Bartholin gland masses

INTRODUCTION — The Bartholin glands (also called the greater vestibular glands) are located bilaterally in the vulvar vestibule (figure 1), and blockage of the Bartholin ducts is a common etiology of a vulvar mass. The most common Bartholin masses are cysts or abscesses; Bartholin gland benign tumors and carcinomas are rare.

Bartholin cysts and abscesses will be reviewed here. Other types of vulvar abscess, vulvar lesions, and vulvar cancer, including Bartholin gland carcinoma, are discussed in detail separately. (See "Vulvar abscess" and "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers" and "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)

BARTHOLIN GLAND

Anatomy — The Bartholin glands (also called the greater vestibular glands (figure 2)) are the female homologue of the male bulbourethral glands. The Bartholin gland's main function is to secrete mucus to provide vaginal and vulvar lubrication [1].

Each Bartholin gland is approximately 0.5 cm in size and drains tiny drops of mucus into a duct 2.5 cm long. The glands are deep to the posterior aspects of the labia majora. The ducts open onto the vulvar vestibule at the four and eight o'clock positions on each side of the vaginal orifice, just below the hymenal ring (figure 1).

The Bartholin gland is composed of several epithelial types: the body is mucinous acini, the duct is predominantly transitional epithelium, and the orifice is squamous epithelium [2].

Types of masses

●Bartholin cyst – If the orifice of the Bartholin duct becomes obstructed, mucus produced by the gland accumulates, leading to cystic dilation proximal to the obstruction. Obstruction is often caused by local or diffuse vulvar edema. Bartholin cysts are usually sterile.

●Bartholin abscess – An obstructed Bartholin duct can become infected and form an abscess (picture 1). While originally Bartholin abscesses were thought to be polymicrobial infections [3], subsequent studies have found that the most common pathogen is Escherichia coli [4,5]. Sexually transmitted infections (STIs) may also contribute to infection (one-third of patients in older studies [6-9]), but this proportion has been declining [4].

Representative studies include:

•In a retrospective study including 219 patients admitted with a Bartholin abscess, purulent cultures were positive in 126 patients (62 percent). The single most common pathogen was E. coli (55 isolates) followed by polymicrobial infections (10 patients), Staphylococcus aureus (8 isolates), Group B Streptococcus (6 isolates), and Enterococcus species (spp; 6 isolates). There were no STIs isolated [5].

•In a prospective study including 224 patients with a Bartholin abscess, microbiologic examination of aspirates yielded 307 positive aerobic cultures and 118 positive anaerobic cultures [4]. The predominant aerobic bacteria were E. coli (78 isolates), Staphylococcus spp (40 isolates), and Streptococcus spp (32 isolates); the most common anaerobic bacteria were Bacteroides spp (30 isolates). There were four positive isolates for Neisseria gonorrhea and one positive isolate for Chlamydia trachomatis (5 patients with STIs among 219 patients with positive cultures, approximately 2 percent).

●Bartholin benign tumor – Benign tumors of the Bartholin gland include nodular hyperplasia, adenomas, and hamartomas. However, the rarity of these lesions limits the ability to further characterize them. Clinically, the significance is minimal, and excision of the tumors is curative [2].

●Bartholin gland carcinoma – Primary carcinoma of the Bartholin gland is most often an adenocarcinoma or squamous cell carcinoma, but transitional cell, adenosquamous, and adenoid cystic carcinomas may also occur. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Bartholin gland carcinoma'.)

EPIDEMIOLOGY AND RISK FACTORS

●Epidemiology – The most common types of Bartholin gland masses are cysts or abscesses. Abscesses are almost three times more common than cysts [10]. In prospective studies including asymptomatic patients undergoing pelvic imaging (eg, magnetic resonance imaging, computed tomography), Bartholin cysts were present in 0.6 to 3 percent of patients [11,12]. Symptomatic patients with Bartholin cysts and abscesses account for approximately 2 percent of all gynecologic visits per year [13].

