Bartholin Gland Marsupialization_ Overview, Periprocedural Care, Overview of Technique

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Bartholin Gland Marsupialization

Author: Tabitha F Perry, MD; Chief Editor: Christine Isaacs, M D more...

Updated: Nov 18, 2015

Overview

Background

The greater vestibular glands (commonly known as the Bartholin glands) make upan important part of the female reproductive system. The Bartholin glands have a

primary function of secreting mucus to help provide vulvar and vaginal lubrication. [1]

To fulfill this purpose, each Bartholin gland contains a duct that measuresapproximately 5 mm in diameter in the average f emale. For proper secretion, theepithelium of each gland is columnar in nature, while the epithelium of each duct is

simple. The orifice is of the stratified squamous type. The secretion produced is ahick, mucoid, clear substance with a basic pH, and it provides lubrication during

sexual activity.[2]

Measuring from 1.5-2 cm on average, each Bartholin gland is oval in shape and

resides just inferior and lateral to the bulbocavernosus muscle. Innervation isreceived from a small branch of the perine al nerve, while arterial blood supply is

received from a small branch of the artery on the bulbocavernosus muscle.Likewise, venous drainage is also via vessels on the bulbocavernosus muscle.

Lymphatics are via the vestibular plexus and pudendal vessels, and this drainage

route is important to consider when in-depth surgery is needed.[2] See the image

below.

Bartholin gland nerve innervation

If a gland becomes infected or a duct becomes obstructed, the result is often the

development of a Bartholin cyst or abscess that may require medical attention.[3, 4]

This occurs in 2% of women. In addition, in rare cases, malignancy of the Bartholin

gland can occur.[5] See the images below.

Bartholin gland cyst

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Bartholin gland abscess

Treatment options for Bartholin gland cysts or abscesses include expectant

management, sitz baths, antibiotics, Word catheter placement, marsupialization,

and gland excision.[6, 7] There has been no proven superiority between surgical and

conservative management strategies.[8]

This article discusses marsupialization, in which the cyst is opened and the edgessutured, forming an "open pocket" or "pouch."

Indications

See the list below:

History of recurrent Bartholin gland cysts or abscessesSignificant patient pain or discomfortFailure of cyst resolution in a timely manner or with alternative treatments

Patient declines or cannot tolerate Word catheter placement in an officesetting

Contraindications

Contraindications to marsupialization are few and far between, with patient refusal

being virtually the only one identified.

Technical Considerations

Several things must be considered when deciding to perform a Bartholin glandmarsupialization. These questions help to guide the choice of procedure location as

well as preoperative, intraoperative, and postoperative treatment. Each of these isbriefly addressed:

Is this a procedure that must be performed in the operating room, or could

an alternative procedure such as Word catheter placement be performed inthe office?

Is it strictly a Bartholin cyst or is it a Bartholin abscess?If it is an abscess, what are the organisms involved and are they being

treated adequately?Is the patient immunocompromised?

Are there comorbidities that may m ake postoperative healing a problem?

Is there significant concern for malignancy?

ord catheterization and marsupialization

For information on Word catherization of Bartholin gland cyst or abscess, pleasesee Bartholin Abscess Drainage.

In general, the effectiveness, complication rates, and recurrence rates are similar between marsupialization and Word catheterization.

In a study of 30 Austrian women with Bartholin cyst or abscess that evaluated office

implementation, recurrence rates, and costs between Word catheterization andmarsupialization, investigators noted an 87% success rate and 3.8% recurrence rate

in women treated using the Word cathether. [8] Word catherization was simpler to

use and cost seven-fold less than marsupialization.

In a different analysis, the investigators also evaluated quality of life and sexualactivity during and following treatment of Bartholin cyst or abscess with Word

catherization and reported improved pain levels as well as significantly improved

pain/discomfort dring sexual activity.[9] The mental component summary score of he quality of life evaluation showed a significant improvement after treatment

compared with the pretreatment period, although the physical component summary

score did not show a significant change. [9]

Periprocedural Care

Anesthesia

The typical anesthesia used for a Bartholin gland marsupialization is procedural

sedation, a local anesthetic alone, or a combination of the two.

