Bartholin abscess is a delimited purulent process involving the parenchyma of the large gland of the vestibule of the vagina (a true abscess) or the cavity of its duct (a false abscess). The disease is manifested by a voluminous formation in the lower third of the labia majora, intense local pain, an increase in body temperature, and general malaise. The diagnosis is made based on the results of a gynecologist’s examination, bacteriological examination, and PCR analysis. Surgical treatment – opening of the abscess with subsequent drainage, marsupialization of a suppurated cyst or extirpation of the gland.
ICD 10
N75.1 Bartholin abscess
General information
Bartholin abscess (abscess of the large vestibular gland) is a localized purulent infection affecting one (rarely both) of the paired glandular organs. These glands are located in the thickness of the labia and perform the function of exogenous secretion – they produce a viscous liquid that moisturizes the external genitalia and protects them from infections.
Women of the childbearing period (20-40 years old) are susceptible to the disease, the incidence is 2%. In practical gynecology, false abscess of the large vestibular glands is more often observed. A bilateral abscess is usually a consequence of gonorrhea. Bartholin abscess does not develop in children, is rarely registered in adolescence and old age, and extremely rarely in senility.
Causes
The disease is infectious in nature and most often occurs as a complication of inflammation of the gland – bartholinitis. From specific pathogens, gonococcus, trichomonas, chlamydia are isolated, from non–specific – conditionally pathogenic representatives of obligate and facultative flora: staphylococci, streptococci, E. coli, fungi, anaerobic bacteria. Anaerobic microorganisms (bacterioids, peptococci, peptostreptococci, less often – clostridia) are sown from a purulent focus in 80-90% of cases. The cause of infection is:
- Inflammation of adjacent organs. The infectious agent penetrates into the bartholinium gland from the epithelium of the vulva, from neighboring hollow organs – the vagina, urethra, rectum in case of non-compliance with the rules of personal hygiene and diseases (bacterial vaginosis, vulvitis, vaginitis, cervicitis, adnexitis, urethritis, proctitis, enteritis, enterobiosis).
- Contact transmission of the pathogen. The reason for the development of pathology is non-compliance with the rules of personal hygiene, unprotected sexual intercourse, poorly treated medical instruments, dirty hands, shared towels.
- Retention cysts. Very often, recurrent abscesses develop against the background of a retention cyst of the bartholin gland, which is an ideal reservoir for the growth of opportunistic flora.
The inflammatory process or the presence of a cyst causes suppuration not in all patients. The tendency of the body to abscess is primarily due to immune insufficiency. This condition is most often caused by endocrine-metabolic diseases (diabetes mellitus, hypothyroidism), foci of chronic infectious inflammation (tonsillitis, sinusitis, caries, bronchitis, cholecystitis), helminth invasion.
A significant role is played by vitamin deficiency in the diet, hypothermia, chronic fatigue, prolonged stress, alcohol abuse, treatment with cytostatics and corticosteroids. Predisposing factors include wearing tight clothes that squeeze the pelvic area and perineum (trousers, underwear), self-treatment of bartholinitis (for example, hot baths).
Pathogenesis
The gate of exogenous infection is the excretory duct of the bartholin gland, the infectious agent can enter the parenchyma hematogenically. The penetration of the pathogen causes inflammation of the mucous membrane, expressed by hyperemia, exudation and violation of microcirculation, which leads to its edema and narrowing of the lumen of the main duct. As a result of peeling and ulceration of the upper layer of the epithelium, blockage of the mouth and (or) adhesion of the duct walls may occur.
These changes entail stagnation of purulent exudate with the further spread of the pathological process to the parenchyma of the bartholin gland, the soft tissues of the labia and vagina, and the parotid tissue. Purulent infiltration of the gland and neighboring structures leads to the formation of an abscess: first, leukocyte enzymes melt the tissues to form a cavity filled with pus, then a shell of granulation tissue is formed around the cavity – a demarcation shaft (pyogenic membrane).
During chronization, the abscess is covered from the outside with a layer of connective tissue. The capsule surrounding the abscess does not prevent intoxication of the body by decay products, however, it significantly hinders the penetration of antibacterial drugs from the bloodstream.