Incidence appears to peak around menopause. In one retrospective study, the incidence of Bartholin cysts and abscesses increased with age until menopause and then decreased [14].

Benign tumors of the Bartholin gland and Bartholin gland carcinoma are rare. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Bartholin gland carcinoma'.)

●Risk factors – While there are no established risk factors for Bartholin cysts and abscesses, a previous Bartholin cyst or abscess is a risk factor for recurrence.

Risk factors for Bartholin gland carcinoma are also not well established. (See 'Biopsy' below.)

CLINICAL PRESENTATION

●Cyst – A Bartholin cyst is typically painless and may be asymptomatic. Most Bartholin cysts are detected during a routine pelvic examination or by the patient themself. Larger cysts may cause discomfort, typically during sexual intercourse, sitting, or ambulating. Patients may also find the presence of a cyst to be disfiguring, even in the absence of symptoms.

●Abscess – Bartholin abscesses typically present with such severe pain and swelling that patients often find it difficult or impossible to walk, sit, or have sexual intercourse.

The clinical presentation of Bartholin gland carcinoma is presented separately. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Clinical presentation'.)

EVALUATION — Evaluation of a suspected Bartholin mass includes a medical history, pelvic examination, and often culture of the cyst contents (in the case of abscess). There is no role for imaging studies in the evaluation of a Bartholin mass. There is also no role for blood tests, if systemic infection is not suspected.

History — A history of the presenting symptoms should be elicited, including:

●Days since the onset of the mass.

●Presence of pain – If the mass is painful, the severity and associated characteristics of the pain should be elicited, including whether the pain is constant or intermittent; whether it is worsening; and if there is pain with activity such as sitting, walking, or during sexual intercourse. Cysts may be nonpainful or associated with mild pain, but a Bartholin abscess is typically very painful. (See 'Clinical presentation' above.)

●Drainage of fluid from the mass and whether the drainage was purulent – If there was drainage, the patient should be asked what the color of the drainage was. Cysts are likely to have clear or white fluid. Abscesses have a purulent discharge that is typically yellow or green. The patient should be asked whether the pain decreased after drainage.

●Fever – One-fifth of patients with abscess are febrile [5].

●Previous history of vulvar mass, particularly a Bartholin mass.

●Comorbidities, including diabetes or immunosuppression – These may impact the severity of infection and wound healing.

●Previous history of vulvar conditions or surgery – This may impact the vulvar examination or surgical planning.

Physical examination — A complete physical examination should be performed in patients in whom systemic infection is suspected (rare).

A pelvic examination is performed in all patients, including visual inspection of the vulva and palpation of the Bartholin gland. The Bartholin gland is typically palpated on examination by holding the labium majus between a finger in the posterior vaginal introitus and a thumb lateral to the labium. A normal Bartholin gland is not palpable, except possibly in very thin patients.

A Bartholin cyst averages 1 to 3 cm in size and is usually soft, nontender, and unilateral [11,15]. In the prospective study including asymptomatic patients described above (see 'Epidemiology and risk factors' above), unilateral cysts were identified in 93 percent of patients with cysts (50 percent right-sided, 43 percent left-sided); one patient was diagnosed with bilateral Bartholin gland cysts [11].

A Bartholin abscess is typically larger (eg, 3 to 6 cm in size) than a Bartholin cyst and is also usually unilateral. On examination, an abscess is often a soft, tender, warm, or fluctuant mass, occasionally surrounded by erythema (cellulitis) and edema (lymphangitis). A large abscess, however, can expand into the upper labia (picture 1). If the abscess is very close to the surface, pus may break through the thin layer of skin at a point (pointing) and may drain spontaneously.

