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BartholinGlandMarsupialization:Overview,PeriproceduralCare,OverviewofTechnique

BartholinGlandMarsupialization
Author:TabithaFPerry,MDChiefEditor:ChristineIsaacs,MDmore...
Updated:Nov18,2015

Overview
Background
Thegreatervestibularglands(commonlyknownastheBartholinglands)makeup
animportantpartofthefemalereproductivesystem.TheBartholinglandshavea
primaryfunctionofsecretingmucustohelpprovidevulvarandvaginallubrication. [1]
Tofulfillthispurpose,eachBartholinglandcontainsaductthatmeasures
approximately5mmindiameterintheaveragefemale.Forpropersecretion,the
epitheliumofeachglandiscolumnarinnature,whiletheepitheliumofeachductis
simple.Theorificeisofthestratifiedsquamoustype.Thesecretionproducedisa
thick,mucoid,clearsubstancewithabasicpH,anditprovideslubricationduring
sexualactivity. [2]
Measuringfrom1.52cmonaverage,eachBartholinglandisovalinshapeand
residesjustinferiorandlateraltothebulbocavernosusmuscle.Innervationis
receivedfromasmallbranchoftheperinealnerve,whilearterialbloodsupplyis
receivedfromasmallbranchofthearteryonthebulbocavernosusmuscle.
Likewise,venousdrainageisalsoviavesselsonthebulbocavernosusmuscle.
Lymphaticsareviathevestibularplexusandpudendalvessels,andthisdrainage
routeisimportanttoconsiderwhenindepthsurgeryisneeded. [2]Seetheimage
below.

Bartholinglandnerveinnervation

Ifaglandbecomesinfectedoraductbecomesobstructed,theresultisoftenthe
developmentofaBartholincystorabscessthatmayrequiremedicalattention. [3,4]
Thisoccursin2%ofwomen.Inaddition,inrarecases,malignancyoftheBartholin
glandcanoccur. [5]Seetheimagesbelow.

Bartholinglandcyst

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Bartholinglandabscess

TreatmentoptionsforBartholinglandcystsorabscessesincludeexpectant
management,sitzbaths,antibiotics,Wordcatheterplacement,marsupialization,
andglandexcision. [6,7]Therehasbeennoprovensuperioritybetweensurgicaland
conservativemanagementstrategies. [8]
Thisarticlediscussesmarsupialization,inwhichthecystisopenedandtheedges
sutured,formingan"openpocket"or"pouch."

Indications
Seethelistbelow:
HistoryofrecurrentBartholinglandcystsorabscesses
Significantpatientpainordiscomfort
Failureofcystresolutioninatimelymannerorwithalternativetreatments
PatientdeclinesorcannottolerateWordcatheterplacementinanoffice
setting

Contraindications
Contraindicationstomarsupializationarefewandfarbetween,withpatientrefusal
beingvirtuallytheonlyoneidentified.

TechnicalConsiderations
SeveralthingsmustbeconsideredwhendecidingtoperformaBartholingland
marsupialization.Thesequestionshelptoguidethechoiceofprocedurelocationas
wellaspreoperative,intraoperative,andpostoperativetreatment.Eachoftheseis
brieflyaddressed:
Isthisaprocedurethatmustbeperformedintheoperatingroom,orcould
analternativeproceduresuchasWordcatheterplacementbeperformedin
theoffice?
IsitstrictlyaBartholincystorisitaBartholinabscess?
Ifitisanabscess,whataretheorganismsinvolvedandaretheybeing
treatedadequately?
Isthepatientimmunocompromised?
Aretherecomorbiditiesthatmaymakepostoperativehealingaproblem?
Istheresignificantconcernformalignancy?

Wordcatheterizationandmarsupialization
ForinformationonWordcatherizationofBartholinglandcystorabscess,please
seeBartholinAbscessDrainage.
Ingeneral,theeffectiveness,complicationrates,andrecurrenceratesaresimilar
betweenmarsupializationandWordcatheterization.
Inastudyof30AustrianwomenwithBartholincystorabscessthatevaluatedoffice
implementation,recurrencerates,andcostsbetweenWordcatheterizationand
marsupialization,investigatorsnotedan87%successrateand3.8%recurrencerate
inwomentreatedusingtheWordcathether. [8]Wordcatherizationwassimplerto
useandcostsevenfoldlessthanmarsupialization.
Inadifferentanalysis,theinvestigatorsalsoevaluatedqualityoflifeandsexual
activityduringandfollowingtreatmentofBartholincystorabscesswithWord
catherizationandreportedimprovedpainlevelsaswellassignificantlyimproved
pain/discomfortdringsexualactivity. [9]Thementalcomponentsummaryscoreof
thequalityoflifeevaluationshowedasignificantimprovementaftertreatment
comparedwiththepretreatmentperiod,althoughthephysicalcomponentsummary
scoredidnotshowasignificantchange. [9]

