Trauma or infection may involve the Bartholin duct, causing obstruction of the gland. Drainage of secretions is prevented, leading to pain, swelling, and abscess formation (Figure 18–4). The infection usually resolves and pain disappears, but stenosis of the duct outlet with distention often persists. Reinfection causes recurrent tenderness and further enlargement of the duct.
Right-sided Bartholin cyst (abscess). The Bartholin gland is located in the lower two-thirds of the introitus. (From Susan Lindsley, Public Health Image Library, CDC.)
The principal symptoms are periodic painful swelling on either side of the introitus and dyspareunia. A fluctuant swelling 1–4 cm in diameter lateral to either labium minus is a sign of occlusion of Bartholin duct. Tenderness is evidence of active infection.
Pus or secretions from the gland should be cultured for Chlamydia and other pathogens and treated accordingly (see Chapters 33-40, 39-41 and 39-42); frequent warm soaks may be helpful. If an abscess develops, aspiration or incision and drainage are the simplest forms of therapy, but the problem may recur. Marsupialization (in the absence of an abscess), incision, and drainage with the insertion of an indwelling Word catheter, or laser treatment will establish a new duct opening. Antibiotics are unnecessary unless cellulitis is present. In women under 40 years of age, asymptomatic cysts do not require therapy; in women over age 40, biopsy or removal are recommended to rule out vulvar carcinoma.
Surgical therapy (marsupialization) is indicated.
EFFECTS OF EXPOSURE TO DIETHYLSTILBESTROL IN UTERO
Between 1947 and 1971, diethylstilbestrol (DES) was widely used in the United States for diabetic women during pregnancy and to treat threatened abortion. It is estimated that at least 2–3 million fetuses were exposed. A relationship between fetal DES exposure and clear cell carcinoma of the vagina was later discovered, and a number of other related anomalies have since been noted. In one-third of all exposed women, there are changes in the vagina (adenosis, septa), cervix (deformities and hypoplasia of the vaginal portion of the cervix), or uterus (T-shaped cavity) (eFigure 18–6).
Cervical changes in women exposed to DES in utero. A: Circular sulcus. B: Central depression and ectopy. C: Portio vaginalis covered by columnar epithelium (ectopy). D: Anterior cervical protuberance (rough). E: Anterior cervical protuberance (smooth). (Reproduced, with permission, from DeCherney AH, Pernoll ML [editors]. Current Obstetrics & Gynecology Diagnosis & Treatment, 8th ed. Originally published by Appleton & Lange. Copyright © 1994 by The McGraw-Hill Companies, Inc.)