Abscess cultures — If purulent material is obtained from a spontaneously draining abscess or at the time of incision and drainage (I&D), we obtain cultures for aerobic bacteria and nucleic acid amplification testing for gonorrhea and chlamydia in patients at risk of sexually transmitted infections (STIs). (See "Clinical manifestations and diagnosis of Neisseria gonorrhoeae infection in adults and adolescents", section on 'Diagnostic techniques' and "Clinical manifestations and diagnosis of Chlamydia trachomatis infections", section on 'Nucleic acid amplification testing (test of choice)'.)

Historically, Bartholin abscess fluid was not always sent for culture because drainage is usually curative. However, this practice has changed because of the increase in community-associated methicillin-resistant S. aureus infections [5,16-18]. (See "Methicillin-resistant Staphylococcus aureus (MRSA) in adults: Epidemiology".)

The role of antibiotics is discussed below. (See 'Role of antibiotics' below.)

Biopsy — For patients of any age in whom there is suspicion for malignancy of the Bartholin gland or other vulvar site, biopsy is required. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Diagnostic evaluation'.)

As risk factors for Bartholin gland carcinoma are not well established (see 'Epidemiology and risk factors' above), it is not possible to select patients for biopsy based upon risk factors [19,20]. Some experts advise performing a biopsy in all patients with a Bartholin gland mass who are age 40 years or older. In our practice, we perform a biopsy if any of the following are present:

●Mass with a solid component

●Cyst or abscess wall is fixed to surrounding tissue

●Mass is persistent (ie, unresponsive or worsening) despite treatment

●Patient is postmenopausal

To perform the biopsy, we biopsy from inside the gland at the time of I&D, marsupialization, or gland excision (or perform biopsy alone if other procedures are not planned). A description of vulvar biopsy technique is provided separately. (See "Vulvar lesions: Diagnostic evaluation", section on 'Procedure'.)

DIAGNOSIS — The diagnosis of a Bartholin cyst or abscess is clinical and based on the following physical examination findings (see 'Physical examination' above):

●Cyst – A soft, nontender mass at the posterior aspect of the vaginal introitus at the site of the Bartholin duct and gland (figure 1).

●Abscess – A soft, tender, warm, or fluctuant mass at the location of the Bartholin duct and gland; erythema, edema, and/or pointing may also be present.

A Bartholin gland tumor or carcinoma is a histologic diagnosis made based on biopsy. (See 'Biopsy' above and "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Diagnosis'.)

DIFFERENTIAL DIAGNOSIS — While there are many different types of vaginal and vulvar masses (table 1), a Bartholin mass can typically be differentiated from these by its anatomic location (ie, at the site of the Bartholin duct and gland in the lower medial labia majora or lower vestibular area). (See "Vulvar abscess" and "Vulvar lesions: Differential diagnosis of vesicles, bullae, erosions, and ulcers" and "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment".)

MANAGEMENT — Many treatment options are available for the treatment of a cyst or abscess of the Bartholin gland. Incision and drainage (I&D) is usually combined with an additional method (eg, Word catheter, marsupialization) to keep the tract open, allow continued drainage of cyst or abscess contents, and decrease the risk of recurrence. Lesser-used techniques include silver nitrate and placement of a Jacobi ring catheter. In a meta-analysis of eight randomized trials including almost 700 patients with symptomatic Bartholin cyst or abscess, no specific surgical intervention was more effective than another in preventing disease recurrence [21].

Definitive management is with excision of the Bartholin gland and duct.

Our approach

Initial management — Initial management of a mass of the Bartholin gland depends on the size of the mass and whether it is a cyst or an abscess (algorithm 1). The typical patient (ie, well appearing, no signs of systemic or progressive infection) can be managed in the office or emergency department. In all cases, biopsy should be performed when indicated. (See 'Biopsy' above.)

In some cases, a cyst or abscess ruptures and drains spontaneously. These patients may only need analgesics or soaking of the genital area with warm compresses or sitz baths.

