Bartholinitis

Bartholinitis is an inflammatory disease of a large gland located at the entrance to the vagina. Uncomplicated forms do not lead to a deterioration of the general condition and a decrease in working capacity, are accompanied by minor pain and swelling in the labia, scanty discharge, a slight increase in temperature. The diagnosis is usually established during a gynecological examination, for the choice of antibacterial treatment, a cultural analysis of the gland secretion is performed. Conservative treatment – medication, physiotherapy, in case of purulent complications, surgical intervention is necessary.

ICD 10

N75.8 Other diseases of the bartholin gland

General information

Bartholinitis is a unilateral, rarely bilateral infectious inflammation of the paired bartholin (large vestibular) gland located in the area of the vestibule of the vagina and named after the Danish anatomist Kaspar Bartholin, who described it in the XVII century. This is a common disease in gynecology, to which women of reproductive age are susceptible, the peak incidence is 20-30 years old, the frequency of occurrence is 15%. In girls, the disease is not registered, in postmenopausal women it is extremely rare, because in children the gland is not sufficiently developed, and in the elderly it undergoes involutive changes. Bilateral forms are characteristic of highly contagious infections (for example, gonorrhea, less often – trichomoniasis) or develop against the background of a significant decrease in immune activity.

Causes

Bartholinitis is a consequence of damage to the gland tissues by specific (gonococcus, trichomonas, pathogenic types of chlamydia, ureaplasma) and non–specific (E. coli, streptococci, staphylococci, peptococci, bacteroid, clostridium) infectious agents. Infection can enter the gland as exogenous (from the outside) and in an endogenous way (the spread of pathogens present in the body). Infection with specific microorganisms most often occurs from external sources, whereas autoinfection is more characteristic of non-specific bacteria.

• Exogenous infection. In most cases, it occurs during sexual contact. Other sources of infection are other people’s personal items, dirty hands, poorly treated medical instruments. Thus, the risk factors for external infection include sexual contact with an infected partner, neglect of personal hygiene. Not only specific (venereal) infections can be transmitted exogenously, but also conditionally pathogenic ones, for example, if a sexual partner has a nonspecific urogenital infection.
• Endogenous infection. The main sources of endogenous infection are foci of infection in the higher parts of the genital tract (bacterial vaginosis, colpitis, cervicitis), urinary system (cystitis, urethritis, pyelonephritis), intestines (enterocolitis).

Predisposing conditions for the development of nonspecific bartholinitis are injuries and operations on the external genitals, wearing tight underwear, immune disorders. Factors that increase the likelihood of non-specific infection include endocrine-metabolic diseases (diabetes mellitus, pathology of the ovaries and thyroid gland), hypovitaminosis, taking antibiotics, corticosteroids, cytostatics, fatigue, stress, frequent change of even healthy sexual partners (contributes to the development of bacterial vaginosis), frequent alcohol abuse, intensive tobacco smoking. Severe immunodeficiency can lead to hematogenic infection, the sources of which are cholecystitis, caries, chronic ENT infections (tonsillitis, sinusitis).

Pathogenesis

The bartholin glands are located in the thickness of the lower third of the labia majora, their ducts open on the inside of the labia minora. The organ produces mucus that moisturizes the vestibule of the vagina under the influence of estrogens. With age, when the level of female sex hormones in the blood decreases significantly, the bartholin glands lose activity, and with it their susceptibility to the development of inflammation. When an infectious agent enters the mouth of the excretory duct, inflammation of its mucous membranes first develops – canalicular bartholinitis (canaliculitis). When the infection spreads deep into the inflammatory process captures smaller ducts and parenchymal tissue of the organ, where inflammatory infiltrates occur. At any of these stages, inflammation can resolve under the influence of treatment or, less often, spontaneously.

Further progression of bartholinitis leads to purulent complications. As a result of pathological changes associated with the inflammatory process (edema, adhesion of the walls of the canal, its obstruction by exfoliated epithelial cells), obstruction of the excretory duct occurs with the accumulation of purulent exudate in its cavity – a false abscess, or empyema of the gland, is formed. A rarer complication is a true abscess characterized by purulent resorption of glandular tissue with the formation of a restrictive pyogenic membrane around the focus.

Classification

According to the type of inflammation, serous and purulent bartholinitis are isolated. Serous inflammation develops as a result of infection with non-foreign (chlamydia, trichomonas, E. coli) microorganisms, proceeds more easily. Purulent inflammation is the result of infection with pyogenic (staphylococcus, streptococcus, gonococcus, proteus) bacteria and quickly leads to complications. Since inflammation is accompanied by an uncontrolled growth of the entire conditionally pathogenic microflora, serous bartholinitis often turns into purulent over time. According to the clinical course , there are three forms of bartholinitis:

• Sharp. It is usually observed during the manifestation of the disease, characterized by the most pronounced symptoms, the best response to treatment, resolution within three to four weeks.
• Chronic (recurrent). Recurrent bartholinitis proceeds for a long time (often for years), almost asymptomatic phases of remission alternate with phases of exacerbation. The chronic form is difficult to treat conservatively.

