<div>Title</div><div>Bartholin’s Gland Cyst or Abscess: A Novel Surgical Treatment Using a
Looped Packing Strip: a case report</div><div>Author</div><div>David W. Hobson, MD, American Board of Obstetrics and Gynecology, Fellow
American College of Obstetricians and Gynecologists</div><div>Department of Obstetrics and Gynecology, Spring Branch Community Health
Center, Houston Texas</div><div>Correspondence</div><div>Spring Branch Community Health Center 800 West Sam Houston Parkway South
Suite 200 Houston Texas 77042-1914 Email: dhobson@sbchc.net</div><div>Comments</div><div>This case report is submitted to BJOG An International Journal of
Obstetrics and Gynaecology in response to the paper written by
Illingworth BJG, Stocking K, Showell M, Kirk E, Duffy JMN. Evaluation of
treatments for Bartholin’s cyst or abscess: a systematic review. BJOG
2020;127:671-678.</div><div>Illustrations(Figures)</div><div>Title</div><div>Bartholin’s Gland Cyst or Abscess: A Novel Surgical Treatment using a
Looped Packing Strip: a case report</div><div>Keywords: Bartholin’s Cyst, Bartholin’s Abscess, Word Catheter, case
report, packing strip</div><div>Abstract</div><div>This is the first reported surgical treatment of a Bartholin’s cyst
under local anesthesia using a looped plain packing strip passed through
two incisions of the Bartholin’s cyst or abscess, loosely tied and left
in place four to six weeks creating a permanent fistula. The potential
advantages of this procedure include: 1) ease of use 2) low cost 3)
lower risk for recurrences 4) requires minimal training 5) alternative
choice in patients who would like to avoid the use of a catheter and
other more invasive treatments 6) use in cysts smaller than 2 cm in
size.</div><div>Introduction</div><div>The Bartholin’s gland produces mucoid secretions that provide
lubrication of the distal vagina and labia minora. The Bartholin’s duct
commonly becomes obstructed leading to the formation of a cyst or
abscess. This affects about 2% of women mostly of reproductive
age11Omole F, Simmons DJ, Hacker Y. Management of Bartholin’s
duct cyst and gland abscess. Am Fam Physician 2003;68:135-40.
Patients often complain of pain in the vulva when sitting, walking and
during intercourse. They are seen in many clinical settings such as
emergency rooms, outpatient clinics and Doctors’ offices. Treatments
have included aspiration, incision and drainage, packing the abscess,
insertion of catheters, rings, silver nitrate gland ablation,
marsupialization, sclerotherapy, resection of the gland,and carbon
dioxide laser procedures. Systematic reviews22Illingworth BJG,
Stocking K, Showell M, Kirk E, Duffy JMN. Evaluation of treatments for
Bartholin’s cyst or abscess: a systematic review. BJOG
2020;127:671-678 have not identified the best approach. Currently,
placement of the Word catheter under local anesthesia is the favored
procedure.33Krose JA, van der Velde M, Morssink LP, Zafarmand
MH, Geomini P, van Kesteren P, et al. Word catheter and
marsupialization in women with a cyst or abscess of the Bartholin
gland (WoMan-trial): a randomized clinical trial. BJOG 2017:124:243-9.
However the use of the Word catheter has several limitations such as: 1)
balloon loss reported as high as 43%, <sup>2</sup>44Reif,
P, Ulrich D, Bjelic-Radisic V, Hausler M, Schnedl-Lampprecht E,
Tamussino K. Management of Bartholin’s cyst and abscess using the Word
catheter: implemenatation, recurrence, rates and costs. Eur J Obstet
Gynecol Reprod Biol 2015;190:81-84 2) technical challenges such as
catheter leak, deflation, inflating the catheter with a needle larger
than 24 gauge, failure to direct the needle into the lumen of the
catheter, failure to maintain pressure on the syringe plunger as you
remove the needle from the inflated catheter, and vulvar pain from the
inflated catheter,55Mellick L. A word about Word Catheters. 2012
Aug 1. Available from:
https://journals.lww.com/em_news/pages/blogs.aspx 3) recurrences of
the cyst or abscess ranging from 4-17%66Wechter ME, Wu JM,
Marzano D, Haefner H. Management of Bartholin duct cysts and
abscesses. A systematic review.Obstet Gynecol Surv 2009;64:395-404.
