouch, such as a kangaroo, is a marsupial. Marsupialisation creates a surgical pouch and is associated with a 5–15% recurrence rate.9 Marsupialisation was first described by Jacobson in 1950; a small incision is made over the medial aspect of the abscess to minimise scarring and to allow drainage of gland secretions into the vagina. The incision should be distal to the hymeneal ring. The abscess is then drained. Recurrent or chronic abscesses may need loculations broken down, and large abscess cavities may require temporary packing with ribbon gauze for haemostasis. Suturing of the cyst capsule edges to the external incision edges prevents closure of the incision and reformation of the abscess, and to maintain duct patency (Fig. 2). Over time, the newly created tract shrinks and re-epithelialises. The procedure is normally conducted under general anaesthetic; however this can be done under local anaesthetic or with a pudendal nerve block.10 The most common postoperative complications include pain, haematoma formation, prolonged healing, scarring and dyspareunia. Conservative management of Bartholin’s abscess reduce the need for a general anaesthetic and therefore hospital admission and include usage of the Word catheter, insertion of Jacobi ring, carbon dioxide (CO2) laser vaporisation, silver nitrate and alcohol sclerotherapy.11–18 The Word catheter is a short rubber tube measuring around 6 cm, the tip of which has a small balloon, which holds 3 ml of saline (Fig. 3). This was described by Buford Word in 1964.11 A 5 mm incision is made within the introitus, external to the hymenal ring in the area of the duct orifice, the abscess is drained and a catheter inserted12 under local anaesthetic infiltration. The balloon is inflated with 2–3 ml of saline and the free end can be tucked into the vagina for comfort.13 It is left in place for 4–6 weeks whilst under follow-up. It is a simple, safe and effective outpatient procedure, which is well tolerated, and an alternative to marsupialisation. Reported problems with the procedure include pain post-insertion, the catheter falling out before follow-up and recurrence.13 In 1698, Word described only two cases of recurrence out of 68 up to 5 years11 and, more recently, Haider found one case of recurrence in 35 women (3%) in a non-randomised prospective study comparing the Word catheter to marsupialisation.
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
663
Fig. 2 Marsupialisation of Bartholin’s abscess: The cyst capsule edges sutured to the external incision site.
The Jacobi ring is a rubber ring catheter made from a 7-cm length of an 8-French T-tube threaded with a 20-cm length of 2/0 silk suture. The catheter enters the abscess through two separate incisions to form a closed rubber ring, and the suture ends are tied. In a randomised controlled trial, the Word catheter was compared to the Jacobi ring. No difference in recurrence of Bartholin’s abscess was found; however, the authors postulated there may be better patient satisfaction with the Jacobi ring.14 CO2 laser vaporisation has been described in several case series.15–17 It involves incision of the vaginal mucosa, drainage and laser vaporisation of the inner cyst wall. A less expensive alternative is
Fig. 3 Word catheter.
664
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
the use of silver nitrate sticks; however, this has been found to be associated with postoperative pain secondary to chemical burns, oedema formation, ecchymosis and scar formation.18 Antibiotics should be advocated only in women with cellulitis, otherwise they have no place in the treatment of Bartholin’s abscess.19 Incision and drainage, although simple and effective in the short term, are associated with a high recurrence rate and are not recommended.3 Excision of the gland at the time of abscess drainage is technically difficult and not recommended. Unless marsupialisation and conservative attempts have failed in women with recurrences1, elective excision can be performed in the absence of infection.20 It can be associated with vaginal dryness and dyspareunia and is generally reserved as a last resort. Vulval abscess Abscesses occurring between urethra and the fourchette may be of uncertain origin. However, a surgical and histological study has shown that the majority of these do in fact represent anterior extensions of Bartholin’s cysts or abscesses.8 Sebaceous cysts are common in the labia majora and tend to be superficial. If infected it is recommended that sebaceous cysts should be incised and drained as for any abscess. Folliculitis is commonly found around the mons and vulva, usually associated with Staphylococcus aureus infection. However, pustules are more common than abscesses and usually only antibiotics are needed with occasional incision of an enlarged pustule under a local anaesthetic. Urethral diverticulae are rare but if present are found in the anterior midline of the vagina over the ventral portion of the mid-urethra, approximately 2–3 cm from the introitus. The history of dysuria, post-void dribbling and dyspareunia aid the diagnosis. Urethral diverticulae need careful investigation and specialist repair, but the presence of an abscess is an indication for incision and drainage, prior to definitive surgery.21 Enlargements of Gartner’s duct cysts and Skene’s gland cysts, located on the lateral and anterior walls of the vulva, respectively, can also present with abscess in the form of a peri-urethral swelling. When severe, if adjacent to the urethral orifice, the abscess can cause urethral obstruction and urinary retention.2 Hidradenitis suppurativa may involve apocrine glands anywhere within the milk-line running from the labia majora to the axilla, with a predilection for genital skin. It is found more commonly in darkerpigmented individuals, begins