Symptoms

The first symptoms are redness of the labia minora in the area of the outlet of the duct of the gland with the formation of a small (the size of a grain to a pea) nodule or string, swelling of the mucous membrane, a slight burning sensation. Later, a moderately painful or painless swelling of the lower third of the labia majora, minor serous or purulent discharge, an increase in body temperature to 37-37.5 ° C. Sometimes there is local itching, slight general malaise, slight discomfort when walking.

The development of purulent forms of the disease is accompanied by a rapid growth of formation in the thickness of the labia, intense, often unbearable pulsating local pain (including at rest), giving to the hip, difficulty walking, fever attacks, deterioration of the general condition – weakness, depression, decreased appetite. Especially pronounced symptoms are characteristic of a true bartholin gland abscess. Recurrent bartholinitis in the remission phase is asymptomatic or with indefinite discomfort in the vulva, dyspareunia. Menstruation, intense sexual activity, hypothermia, intercurrent disease can provoke an exacerbation. During the period of exacerbation, the symptoms correspond to acute bartholinitis.

Complications

The most common complication of bartholinitis is abscesses, which significantly worsen the quality of life, which, when resolved, can lead to deformation of the labia, formation of vaginal fistulas, septic condition. Another common complication, usually concomitant with recurrent bartholinitis, is associated with the formation of a retention cyst of the bartholin gland, which tends to frequent suppuration with the development of a pseudoabcess. Untreated bartholinitis in pregnant women complicates the course of natural (vaginal) childbirth, can be a source of obstetric sepsis, cause perinatal infections of the fetus and neonatal infection of the newborn.

Diagnostics

The diagnosis is made by a gynecologist and includes an objective examination of the genitals and smear tests. Differential diagnosis of bartholinitis is carried out with other purulent formations (furuncle of the labia, inflammation of the paraproctitis), infectious processes (atypical form of syphilitic chancre, tuberculous onslaught), as well as cancer of the bartholin gland. To distinguish these pathologies, consulting techniques of an oncogynecologist, dermatovenerologist, proctologist, etc. may be required.

• Gynecological examination. Upon examination and palpation of the vulva, hyperemia and maceration of the small lip, compaction, redness and a convex “roller” around the mouth of the duct of the bartholin gland are detected, when pressed on which serous or purulent exudate is released.
• Identification of the pathogen. Microscopy and bacterial seeding of inflammatory exudate and vaginal smear are used to identify the infectious agent. In addition, culture analysis allows you to determine sensitivity to antibiotics. For accurate diagnosis of gonorrhea, chlamydia infection, a PCR study is performed.

With frequent relapses of bartholinitis, a comprehensive examination with the involvement of a therapist and narrow specialists – a urologist, endocrinologist, gastroenterologist – is necessary to identify and eliminate predisposing factors. In the case of persistent, untreatable inflammation with rapid infiltration growth, especially in postmenopausal patients, cytological examination is required to exclude carcinoma.

Treatment

Uncomplicated acute forms of the disease are successfully cured by conservative methods – the use of antibiotics inside, local treatments and physiotherapy. The main method of treating abscesses is surgery. With frequent exacerbations of chronic bartholinitis associated with a retinoctonic cyst, surgical treatment (marsupialization, cyst removal) is also indicated.

• Medical treatment. Empirical therapy of bartholinitis includes broad–spectrum antibiotics – inhibitor-protected penicillins, fluoroquinolones, macrolides. Antiseptics are treated locally. After verification of the pathogen, antibacterial agents are prescribed depending on the results of culture analysis and PCR. Nonsteroidal anti-inflammatory drugs are used to relieve pain, fever.
• Physical therapy. It is prescribed to prevent relapses after the acute phase of inflammation subsides, during the remission of chronic bartholinitis. In acute inflammations, UV, UHF, SMT is carried out on the perineal area, in chronic ones – treatment with an infrared laser, applications of mud, paraffin, ozokerite.

Prognosis and prevention

The prognosis for acute bartholinitis is favorable, most cases end in complete cure, however, in about a quarter of patients, the disease turns into a recurrent form, usually associated with the formation of a cyst. Prevention includes compliance with personal hygiene rules, exclusion of accidental unprotected sexual contacts, wearing loose underwear made of natural fabric, timely detection and treatment of vaginal dysbiosis, inflammatory diseases of the urogenital tract and intestines, chronic infections of the oral cavity, ENT organs, pathologies of the metabolic and endocrine system. To minimize the likelihood of nonspecific bartholinitis helps a healthy lifestyle (compliance with work and rest, physical activity, eating a balanced meal, giving up bad habits).