A 25-year-old woman attends accident and emergency with an exquisitely sore, large swelling of her vagina which she noticed only a couple of days before.
It has steadily got much bigger. On examination there is a soft fluctuant mass on the right labia minora which is very tender.
What is the most appropriate management?
B. Oral ofloxacin and metronidazole
C. Sebaceous cystectomy
D. Local 2 per cent clotrimazole (Canestan)
E. Referral to a vulval clinic
Answer is A Marsupialization:
The clinical history and examination findings make it clear that this is a Bartholin’s abscess. The paired Bartholin’s glands, about 0.5 cm in diameter, are commonly found at the 4- and 8-o’clock positions in the labia minora.
They are normally non-palpable. Their role is to secrete vaginal lubricant into the vestibule via the Bartholin’s ducts during sexual arousal. If the ducts become blocked, an abscess of the gland can develop.
Treatment of this is normally with marsupialization (A): surgery involving opening
the abscess and suturing its lining to the outside to create a permanent opening, thereby preventing recurrence. Oral antibiotics (B) may be useful after surgery, or before if the abscess is small, but not when it is large like in this case. Note however that ofloxacin and metronidazole
are agents commonly used for pelvic inflammatory disease and not usually for abscesses.
Sebaceous cystectomy (C), as the name implies, is a treatment for sebaceous cysts, and is only employed if the cyst is very symptomatic. Vaginal clotrimazole (D) is a treatment for thrush. Simple Bartholin’s abscesses do not require specialist assessment in a vulval clinic (E) unless there are signs of Bartholin’s gland malignancy which is very rare (<1:1 000 000).