after menarche, and improves after menopause. Mild cases may present as recurrent isolated nodules, while severe instances of the disease with chronic inflammation may lead to scarring, functional impairment and, rarely, squamous cell carcinoma.22,23 Early surgical intervention reduces the risk of abscess, sinus tract infection, fistulae and scarring.24 Pilonidal sinuses, although more common in men and traditionally originating from the natal cleft25, have been reported as unusual causes of vulval infection and abscess formation.26,27 Perianal infections can also extend to the perineal area of women, the more common of which are anorectal abscesses.28 These are superficial collections of purulent material located beneath the skin of the anal canal and do not transverse the external sphincter. Other ano-rectal abcesses include ischiorectal, intersphincteric and supralevator and as fistula formation can occur in 25–50% of cases definitive treatment is timely surgical incision and drainage to prevent further complications.28 In presence of doubt, it is important to confer with general surgical colleagues with the aim of appropriately managing perineal abscesses if the origin of infection is indistinct. Carcinoma Four in a series of 17 women diagnosed with vulval malignancies had an initial misdiagnosis of Bartholin’s cyst or abscess. Therefore, careful examination should be performed with consideration of alternative diagnoses if the appearance is atypical.29 Biopsy or referral to a gynaecological oncologist should be carried out if the abscess shows suspicious features or fails to heal. Carcinoma of the Bartholin’s gland accounts for only 1% of female genital malignancies, with a peak incidence in women between 40 and 70 years of age.30 Because the gland shrinks in postmenopausal women, any enlargement of the gland in these women that appears to be irregular, solid or fixed to the underlying structures should be investigated with excisional biopsy.2
S.A. Bora, G. Condous / Best Practice & Research Clinical Obstetrics and Gynaecology 23 (2009) 661–666
665
Summary Perineal infections are a common presenting complaint in women attending acutely to a gynaecology department. The mainstay of treatment of Bartholin’s abscesses is incision and drainage; however, newer conservative methods are replacing the need for hospital admission and surgery, with similar long-term outcome and patient satisfaction. Carcinoma should be considered if the appearance of any vulval lesion is atypical; under these circumstances, biopsy and histological analysis are mandatory. If the origin of a labial or perineal infection or abscess is indistinct, an opinion from surgical colleagues should be sought in order to provide the optimal method of treatment.
Practice points Bartholin’s abcesses is a common gynaecological complaint for women presenting to an emergency department. The mainstay of treatment of Bartholin’s abcesses is incision and drainage. There is no place for antibiotics in the management of these infections unless cellulitis is present. The outpatient management of Bartholin’s abscesses by use of conservative procedures may be an effective alternative to surgical treatment. Other perineal abscesses are often found to represent anterior extensions of Bartholin’s abscesses. Communication with general surgical colleagues is important if the origin of a perineal infection is indistinct.
Research agenda A randomised trial of the usage of the Word catheter versus marsupialisation will demonstrate whether there is a difference in healing, recurrence rates and patient satisfaction.
References *1. Patil S, Sultan AH & Thakar R. Bartholin’s cysts and abscesses. J Obstet Gynaecol 2007; 27(3): 241–245. *2. Omole F, Simmons BJ & Hacker Y. Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician Jul 1 2003; 68(1): 135–140. *3. Pundir J & Auld BJ. A review of the management of diseases of the Bartholin’s gland. J Obstet Gynaecol Feb 2008; 28(2): 161–165. *4. Marzano A & Haefner H. The Bartholin gland cyst: past, present, and future. J Low Genit Tract Dis 2004; 8(3): 195–204. 5. Cheetham DR. Bartholin’s cyst: marsupialization or aspiration? Am J Obstet Gynecol 1985; 152: 569–570. 6. Brook I. Aerobic and anaerobic microbiology of Bartholin’s abscess. Surg Gynecol Obstet 1989; 169: 32–34. 7. Bleker OP, Smalbraak DJ & Schutte MF. Bartholin’s abscess: the role of Chlamydia trachomatis. Genitourin Med Feb 1990; 66(1): 24–25. *8. Rouzier R, Azarian M, Plantier F et al. Unusual presentation of Bartholin’s gland duct cysts: anterior expansions. BJOG 2005; 112(8): 1150–1152. 9. Horowitz IR, Buscema J & Woodruff JD. Surgical conditions of the vulva. In Rock JA & Thompson JD (eds.). Te Linde’s operative gynecology. 8th edn. Philadelphia: Lipincott-Raven, 1997, pp. 890–893. 10. Downs MC & Randall Jr. HW. The ambulatory surgical management of Bartholin duct cysts. J Emerg Med 1990 Jul–Aug; 8(4): 505–506. *11. Word B. Office treatment of cyst and abscess of Bartholin’s gland duct. South Med J 1968; 61: 514–518. 12. Apgar BS. Bartholin’s cyst/abscess: word catheter insertion. In Pfenninger JL & Fowler GC (eds.). Procedures for primary care physicians. St. Louis: Mosby, 1994, pp. 596–600. *13. Haider Z, Condous G & Kirk E. The simple outpatient management of Bartholin’s abscess using the Word catheter: a preliminary study. Aust N Z J Obstet Gynaecol 2007; 47(2): 137–140. 14. Gennis P, Siu Fai L, Provataris J et al. Jacobi ring treatment of Bartholin’s abscesses. Am J Emerg Med 2005; 23(3): 414–415. 15. Lashgari M & Keene M. Excision of Bartholin duct cysts using the CO2 laser. Obstet Gynecol 1986 May; 67(5): 735–737. 16. Davis GD. Management of Bartholin duct cysts with the carbon dioxide laser. Obstet Gynecol 1985 Feb; 65(2): 279–280.
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