Figure 1. Bartholin’s cysts with open ostia</div><div>The WoMan-trial (Word versus Marsupialization) was a randomized clinical
trial that compared treatment of a Bartholin’s cyst or abscess under
local or no anesthesia to marsupialization performed under spinal or
general anesthesia. The recurrence of a cyst or abscess, median time for
recurrence, and postoperative pain scores after 24 hours were not
significantly different between the two groups. Kroese et al concluded
that that treatment using a Word catheter was a faster, lower cost
alternative, and relieved pain sooner after diagnosis compared to
marsupialization.<sup>3</sup></div><div>Randomized clinical trials to date have not identified the best
treatment of a Bartholin’s cyst or abscess. The best approach will be
the development of a novel intervention with devices that are smaller in
size, more comfortable, remains in place four to six weeks, and creates
a permanent fistula.<sup>2</sup></div><div>Materials and Methods</div><div>A 45 year old female was seen in our clinic during the period of May
2018 through May 2020 by the author. Written informed consent was
obtained for treatment and publication. There was no financial or other
incentive for participation. There were no sources of support and no
conflicts of interest. She complained of a six year history of swelling
in the right labia minora. Physical examination confirmed a 4 cm right
Bartholin’s cyst. One week later she presented with a 6 cm right and 4
cm left Bartholin’s cyst. Both cysts were incised and drained. She had
recurrence of both cysts documented on visit day 15. On visit day 15,
the right Bartholin’s cyst was incised, drained with placement of the
looped packing strip. The left Bartholin’s cyst was 4 cm and not
drained. The packing strip was removed 11 days later. The second
recurrence of the right Bartholin’s cyst was 10 days after removal of
the packing strip. On visit day 36 she had a 4cm right Bartholin’s and
10 cm left Bartholin’s cyst. Both Bartholin cysts were incised, drained,
and treated with insertion of bilateral packing strips that remained in
place for 32 days. Incision and drainage consisted of a sterile prep
using povidone iodine 10% solution, local anesthesia using Lidocaine
1% 3ml, 25 gauge 5/8 inch needles, with injections into the labial skin
overlying the cyst 1-2 cm outside of the introitus, and making one 5 mm
stab incision with a no. 11 blade scalpel. The insertion of the packing
strip consisted of making two 5 mm stab incisions with a no. 11 blade
scalpel through the skin and cyst wall, under local anesthesia, one at
the top and bottom edges of the cyst 1-2 cm lateral to the introitus.
The tip of a curved hemostat was inserted into the lower incision
passing through the upper incision. A ½ inch x 15 cm length plain
packing strip was pulled through both incisions and loosely tied using a
square knot. Allowance was made to avoid tension on the skin. The extra
packing strip was cut close to the knot. Postoperative instructions
included twice daily cleansing with a gentle wash and returning to the
clinic in 4-6 weeks for removal of the packing strip.</div><div>Results</div><div>The patient was contacted by telephone and agreed to come in for
evaluation. Informed consent was obtained for publication. The patient
was seen by the author in our clinic 1.72 years after placement of the
looped plain strips that remained in place for 32 days. Examination
confirmed that both Bartholin cysts were draining mucoid secretions
through two ostia. (fig.1)</div><div>Discussion</div><div>This case report demonstrates how the treatment with incision and
drainage alone and removal of the packing strip 11 days after insertion
resulted in the recurrence of a right Bartholin’s cyst. Treatment using
packing strip left in place for 32 days resulted in the creation of
permanent fistulas. Both cysts were noted to drain through created ostia
seen 1.72 years after removal of the looped plain packing strip. The
primary outcome measure in the treatment of a Bartholin’s cyst or
abscess is the creation of a permanent fistula. The preferred treatment
of a Bartholin’s cyst or abscess should be fast, safe, performed in an
outpatient setting under local anesthesia, heal rapidly without
complication, and have low recurrence.<sup>2</sup> This procedure
requires minimal training, is cost effective, and well tolerated by this
patient. The novel placement of the looped packing strip in this patient
with bilateral recurrent Bartholin’s cysts accomplished this goal.
Further research is needed to compare placement of the looped packing
strip versus insertion of the Word catheter.</div><div>Disclosure of interests: there were no financial, personal, political,
intellectual or religious interests</div><div>Contribution to authorship: there is only one author David W. Hobson, MD</div><div>Patient’s consent: consent for evaluation, treatment, procedures and
publication was obtained in writing</div><div>Funding: none required</div><div>References</div>