Bartholin’s Cyst and Abscess: Word Catheter Insertion, Marsupialization

CHAPTER 131 Bartholin’s Cyst and Abscess


Word Catheter Insertion, Marsupialization



Michael L. Tuggy


Bartholin’s glands are located at the vaginal opening between the hymenal ring and labia minora (at approximately the 5 and 7 o’clock positions). Simple incision and drainage (I&D) of a Bartholin’s duct cyst or gland abscess may give immediate results with significant pain relief, but recurrence after such a procedure is common. Bartholin’s cysts and abscesses are best treated using a Word catheter to induce the formation of an epithelialized tract from the vulvar vestibule to the cyst. This allows continued functioning of the Bartholin’s gland, proper drainage, and minimal recurrence. The recurrence rate using this technique is between 2% and 15%. The Word catheter has a short latex stem with an inflatable bulb at the distal end (Fig. 131-1) and can be used for both conditions.


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Figure 131-1 Word catheter (bottom). 3-mL syringe filled with water and 25-gauge needle (middle). Word catheter inflated with water (top).


For patients with noninflamed and recurrent Bartholin’s cysts, marsupialization is a permanent cure. The procedure can be performed in the office but often is done as a same-day surgical procedure. It is very well tolerated by patients, with a rapid healing time and minimal postprocedure discomfort. Complications are rare and the technique is easily learned, especially by those physicians familiar with perineal repairs.



Indications



• Treatment of symptomatic Bartholin’s duct cyst (painful, growing)

• Treatment of Bartholin’s gland abscess


Contraindications


Any condition that would preclude normal I&D of a vulvar cyst or abscess would preclude use of the Word catheter. Small, asymptomatic glands do not need to be drained.



Equipment



• Word catheter (Rusch and Milex; most medical suppliers will have on hand)

• 3-mL syringe (for catheter inflation)

• 22-gauge, 1-inch needle (for catheter inflation)

• 2% lidocaine for anesthesia, usually with epinephrine

• 30-gauge, image-inch needle (for anesthesia)

• 3-mL syringe (for anesthesia)

• No. 11 blade

• Pickups with teeth

• Small hemostats (two)

• 4 × 4 gauze pads

• Normal saline for irrigation

• Antiseptic solution (povidone–iodine if not allergic)

• 4-0 Vicryl suture (if marsupialization is done)


Preprocedure Patient Education


The clinician should explain the procedure to the patient and obtain informed consent. A non-narcotic oral analgesic may be administered before the procedure, if desired.



Procedure



Word Catheter Placement



1 Place the patient in the dorsal lithotomy position.

2 Prepare the labia and vagina with the antiseptic solution. It is preferable to enter the cyst (Fig. 131-2A) or abscess from the vaginal side of the introitus unless this would require a much deeper incision (Fig. 131-2B). Inject lidocaine over the intended site of entry. If the incision is to be made external to the introitus where the abscess is “pointing,” plan to insert the catheter approximately in the area of the original duct orifice, immediately adjacent the hymenal ring (Fig. 131-2C).

3 Lance or incise the cyst or abscess with a no. 11 scalpel blade (see Fig. 131-2C). It is essential that the stab wound penetrate the cyst or abscess wall, which will be evidenced by the free flow of pus or mucus. Culture contents if indicated. Although the majority of simple cysts are sterile, abscesses are typically polymicrobial, and many others contain Neisseria gonorrhoeae. Culture usually will not change initial management. The stab wound must be just large enough for the catheter to be inserted, usually 3 to 4 mm.

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Figure 131-2 Insertion of Word catheter. A, Bartholin cyst after local anesthetic has been injected superficially. B, No. 11 blade points to ideal location inside the hymenal ring for the incision. However, the cyst is more prominent externally, so incision will be made there. C, Incising the cyst. Make the opening just large enough for the uninflated Word catheter tip to enter. D, Slide Adson forceps with teeth along the blade (which is in the cyst/abscess) and gently grasp the tissue. This will define the tract into the cyst. If this is not done, especially in smaller cysts, a false cavity may be created when inserting the catheter. E, The blade is removed but the forceps are kept in place. Insert the catheter along the forceps. F, Remove the forceps. Inflate the balloon with saline. Gently tug the catheter after inflation to ensure it does not fall out of the opening. G, Balloon is inflated within the cavity of the cyst so that it will not fall out through the stab wound. H, Tuck the exposed portion of the catheter into the vagina. I, Appearance of the area immediately after removal of the catheter.

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Bartholin’s Cyst and Abscess: Word Catheter Insertion, Marsupialization

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