A local anesthetic (eg, l idocaine, mepivacaine) should be administered and m ay

minimize postoperative discomfort. Including a vasoconstrictive agent, such asepinephrine, with the local anesthetic may be beneficial. Although bleeding is

usually minimal for the procedure, this step may help during those few times when

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bleeding may otherwise cloud the surgical field. For more information, seeInfiltrative Administration of Local Anesthetic Agents.

The anesthesiologist usually chooses the anesthetic. Depending on body habitus,airway distortion, or prior history of adverse reactions to anesthesia, the

anesthesiologist may decide that general anesthesia, which requires intubation, maybe the best method, and procedural sedation may be forgone. Given that most

marsupializations are relatively quick procedures, this happens rarely.

Equipment

Equipment needed for the procedure consists of the following[10] :

Scalpel

Pickups/tissue forcepsSponges (laparotomy or 4 x 4 gauze sponges)

Scissors (Mayo, Metzenbaum) Allis clamps

Absorbable suture; opti ons and acceptable sizes vary and include thefollowing: Polysorb (usually 2-0 or 3-0); Vicryl (usually 2-0 or 3-0); Chromic

(usually 2-0 or 3-0); and Caprosyn (usually 2-0 or 3-0).Culture swab and tube - OptionalPovidone iodine (eg, Betadine) or alternative prep cleanser such as iodine

povacrylex/isopropyl alcohol (eg,DuraPrep)Foley catheter or straight catheter - Optional

Bovie cautery - OptionalSmall hemostatic clamps (Criles or Mosquitoes)

Local anesthetic - Optional

Positioning

To ensure proper positioning, care must be taken to place the patient carefully in

he lithotomy position. Stirrup choices include Yellow Fin, Allen, and Candy Cane.Proper positioning for any type of gynecological procedure is key to preventunwanted injury to pelvic, buttock, or groin vasculature or nerve. See the imagebelow.

Lithotomy position

Part of positioning the patient includes draping the patient appropriately. Steriledrapes or towels must cover unwanted areas while allowing the surgeon adequate

exposure to the operative site. A sterile towel may be placed over the anal area toguard against anal and rectal bacteria.

Complication Prevention

The operative area should be prepared with an antimicrobial solution such asBetadine. Given that the vulva and vagina are closely linked, a vaginal

prep/cleansing should also be performed. Avoidance of cross-contamination fromhe anal area is important, since those bacteria are numerous and can be easily

ransferred to the vulvar area. If not careful, this can lead to a postoperative woundinfection in women who initially present for marsupialization of a known uninfectedcyst.

Depending on the timeframe between diagnosis and procedure, the patient mayhave already been on broad spectrum antibiotics if cellulits was noted or an abscess

was suspected. In the case of a simple Bartholin gland cyst, antibiotics are usuallynot used.

Overview of Technique

The technique may be summarized as follows[11, 12, 13] :

Once the patient is properly anesthetized, a thorough bimanual examination

should be performed. This helps the surgeon determine the borders andextent of the cyst or abscess. Once properly prepped and draped, thebladder is drained with a straight catheter. A Foley catheter can be placed at

the discretion of the surgeon.The labia are retracted digitally and the introitus is exposed so that the entire

surgical field is visualized. If local anesthetic is to be used, it is applied to thearea immediately surrounding the cyst with care taken not to enter or

puncture the cyst wall.

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A 1.5- t o 2-cm vertical incision is then made over the mucosa just distal to

the hymenal ring and on the wall of the gland at the cyst site. Care must betaken to ensure that the opening into the gland is sufficient to promoteadequate drainage. Any bleeding noted can be controlled with sponges or

suction.The wall of the gland is then incised and the cyst contents are evacuated.

This can be accomplished with gentle expression or with irrigation. At thispoint, cultures of the fluid are obtained and sent to the lab.

The walls of the cyst are grasped with Allis clamps. Absorbable suture suchas Polysorb or Vicryl is used in an interrupted or continuous fashion to suturethe wall of the cyst to the introitus laterally and the vaginal mucosa medially.

The marsupialization is now complete.