Classification
There are two forms of purulent pathology of the bartholin gland: a false (pseudo-abscess) and a true abscess. A pseudoabcess can exist independently for a long time without causing damage to the parenchyma of the gland, or after a short time it can turn into a true abscess: the course of pathology largely depends on the virulence of the pathogen and the immune status.
- False abscess (empyema). It is accompanied by an accumulation of pus in the lumen of the main duct of the bartholin gland. The purulent inflammatory process does not extend to the parenchyma of the gland, being limited to the mucous membrane of the excretory canal. Empyema in most cases is caused by the rapid growth of conditionally pathogenic anaerobic microflora in conditions of stagnation of secretions and often develops against the background of a long-existing retention cyst. The pseudo-process is registered more often than the true one.
- A true abscess. It often occurs when infected with an association of pyogenic cocci (gonococci and pathogenic staphylococci, streptococci), is characterized by infiltration of the gland and adjacent soft tissues with their subsequent purulent melting and the formation of a demarcation shaft around the focus of inflammation. With endogenous infection, a true abscess can develop without prior obstruction of the excretory duct.
Symptoms
A characteristic sign of an abscess of the large glands of the vestibule is a voluminous (reaching the size of a chicken egg), as a rule, one-sided formation in the middle and lower third of the labia. The purulent process is accompanied by an increase and soreness of the inguinal lymph nodes. With empyema, against the background of pronounced edema and hyperemia of the mucous membrane of the vestibule of the vagina, the labia majora and labia minora, there is a rounded swelling of elastic consistency, not soldered to neighboring structures, partially or completely blocking the entrance to the vagina.
With a true abscess, there is also a significant swelling on the side of the lesion, the formation is sedentary, has no clear boundaries, is fixed to a strongly hyperemic skin. An abscess of the bartholin gland is characterized by a pronounced pain syndrome. Acute pain in the labia radiating into the thigh disrupts sleep, increases when walking, sitting, coughing, defecation and is somewhat weakened only in a forced horizontal position on the back with legs spread apart.
A true abscess is distinguished by an acute clinical course: in addition to pain, there is a debilitating fever (often with chills), decreased appetite, tachycardia, low blood pressure, weakness. The general somatic symptoms of the pseudoabcess are not so pronounced, often there is only an increase in temperature to 38 ° C and a slight general malaise. Both with a true and with a false abscess, after opening the abscess (or breaking out), there is a sharp relief of the condition.
Chronic (recurrent) purulent bartholinitis is manifested by periodic maturation and opening of pseudo-processes. The period of remission is characterized by the presence of a dense, sedentary and practically painless formation in the thickness of the labia, as well as uncomfortable sensations during sexual arousal, during and after sexual intercourse. With exacerbations, all signs of an acute abscess appear.
Complications
Spontaneous opening of the Bartholin abscess can lead to the formation of a fistula with its subsequent scarring and deformation of the labia, as well as the walls of the vagina and rectum – in case of a breakthrough of the abscess into their cavity. Sometimes non-healing rectovaginal fistulas can form with the casting of fecal masses into the lumen of the vagina with large defect sizes.
Another unfavorable outcome of an abscess is a breakthrough into the surrounding tissue with the development of a spilled purulent process – perineal phlegmons or, when an infectious agent enters the bloodstream, a generalized purulent process – sepsis, triggering a number of biochemical reactions that fatally violate the most important homeostatic functions of the body.
Diagnostics
Diagnosis of the bartholinium gland abscess is carried out by a gynecologist and a laboratory assistant. Diagnosis, as a rule, does not cause difficulties and is based on the results of the following studies:
- Gynecological examination. Palpation and examination of the labia make it possible to detect asymmetry of the vulva and painful volumetric formation with signs of inflammation: edema, hyperemia, local temperature rise, fluctuation zones. The enlargement and soreness of the inguinal lymph nodes also indicate the inflammatory nature of the formation.
