Bartholin's Abscess & Vaginal FB's - Dr. A. Hunt

Bartholin Abscess
General

• Bartholin’s Gland is a pea sized glands located at the 4 and 8 o’clock positions of the vaginal vestibule, tasked with maintaining moisture of the vestibular surface.
• Can develop into cysts or abscesses (3x more common) with no overwhelming predisposing factors. Majority are polymicrobial but could be gonorrhea/chlamydia in origin.

Management

• Conservative MGMT = Sitz baths if <2cm and pt not immunocompromised
• Gold standard for management is I&D plus drainage device placement (Word catheter vs Loop)
• Word catheter highlights: Keep the cut small! 5mm, instill with approx. 3cc saline, tuck stalk into vagina for comfort
• Loop Drain highlights: Vessel loops or wrist loop of a sterile glove in resource poor environment, 2 incisions made at opposite ends of abscess, 2nd incision made with clamp tip as a marker internally, clamp exits 2nd incision and grasps loop material, pull through and tie ends together. Avoid excess tension that would cause pressure necrosis.
• Aftercare: Guard Word catheter from excess manipulation. Slide loop drain back and forth 2x per day. Sitz baths encouraged.
• Antibiotics IF: -Recurrent Bartholin abscess, Extensive surrounding cellulitis, pregnancy, immunocompromised, Culture-positive MRSA, Signs of systemic infection (eg, fever, chills).
• Antibiotic regimen - 1st line = trimethoprim-sulfamethoxazole DS tablet BID x 7days. Second line = Augmentin + clindamycin, 2nd or 3rd gen cephalosporin or fluoroquinolone, PLUS clinda or doxy.

Follow up

• Goal is to allow for tract formation, Word catheter recommendation is 4-6 weeks and Loop Drain has same time course or wound recheck at 3 weeks.

Vaginal Foreign Bodies

• If you don’t keep it on your differential, you will miss it! Keep in mind in both adult and pediatric populations, can be common in mentally handicapped children.
• Suspect when in cases of foul smelling vaginal discharge +/- vaginal bleeding, recurrent UTIs or vaginitis presentations, premenarchal vaginal bleeding
• More common objects: Adults – tampons, condoms; Pediatrics – toilet paper, toys, safety pins, pencil, crayons, erasers, coins.  
• Diagnosis via direct visualization, plain film, transvaginal vs. transperineal US, vaginography, MRI.
• Treatment is removal
• In pediatrics you can try:

- Examine external genitalia (knees to chest) and remove any obvious partially inserted objects
- Instill saline, irrigate
- Pediatric speculum or nasal speculum
- May require general anesthesia

**Do not forget potential sexual abuse in either population**

• Know when to consult GYN. Complications such as rectovaginal, rectovesicular fistulas CAN occur.

---