Post Procedure

Postoperative care

Aft er t he procedure, the patient is usually placed on a regimen t hat includes the

following:

Hot sitz baths starting post operative day 1 or 2Oral pain medication such as Ibuprofen, acetaminophen, or an appropriate

narcotic if pain is severe Antibiotics are not routinely prescribed f or B artholin gland cysts unless there

is evidence of cellulitis. Broad spectrum antibiotics can then be used. For Bartholin gland abscesses, broad-spectrum antibiotics can also be

administered until final culture results are obtained. [6] Antibiotic

administration has not been shown to prevent recurrence. [14]

The patient may resume sexual intercourse by 4 weeks after surgery.

Complications

Complications vary in their risk of development and can include recurrence,

postoperative infection, dyspareunia and unresolved pain, scarring, and neuropathy(rare).

Recurrence

Recurrence rates range from 2% to 25% with varying periods of follow upconsidered.

A study by Randall and Downs found that 63% of their study population (12 out of 19) reported a total of 28 incision and drainage procedures prior to marsupialization.

Aft er m arsupialization, none of these patients had a recurrence in the first 1 week

after surgery.[15]

Andersen et al completed a study in 1992 that compared marsupialization alone t oprimary suture technique plus antibiotic coverage in 19 patients with Bartholin glandabscesses. They found no significant difference in recurrence rates between the two

groups at 6 month follow-up.[16]

Postoperative infection

Postoperative infection can be due to preexisting Neissaria gonorrhea or Chlamydiatrachomatis. Prophylactic antibiotics are not usually administered preoperatively for

uncomplicated Bartholin gland cysts.

Postoperative infection can be polymicrobial in origin, and it can have bacteria

commonly associated with the gastrointestinal tract due to its proximity to the vulva.

Dyspareunia and unresolved pain

These may be associated with the size of the cyst/abscess and the size of the

operative site.

Long-term monitoring

It is important to evaluate patients who have undergone Bartholin's GlandMarsupialization at their well woman visits for any signs or symptoms consistent

with suspected healing difficulties or recurrence. In addition, it is important todiscuss any new symptoms that have arisen since the procedure, such as

dyspareunia, vaginal discharge, and vulvar or labial numbness. If found early, thesesymptoms can be evaluated and addressed appropriately to provide patient careand comfort.

Medications and Medical Devices

Medication Summary

Infections of the Bartholin gland can be associated with N gonorrhea and C trachomatis infections. Infections are also often polymicrobial in nature. As such,

hey often require broad spectrum antibiotic coverage. Antibiotic choices for Bartholin gland infections are numerous. Likewise, the same can be said for localanesthetics often used during the marsupialization procedure. An overview of both

is listed below and can also be found in Bartholin Gland Diseases.

Common antibiotics used include the following:

Ceftriaxone (broad-spectrum and N gonorrhea coverage)Ciprofloxacin (broad-spectrum coverage)

Doxycycline ( C trachomatis coverage) Azithromycin ( C trachomatis coverage)

Common local anesthetics include the following:

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Lidocaine: 1% or 2% concentrations available; used with or without

epinephrineBupivicaine (Marcaine, Sensorcaine): 0.25% or 0.5% concentrationsavailable; used with or without epinephrine

Contributor Information and Disclosures

Author Tabitha F Perry, MD Resident Physician, Department of Obstetrics and Gynecology, Western Pennsylvania

Hospital

Tabitha F Perry, MD is a member of the following medical societies: American College of Obstetricians andGynecologists, American Medical A ssociation

Disclosure: Nothing to disclose.

Coauthor(s)

Roseann H Covatto, MD Associate Program Director, Ob/Gyn Residency Program, Director, Ob/Gyn AmbulatoryCare Center, Department of Obstetrics and Gynecology, Western Pennsylvania Hospital, West Penn Allegheny

Health System

Roseann H Covatto, MD is a member of the following medical societies: American College of Obstetricians andGynecologists, American Medical A ssociation


Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference


Chief Editor Christine Isaacs, MD Associate Professor, Department of Obstetrics and Gynecology, Division Head, GeneralObstetrics and Gynecology, Medical Director of Midwifery Services, Virginia Commonwealth University School of

Medicine

Christine Isaacs, MD is a member of the following medical societies: American College of Obstetricians and

Gynecologists


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Bartholin Gland Marsupialization_ Overview, Periprocedural Care, Overview of Technique

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