Small mass (<3 cm)

●Cyst – Small Bartholin cysts may be managed expectantly. Other options, particularly for symptomatic cysts, are sitz baths or warm compresses with the goal of eliciting drainage of the cyst contents and resolution of the mass.

●Abscess – Small abscesses are managed with I&D. (See 'Incision and drainage' below.)

Unlike a large mass (see 'Large mass (≥3 cm)' below), it is often not possible to place a Word catheter to keep the tract open for drainage. Thus, sitz baths or warm compresses are advised until the swelling and pain resolve.

Large mass (≥3 cm) — Large Bartholin cysts and abscesses should undergo I&D to allow evacuation of the contents of the mass; cultures of the cyst contents are obtained in cases of cyst abscess. (See 'Incision and drainage' below and 'Abscess cultures' above.)

An additional procedure (ie, Word catheter, marsupialization) is needed to keep the tract open for drainage. For most patients, we suggest Word catheter placement rather than marsupialization as a Word catheter can be inserted in the office setting with local anesthesia; marsupialization is needed for patients with latex allergy. (See 'Comparison of methods' below and 'Word catheter' below.)

For patients with a large mass (abscess or cyst) at high risk for systemic or progressive illness, oral antibiotic therapy is initiated. Parental therapy is used if systemic or progressive infection is suspected or in patients unable to tolerate oral antibiotics. (See 'Role of antibiotics' below.)

Role of antibiotics — There are no randomized trials that address the role of antibiotics in the management of Bartholin's cysts or abscesses. Our approach is based on clinical experience and expert opinion.

In our practice, we limit antibiotic treatment to patients with:

●Recurrent Bartholin abscess (≥2^nd occurrence).

●High risk of complicated infection (eg, sepsis), including extensive surrounding cellulitis, pregnancy, immunocompromise, or risk factors for methicillin-resistant S. aureus (MRSA (table 2)) [5].

●Culture-positive MRSA. (See 'Abscess cultures' above.)

●Signs of systemic infection (eg, fever, chills) [22]. Rare cases of necrotizing fasciitis and sepsis after Bartholin abscess drainage have been reported [23,24].

Known or suspected gonorrhea or chlamydia infection should be treated with appropriate antibiotics. (See "Treatment of uncomplicated gonorrhea (Neisseria gonorrhoeae infection) in adults and adolescents" and "Treatment of Chlamydia trachomatis infection".)

Antibiotic regimens — Oral antibiotic therapy for patients with a vulvar abscess should provide adequate coverage for staphylococcal (including MRSA) and streptococcal species (spp) and enteric gram-negative aerobes, specifically E. coli. Options for oral antimicrobial therapy are shown in the table (table 3).

Patients who have signs of systemic illness or who have failed or are unable to tolerate oral therapy require parenteral therapy with coverage for MRSA, enteric gram-negative aerobes, and anaerobes (table 3). Management of these patients may require consultation with a specialist in infectious diseases. This is discussed in more detail elsewhere. (See "Vulvar abscess", section on 'Antimicrobial agents'.)

Follow-up — Following initial management, we typically schedule follow-up in one month and sooner should the Word catheter fall out or in patients at high risk for complicated infection (see 'Role of antibiotics' above). Specific follow-up after Word catheter placement is discussed in detail separately. (See "Bartholin gland cyst and abscess: Word catheter placement", section on 'Follow-up'.)

If the mass (ie, cyst or abscess) resolves, no further management is required.

If the mass (ie, cyst or abscess) is persistent despite treatment, biopsy is performed and then managed similarly to disease recurrence. (See 'Biopsy' above and 'Management of recurrent masses' below.)

Management of recurrent masses — Recurrence may occur immediately after, or remote from, treatment and presents with the same signs and symptoms as an initial occurrence. (See 'Clinical presentation' above.)

In our practice, management is as follows (algorithm 2):

●For a cyst that recurs:

•If it is not infected, we offer expectant management or I&D with or without Word catheter placement. (See 'Incision and drainage' below and 'Word catheter' below.)