- Laboratory identification of the pathogen. Culture analysis of the discharge from the duct is performed in order to prescribe optimal antibacterial therapy. As a result of the study, conditionally pathogenic pathogens of the disease are identified, as well as their sensitivity to antibiotics. PCR analysis is carried out in order to identify and adequately treat latent infections. The study makes it possible to detect trichomonas, chlamydia and gonococci.
Additionally, a clinical blood test is prescribed, a bacteriological analysis of a smear from the vagina. Bartholin abscess is differentiated with a furuncle (carbuncle) of the labia, tuberculous flow abscess, purulent cyst of the Gartner course, malignant tumors – cancer and sarcoma of the vulva, cancer of the bartholin gland. To exclude malignant neoplasms with recurrent abscesses in women over forty years of age, a histological examination of a biopsy of a pathological formation is carried out. For differential diagnosis, oncogynecologist, phthisiogynecologist, pathomorphologist can be involved.
Treatment
Bartholin abscesses are treated promptly. The choice of surgical method depends on the form of suppuration (empyema or abscess), the nature of the process (primary or recurrent), the skills of the operating gynecologist, the wishes of the patient. With an abscess of the large vestibular glands ,:
- Broad incision. On the side of the mucous membrane, an incision of 5-6 cm is made, through which the contents of the abscess are emptied, the cavity is sanitized, a drainage tube is installed in the incision. Daily rinsing of the cavity is prescribed for a week. The opening of the abscess can be performed both in the case of a true and false abscess. After a wide autopsy, the pseudoabcess may recur.
- Incision with the installation of a word catheter. A relatively new method in domestic gynecology. Purulent contents are evacuated through a 3-5 mm incision and sanitation is performed, after which a word catheter is inserted into the hole – a silicone tube with an inflated ball that provides fixation and promotes the formation of a channel for the outflow of secretions. The catheter is left for 1.5-2 months. The operation is prescribed for a single-chamber false abscess, the probability of recurrence is about 10%.
- Marsupialization. Through the incision of the mucous membrane of the vulva and the cyst capsule, the abscess cavity is cleaned and washed, after which the capsule walls are sewn to the labia mucosa to form a full-fledged duct. Marsupialization is used to treat multicameral or small false abscesses when the installation of a word catheter is impossible. Relapse occurs in 10% of cases.
- Extirpation of the bartholinium gland. Through an incision on the side of the vaginal mucosa, the gland is completely removed along with the duct, then its bed is sutured. Due to the risk of massive bleeding, hemotransfusion may be required. The operation is indicated for recurrent pseudoabsesses, when other methods have not brought satisfactory results: the absence of an organ completely excludes relapse.
In order to prevent local and generalized purulent complications, systemic empirical antibacterial therapy with broad-spectrum drugs (inhibitor-protected penicillins, macrolides, nitroimidazoles) is prescribed, after determining the type of pathogen of infection, specific treatment is carried out. If necessary, detoxification therapy (intravenous administration of saline solutions) is prescribed.
Prognosis and prevention
The prognosis is favorable: in the absence of serious complications, rational therapeutic measures make it possible to achieve a complete cure of the Bartholin abscess. In the case of using non-radical surgical techniques, a relapse of education is possible in some patients. Timely treatment of urogenital and intestinal infections, daily thorough toilet of the perineum, a healthy lifestyle will help prevent the disease. Secondary prevention consists in the radical treatment of retention cysts of the bartholin glands.
Literature
- Haider Z., Condous G., Kirk E., Mukri F., Bourne T. The simple outpatient management of Bartholin’s abscess using the Word catheter:a priliminare study // Comput Assist Tomogr. — 2018; 42(1): 162-166.
- Omole F., Simmons B. J., Hacker Y. Management of Bartholin’s duct cyst and gland abscess // Am Fam Physician. — 2003; 68: 135-140.
- Lee M. Y., Dalpiaz A., Schwamb R., Miao Y., Waltzer W. and Khan A. Clinical Pathology of Bartholins Glands: A Review of the Literature. Current Urology. — 2014; 8: 22-25. link
- Bhide A. et al. Microbiology of Cysts/Abscesses of Bartholin’s Gland: Review of Empirical Antibiotic Therapy Against Microbial Culture. // Obstet Gynaecol. — 2010. link