PeriproceduralCare
Anesthesia
ThetypicalanesthesiausedforaBartholinglandmarsupializationisprocedural
sedation,alocalanestheticalone,oracombinationofthetwo.
Alocalanesthetic(eg,lidocaine,mepivacaine)shouldbeadministeredandmay
minimizepostoperativediscomfort.Includingavasoconstrictiveagent,suchas
epinephrine,withthelocalanestheticmaybebeneficial.Althoughbleedingis
usuallyminimalfortheprocedure,thisstepmayhelpduringthosefewtimeswhen

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bleedingmayotherwisecloudthesurgicalfield.Formoreinformation,see
InfiltrativeAdministrationofLocalAnestheticAgents.
Theanesthesiologistusuallychoosestheanesthetic.Dependingonbodyhabitus,
airwaydistortion,orpriorhistoryofadversereactionstoanesthesia,the
anesthesiologistmaydecidethatgeneralanesthesia,whichrequiresintubation,may
bethebestmethod,andproceduralsedationmaybeforgone.Giventhatmost
marsupializationsarerelativelyquickprocedures,thishappensrarely.

Equipment
Equipmentneededfortheprocedureconsistsofthefollowing[10]:
Scalpel
Pickups/tissueforceps
Sponges(laparotomyor4x4gauzesponges)
Scissors(Mayo,Metzenbaum)
Allisclamps
Absorbablesutureoptionsandacceptablesizesvaryandincludethe
following:Polysorb(usually20or30)Vicryl(usually20or30)Chromic
(usually20or30)andCaprosyn(usually20or30).
CultureswabandtubeOptional
Povidoneiodine(eg,Betadine)oralternativeprepcleansersuchasiodine
povacrylex/isopropylalcohol(eg,DuraPrep)
FoleycatheterorstraightcatheterOptional
BoviecauteryOptional
Smallhemostaticclamps(CrilesorMosquitoes)
LocalanestheticOptional

Positioning
Toensureproperpositioning,caremustbetakentoplacethepatientcarefullyin
thelithotomyposition.StirrupchoicesincludeYellowFin,Allen,andCandyCane.
Properpositioningforanytypeofgynecologicalprocedureiskeytoprevent
unwantedinjurytopelvic,buttock,orgroinvasculatureornerve.Seetheimage
below.

Lithotomyposition

Partofpositioningthepatientincludesdrapingthepatientappropriately.Sterile
drapesortowelsmustcoverunwantedareaswhileallowingthesurgeonadequate
exposuretotheoperativesite.Asteriletowelmaybeplacedovertheanalareato
guardagainstanalandrectalbacteria.

ComplicationPrevention
Theoperativeareashouldbepreparedwithanantimicrobialsolutionsuchas
Betadine.Giventhatthevulvaandvaginaarecloselylinked,avaginal
prep/cleansingshouldalsobeperformed.Avoidanceofcrosscontaminationfrom
theanalareaisimportant,sincethosebacteriaarenumerousandcanbeeasily
transferredtothevulvararea.Ifnotcareful,thiscanleadtoapostoperativewound
infectioninwomenwhoinitiallypresentformarsupializationofaknownuninfected
cyst.
Dependingonthetimeframebetweendiagnosisandprocedure,thepatientmay
havealreadybeenonbroadspectrumantibioticsifcellulitswasnotedoranabscess
wassuspected.InthecaseofasimpleBartholinglandcyst,antibioticsareusually
notused.

OverviewofTechnique
Thetechniquemaybesummarizedasfollows[11,12,13]:
Oncethepatientisproperlyanesthetized,athoroughbimanualexamination
shouldbeperformed.Thishelpsthesurgeondeterminethebordersand
extentofthecystorabscess.Onceproperlypreppedanddraped,the
bladderisdrainedwithastraightcatheter.AFoleycathetercanbeplacedat
thediscretionofthesurgeon.
Thelabiaareretracteddigitallyandtheintroitusisexposedsothattheentire
surgicalfieldisvisualized.Iflocalanestheticistobeused,itisappliedtothe
areaimmediatelysurroundingthecystwithcaretakennottoenteror
puncturethecystwall.

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A1.5to2cmverticalincisionisthenmadeoverthemucosajustdistalto
thehymenalringandonthewalloftheglandatthecystsite.Caremustbe
takentoensurethattheopeningintotheglandissufficienttopromote
adequatedrainage.Anybleedingnotedcanbecontrolledwithspongesor
suction.
Thewalloftheglandisthenincisedandthecystcontentsareevacuated.
Thiscanbeaccomplishedwithgentleexpressionorwithirrigation.Atthis
point,culturesofthefluidareobtainedandsenttothelab.
ThewallsofthecystaregraspedwithAllisclamps.Absorbablesuturesuch
asPolysorborVicrylisusedinaninterruptedorcontinuousfashiontosuture
thewallofthecysttotheintroituslaterallyandthevaginalmucosamedially.
Themarsupializationisnowcomplete.