•If it has become infected, we manage as a recurrent abscess, as described below.

●For an abscess that recurs, the approach depends on the number of recurrences and on patient preferences:

•For the second episode of an abscess, we typically repeat I&D, Word catheter placement, and treat with antibiotics. Others may prefer to perform marsupialization to keep the tract open. (See 'Role of antibiotics' above and 'Comparison of methods' below.)

•For patients who have failed treatment and now have a third episode, we suggest marsupialization and treat with antibiotics. (See 'Marsupialization' below.)

•If there is a recurrence after marsupialization, we offer the patient gland excision. (See 'Gland excision' below.)

Comparison of methods

●I&D alone – In our practice we perform I&D alone only when a Word catheter is not available or if the cavity is too small to fit the Word catheter. I&D alone is easy to perform, has minimal risk of complications, and can typically be performed in an outpatient setting. Most symptomatic patients experience immediate pain relief upon drainage of cyst contents. However, when performed as the sole procedure, it carries a high risk of recurrent cyst/abscess formation (13 percent, one study) [25].

●Word catheter and marsupialization – We suggest Word catheter placement for most patients with a first or second occurrence of an uncomplicated Bartholin cyst/abscess and reserve marsupialization for patients who have failed one or two placements of a Word catheter.

Word catheter and marsupialization appear to be equally effective [21], and complications rates appear to be similarly low for both interventions [26]. However, a Word catheter may be advantageous because it can be performed in an office setting rather than operating room, avoids general or spinal block/epidural anesthesia, and reduces resource utilization (eg, hospital beds) [21,27].

The main disadvantages of a Word catheter are that it may be irritating and often dislodges or falls out before the tract is epithelialized, which would place the patient at increased risk of recurrence. As the stem of the Word catheter is latex, the device is also contraindicated in patients with latex allergy. For these patients, marsupialization is the procedure of choice. An advantage of marsupialization is that patients experience less postprocedure discomfort.

Recurrence rates after either procedure are similar. In the meta-analysis of randomized trials discussed above (see 'Management' above), recurrence rates were similar for patients treated with Word catheter compared with marsupialization (23 versus 9.5-32.4 percent, respectively) [21]. Other studies have found lower recurrence rates (Word catheter: 2 to 18 percent [13,28-30], marsupialization: 2 to 13 percent [13,26]).

●Silver nitrate and other procedures – I&D followed by silver nitrate stick ablation is effective [13,31]. Postprocedure discomfort is the major disadvantage.

•Compared with marsupialization, silver nitrate appears to result in less scarring. In a randomized trial including 159 patients with Bartholin cysts or abscesses, patients treated with silver nitrate ablation compared with marsupialization had similar rates of recurrence and dyspareunia at six months [31]. However, more patients in the silver nitrate group experienced complete healing without scar formation (56 versus 31 percent).

•Compared with complete excision (see 'Gland excision' below), silver nitrate appears to be equally effective. In a randomized trial including 50 patients with Bartholin cysts or abscesses, treatment with silver nitrate ablation or complete excision were similarly effective; no patient developed a recurrence during two years of follow-up [32]. However, operating and healing times were shorter in the silver nitrate group.

•Comparison of silver nitrate ablation with Word catheter placement has not been performed.

●Jacobi ring catheter and Word catheter – Use of a Jacobi ring catheter rather than a Word catheter has been proposed, with the benefit of two drainage tracts and no risk of premature expulsion of ring catheter. However, clinical experience is limited [33].

●Gland excision – Excision of the entire Bartholin gland and duct is the definitive procedure for treatment of both cysts and abscesses. It is usually only performed after other less invasive methods have repetitively failed or for Bartholin carcinoma. (See "Vulvar cancer: Epidemiology, diagnosis, histopathology, and treatment", section on 'Bartholin gland carcinoma'.)

