• Indications — separated into malignant (where BSO is mandatory) vs. benign (where ovarian conservation decisions are nuanced), plus prophylactic BSO for high-risk genetics
• Surgical technique — step-by-step with intraoperative images from Sabiston and Schwartz's showing the key pedicle divisions
• Complications — organized intraoperatively vs. postoperatively, including the long-term hormonal sequelae unique to BSO in premenopausal women
• Perioperative care — covers the full continuum from NPO to discharge to activity restrictions
• Route comparison — contextualizes when open TAH remains appropriate vs. minimally invasive alternatives, supported by the 2023 Cochrane review

Bartholin Cyst (Bartholin Duct Cyst & Abscess)

Anatomy

Pathophysiology

"Obstruction of the duct may result in a cyst or abscess. A cyst does not need to be present before an abscess can develop." — Tintinalli's Emergency Medicine

Epidemiology

• Occur at all ages, predominantly in reproductive-age women
• Bartholin abscesses affect approximately 2% of women
• Uncommon after menopause (gland involutes); any Bartholin gland mass in a woman >40 years must raise suspicion for malignancy

Microbiology (Abscess)

Clinical Features

Bartholin Duct Cyst

• Unilateral, smooth, fluctuant mass at the posterior vestibule (4 or 8 o'clock)
• Often asymptomatic if small
• Larger cysts cause local pressure, discomfort, dyspareunia
• No erythema or warmth (unless infected)

Bartholin Abscess

• Rapidly enlarging, extremely painful mass at same location
• Induration, erythema, fluctuance
• Patient may have difficulty walking or sitting
• Systemic symptoms (fever, chills) are rarely present — their absence does not exclude an abscess
• Develops over several days (or longer if preceded by a cyst)

Diagnosis

• Characteristic location at posterior introitus (labia minora transecting the mass)
• Fluctuance confirms abscess

Caution: Distinguish a Bartholin abscess from an abscess of the labia majora, which requires gynecologic consultation. Any solid component or atypical appearance in a woman >40 warrants biopsy to exclude carcinoma.

Treatment

1. Asymptomatic Cyst

• No treatment required — observation is appropriate for small, asymptomatic cysts

2. Symptomatic Cyst or Abscess — First-line: Word Catheter

1. Patient in dorsal lithotomy position; identify abscess at 5 or 7 o'clock with labia minora transecting it
2. Analgesia: 2–4 mL 1% lidocaine infiltrated through the mucosal surface (not skin surface); IV opioids/procedural sedation for severe pain
3. #11 scalpel — stab incision on the mucosal surface of the vestibule, just lateral to the hymenal ring, where fluctuance is maximal. Incision must be large enough for catheter, but not so large the balloon is displaced
4. Alternatively: stabilize abscess with thumb/index finger and "skewer" onto a hemostat for entry
5. Drain pus (expect a palpable pop and free flow of pus); insert Word catheter to the hilt
6. Inflate balloon with 2–4 mL saline; tuck catheter end into vagina
7. Catheter remains in place 4–6 weeks to allow epithelialization of a new permanent duct opening
8. Send pus for culture (including MRSA, GC, chlamydia)
9. Prescribe analgesics; antibiotics after drainage are of no proven value routinely (cover GC/CT if suspected)

3. Recurrent Cyst/Abscess — Marsupialization

1. Patient in dorsal lithotomy; local anesthetic (2% lidocaine ± epinephrine) or pudendal block
2. Retract labium laterally; identify incision site internal to the hymenal ring (mucosa, not skin)
3. Longitudinal fusiform incision 1–2 cm wide over the cyst wall; excise an ellipse of mucosa
4. Grasp cyst wall with two hemostats before segment is removed; cyst will decompress
5. Break up any loculations with small hemostats; irrigate with normal saline
6. In patients >40 years: inspect interior for neoplastic-appearing epithelium; send for biopsy
7. Suture cyst wall edge to adjacent vaginal mucosa with interrupted 4-0 Vicryl — this is the marsupialization step, suturing the cavity open permanently
8. Minimum gap of ≥1 cm across the open marsupialization
9. No dressing required; sitz baths daily for 3–4 days

4. Failed/Persistent Cases — Complete Gland Excision

• Technically more demanding; risks include hemorrhage and hematoma
• A common surgical error is making the incision on the lateral vulvar skin rather than the vestibular mucosa

CPT / Procedure Codes

Bartholin Gland Carcinoma

• Squamous cell carcinoma (most common)
• Adenocarcinoma
• Adenoid cystic carcinoma (characteristically slow-growing, perineural invasion)
• Transitional cell carcinoma

Special Considerations

Summary Algorithm

Bartholin lesion
     │
     ├── Asymptomatic cyst → Observe
     │
     ├── Symptomatic cyst or abscess (1st episode)
     │         → Word catheter (4–6 weeks)
     │
     ├── Recurrent cyst/abscess
     │         → Marsupialization
     │
     ├── Failed marsupialization / persistent
     │         → Complete gland excision
     │
     └── Solid mass / age >40 / postmenopausal
               → Biopsy to exclude carcinoma