PostProcedure
Postoperativecare
Aftertheprocedure,thepatientisusuallyplacedonaregimenthatincludesthe
following:
Hotsitzbathsstartingpostoperativeday1or2
OralpainmedicationsuchasIbuprofen,acetaminophen,oranappropriate
narcoticifpainissevere
AntibioticsarenotroutinelyprescribedforBartholinglandcystsunlessthere
isevidenceofcellulitis.Broadspectrumantibioticscanthenbeused.For
Bartholinglandabscesses,broadspectrumantibioticscanalsobe
administereduntilfinalcultureresultsareobtained. [6]Antibiotic
administrationhasnotbeenshowntopreventrecurrence. [14]
Thepatientmayresumesexualintercourseby4weeksaftersurgery.

Complications
Complicationsvaryintheirriskofdevelopmentandcanincluderecurrence,
postoperativeinfection,dyspareuniaandunresolvedpain,scarring,andneuropathy
(rare).
Recurrence
Recurrenceratesrangefrom2%to25%withvaryingperiodsoffollowup
considered.
AstudybyRandallandDownsfoundthat63%oftheirstudypopulation(12outof
19)reportedatotalof28incisionanddrainageprocedurespriortomarsupialization.
Aftermarsupialization,noneofthesepatientshadarecurrenceinthefirst1week
aftersurgery. [15]
Andersenetalcompletedastudyin1992thatcomparedmarsupializationaloneto
primarysuturetechniqueplusantibioticcoveragein19patientswithBartholingland
abscesses.Theyfoundnosignificantdifferenceinrecurrenceratesbetweenthetwo
groupsat6monthfollowup. [16]
Postoperativeinfection
PostoperativeinfectioncanbeduetopreexistingNeissariagonorrheaorChlamydia
trachomatis.Prophylacticantibioticsarenotusuallyadministeredpreoperativelyfor
uncomplicatedBartholinglandcysts.
Postoperativeinfectioncanbepolymicrobialinorigin,anditcanhavebacteria
commonlyassociatedwiththegastrointestinaltractduetoitsproximitytothevulva.
Dyspareuniaandunresolvedpain
Thesemaybeassociatedwiththesizeofthecyst/abscessandthesizeofthe
operativesite.

Longtermmonitoring
ItisimportanttoevaluatepatientswhohaveundergoneBartholin'sGland
Marsupializationattheirwellwomanvisitsforanysignsorsymptomsconsistent
withsuspectedhealingdifficultiesorrecurrence.Inaddition,itisimportantto
discussanynewsymptomsthathavearisensincetheprocedure,suchas
dyspareunia,vaginaldischarge,andvulvarorlabialnumbness.Iffoundearly,these
symptomscanbeevaluatedandaddressedappropriatelytoprovidepatientcare
andcomfort.

MedicationsandMedicalDevices
MedicationSummary
InfectionsoftheBartholinglandcanbeassociatedwithNgonorrheaandC
trachomatisinfections.Infectionsarealsooftenpolymicrobialinnature.Assuch,
theyoftenrequirebroadspectrumantibioticcoverage.Antibioticchoicesfor
Bartholinglandinfectionsarenumerous.Likewise,thesamecanbesaidforlocal
anestheticsoftenusedduringthemarsupializationprocedure.Anoverviewofboth
islistedbelowandcanalsobefoundinBartholinGlandDiseases.
Commonantibioticsusedincludethefollowing:
Ceftriaxone(broadspectrumandNgonorrheacoverage)
Ciprofloxacin(broadspectrumcoverage)
Doxycycline(Ctrachomatiscoverage)
Azithromycin(Ctrachomatiscoverage)
Commonlocalanestheticsincludethefollowing:

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Lidocaine:1%or2%concentrationsavailableusedwithorwithout
epinephrine
Bupivicaine(Marcaine,Sensorcaine):0.25%or0.5%concentrations
availableusedwithorwithoutepinephrine

ContributorInformationandDisclosures
Author
TabithaFPerry,MDResidentPhysician,DepartmentofObstetricsandGynecology,WesternPennsylvania
Hospital
TabithaFPerry,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansand
Gynecologists,AmericanMedicalAssociation
Disclosure:Nothingtodisclose.
Coauthor(s)
RoseannHCovatto,MDAssociateProgramDirector,Ob/GynResidencyProgram,Director,Ob/GynAmbulatory
CareCenter,DepartmentofObstetricsandGynecology,WesternPennsylvaniaHospital,WestPennAllegheny
HealthSystem
RoseannHCovatto,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansand
Gynecologists,AmericanMedicalAssociation
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
ChiefEditor
ChristineIsaacs,MDAssociateProfessor,DepartmentofObstetricsandGynecology,DivisionHead,General
ObstetricsandGynecology,MedicalDirectorofMidwiferyServices,VirginiaCommonwealthUniversitySchoolof
Medicine
ChristineIsaacs,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofObstetriciansand
Gynecologists
Disclosure:Nothingtodisclose.

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