In contrast to other methods, excision carries a high risk of complications, particularly excessive bleeding. Other complications include hematoma formation, cellulitis, scarring, disfigurement, and dyspareunia. Loss of Bartholin gland function may cause vaginal dryness or dyspareunia, although this is uncommon.

PROCEDURE TECHNIQUE

Incision and drainage — For incision and drainage (I&D), a small incision (eg, 3 to 5 mm) is made at, or superior to, the hymenal ring. This location prevents obvious vulvar scarring. A small incision helps to keep a Word catheter (if used) in place. The fluid then drains spontaneously or is expressed through gentle pressure and may be sent for culture (see 'Abscess cultures' above). The cavity may be irrigated and suctioned.

The I&D procedure for a Bartholin mass is similar to other superficial abscesses, which is described in detail separately. (See "Techniques for skin abscess drainage".)

Word catheter — The Word catheter is a balloon-tipped device that is inserted into the cyst/abscess cavity immediately after I&D (picture 2 and figure 3), and can be performed under local anesthesia in the office or emergency department. The bulb of the catheter is then inflated and left in place for at least four weeks to promote formation of an epithelialized tract for drainage of glandular secretions. The end of the catheter is tucked into the vagina to minimize discomfort. When the tract appears well epithelialized, the balloon is deflated, and the catheter is removed in the office; anesthesia is not necessary.

Latex allergy is a contraindication to Word catheter placement. (See 'Comparison of methods' above.)

The Word catheter procedure is described in detail separately. (See "Bartholin gland cyst and abscess: Word catheter placement".)

Marsupialization — Marsupialization refers to a procedure whereby a new ductal orifice is created in the Bartholin gland wall. This is achieved by incising the cyst/abscess and then everting and suturing the epithelium to the skin at the edge of the incision.

The procedure is performed in the operating room as follows (figure 4):

●An incision is made where the cyst protrudes into the vestibule and just outside of the hymenal ring. The incision may be either a single 1.5 to 2 cm incision into the cyst, a cruciate incision in the cyst, or an excision of a 1 to 2 cm ellipse of tissue that includes the epithelial surface and the roof of the cyst.

●The edge of the proximal duct wall is then grasped with fine forceps and everted onto the epithelial surface where it is sutured with interrupted absorbable sutures, thus creating a fenestration for egress of glandular secretions.

●The cyst/abscess cavity is irrigated; some clinicians insert a drain or pack for a few days, but this is probably unnecessary.

Potential postoperative issues include hematoma formation, pain, infection, scarring, dyspareunia, and recurrence. (See 'Comparison of methods' above.)

Silver nitrate sclerotherapy — For this procedure, I&D is performed, and then a silver nitrate stick 0.5 cm in length and diameter is placed deep within the cyst/abscess cavity, and the wound is covered with a gauze dressing. The patient is asked to return to the office in 48 hours, at which time the incision site is cleansed and necrotic tissue with the remaining silver nitrate particles is removed.

Side effects include pain, chemical burns of nearby tissue, labial edema, ecchymoses, several days of discharge, and scarring.

Gland excision — Excision must be performed in an operating room. Attention to hemostasis, recognition of inadvertent entry into the vagina or rectum, and ascertaining that the entire gland has been resected are important considerations during the procedure. The procedure is shown in the video (movie 1).

SPECIAL POPULATIONS

Pregnant patients — The incidence of Bartholin gland abscess in pregnant patients is low (0.13 percent, one study [34]). The bacterial characteristics are similar to nonpregnant patients. In our practice, we treat pregnant patients in the same manner as nonpregnant patients. One exception is that we usually do not perform cyst excision during pregnancy or the immediate postpartum period given the increased risk of excessive bleeding.

Immunocompromised patients — There are no data to guide the management of Bartholin gland abscess in immunocompromised patients. We follow the same approach as for other vulvar abscesses in this patient population. (See "Vulvar abscess", section on 'Immunocompromised patients'.)

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic infectious diseases (non-sexually transmitted)".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5^th to 6^th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10^th to 12^th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

●Basics topic (see "Patient education: Bartholin gland cyst (The Basics)")

SUMMARY AND RECOMMENDATIONS

●Anatomy – The Bartholin glands are located bilaterally in the vulvar vestibule at approximately the four and eight o'clock positions with respect to the vaginal orifice (figure 1). If the orifice of the Bartholin duct becomes obstructed, a cyst (sterile) or abscesses can form; benign tumors and carcinoma of the Bartholin gland are rare. (See 'Bartholin gland' above.)

●Clinical presentation – Bartholin cysts are usually asymptomatic or mildly bothersome, whereas abscesses typically present with such severe pain and swelling that patients find it difficult to walk, sit, or have sexual intercourse. (See 'Clinical presentation' above.)

●Diagnosis – Diagnosis is based on physical examination. A cyst is a soft, nontender mass at the site of the Bartholin duct and gland. An abscess is a soft, tender, warm, or fluctuant mass; occasionally, erythema, edema, and pointing (opening with abscess at a point in the skin, often with purulent discharge) are present. (See 'Physical examination' above and 'Diagnosis' above.)

●Initial management – Initial management of a Bartholin mass is determined by its size and whether it is a cyst or an abscess (algorithm 1).

•Small cysts (<3 cm) – Small cysts may be managed expectantly. Sitz baths or warm compresses may elicit drainage of the cyst contents and help with resolution of the mass. (See 'Small mass (<3 cm)' above.)

•Small abscesses (<3 cm) – For patients with small abscesses, we suggest treatment with incision and drainage (I&D) alone (Grade 2C). It is often not possible to place a Word catheter in a small abscess, thus, sitz baths or warm compresses are advised for such patients.

•Large masses (≥3 cm) – For patients with large masses, we suggest I&D along with placement of a Word catheter (Grade 2C). A Word catheter allows for continued drainage and decreases the risk of recurrence. Marsupialization is an alternative to a Word catheter, particularly in patients with a latex allergy which contraindicates Word catheter placement. The efficacy of the two approaches is likely similar; however, marsupialization is a more invasive procedure that requires an operative setting. (See 'Large mass (≥3 cm)' above and 'Comparison of methods' above.)

•Role of antibiotics – We suggest against the use of antibiotics in the initial treatment of most Bartholin cysts or abscesses (Grade 2C). However, for patients with a recurrent abscess and those with a large mass and risk factors for a complicated infection or signs of systemic infection, addition of antibiotics is appropriate (table 3). (See 'Role of antibiotics' above and 'Antibiotic regimens' above.)

●Management of recurrent masses (algorithm 2)

•For a cyst that recurs and is not infected, we offer expectant management or I&D with or without Word catheter placement. (See 'Management of recurrent masses' above.)

•For a cyst that has become infected, or an abscess that recurs, the approach depends on the number of recurrences and on patient preferences (see 'Management of recurrent masses' above):

-For the second episode, we suggest adjunctive antibiotic therapy plus I&D and Word catheter placement (Grade 2C). Alternatively, some may prefer to perform marsupialization.

-For patients with a third episode, we suggest adjunctive antibiotic therapy plus marsupialization rather than repeat I&D with Word catheter placement (Grade 2C).

-If there is a recurrence after marsupialization, we offer the patient gland excision. (See 'Gland excision' above.)

●Biopsy – Biopsy is required for patients with any of the following: solid component; cyst or abscess wall is fixed to surrounding tissue; mass is persistent despite treatment; or patient is postmenopausal. (See 'Biopsy' above.)

●Definitive therapy – Excision of the Bartholin gland is definitive therapy of cysts and abscesses, but it is associated with a high risk of hemorrhage and postoperative morbidity. (See 'Gland excision' above.)