Bab 1 Kista Bartholin

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KISTA BARTHOLIN 1. Definisi Kista Bartholin adalah suatu oklusi non-infeksi dari bagian distal kelenjar Bartholin yang diakibatkan oleh retensi sekresi dari kelenjar tersebut. Kista Bartholin merupakan massa yang menonjol di bagian inferior labia mayor. Sepasang duktus Bartholin terletak pada bagian posterior dari vestibulum yang berfungsi sebagai saluran sekresi dari kelenjar Bartholin. Kista Bartholin bersifat asimptomatik jika ukurannya kecil1.

Gambar 1. Kista Bartholin1 2. Anatomi Kelenjar vestibular utama yang dikenal sebagai kelenjar bartholin adalah salah satu struktur anatomi yang berdekatan dengan hymen dimana lokasinya berada di bawah labia mayora pada vulva. Fungsi dari kelenjar bartholin sendiri adalah sebagai penghasil mukus yang berfungsi untuk pelumasan dan melembabkan introitus. Kelenjar bartholin memiliki saluran kecil dengan panjang

mencapai

2,5cm.

Kelenjar

bartholin

merupakan

kelenjar

tubuloalveolar dengan asinus yang terdiri dari epitel kolumnar sederhana yang mensekresi mukus. Oklusi pada kelenjar tersebut yang disebabkan oleh

1

karena faktor infeksi maupun non infeksi menyebabkan akumulasi mukus dan pembentukan kista pada kelenjar tersebut. Peradangan akut pada kelenjar Bartholin disebut dengan bartholinitis. Sedangkan infeksi primer maupun sekunder dari kista bartholin disebut dengan abses bartholin. Kista bartholin dapat berukuran kecil dan asimptomatik, namun jika berukuran besar dapat menimbulkan rasa sakit, dispareunia, dan mengganggu aktivitas sehari-hari 2.

Gambar 2. Anatomi Kelenjar Bartolin 3 3. Epidemiologi Kista bartholin sering tumbuh pada daerah vulva yaitu labia mayora. Dua persen dari keseluruhan wanita di dunia dapat mengalami kista bartholin maupun abses bartholin. Kejadian abses bartholin bahkan tiga kali lipat dibanding kista bartholin. Kista bartholin dapat ditemukan baik pada wanita kulit putih maupun kulit hitam, sedangkan wanita dengan paritas tinggi memiliki resiko paling rendah3. Involusi bertahap dapat terjadi pada saat wanita mencapai usia 30 tahun. Sehingga dapat dijelaskan bahwa kista serta abses bartholin dapat lebih sering terjadi pada usia-usia reproduksi yaitu sekita 20-29 tahun3.

2

Jika terjadi massa pada vulva saat usia postmenopause perlu dicurigai adanya suatu keganasan, sehingga biopsi eksisi ,mungkin diperlukan. Beberapa peneliti menyatakan bahwa eksisi bedah tidak perlu dilakukan pada kista bartolin, oleh karena rendahnya resiko kanker kelenjar Bartholin. Namun jika diagnosis kanker terlambat untuk ditegakkan, prognosisnya akan lebih buruk3. 3. Etiologi Kista Bartholin timbul akibat adanya obstruksi distal duktus Bartholin yang menuju vestibulum sehingga mengakibatkan retensi sekresi mukus dengan pelebaran saluran dan pembentukan kista. Kelenjar ini berfungsi sebagai lubricating agent saat berhubungan seksual dan melembabkan permukaan vagina. Obstruksi duktus dapat terjadi akibat trauma, infeksi, dan edema yang mengkompresi duktus tersebut3. Ukuran kista tergantung banyaknya akumulasi sekresi kelenjar tersebut. Pembesaran kista juga dapat dipercepat oleh aktivitas seksual.

Kista

Bartholin biasanya teridentifikasi saat mencapai diameter 1 hingga 4 cm. Kista ini dapat terinfeksi sehingga mengakibatkan timbulnya abses. Namun, kista Bartholin tidak selalu muncul sebelum timbulnya abses. Penyebab tersering abses Bartholin adalah Neisseria gonorrhae. Kista Bartholin maupun abses Bartholin tidak lagi murni ditularkan melalui hubungan seksual. Episiotomi, trauma, maupun operasi daerah vulvovaginal juga dapat menyebabkan kejadian tersebut walaupun sangat jarang3.

3

Gambar 3. Bakteri Penyebab Abses Bartholin3 4. Gejala Klinis 

Massa vulva/perinum: berupa massa kistik yang menonjol pada bagian



inferior labia mayor. Penekanan pada vulva: kista dapat menekan introitus sesuai dengan ukurannya. Kista dengan ukuran yang kecil pada umumnya



asimptomatik. Nyeri saat duduk maupun berjalan: kista berukuran besar dapat menimbulkan rasa tidak nyaman. Nyeri saat duduk maupun berjalan

 

dan dapat diperberat dengan adanya abses. Demam: sepertiga wanita mengalami demam saat timbulnya abses. Dyspareunia: sering terjadi jika ukuran kista sangat besar dan

 

menutupi introitus. Eritema pada vulva dan indurasi. Pecahnya abses 4.

5. Faktor Resiko

4



Wanita usia reproduksi: kista bartholin paling sering terjadi pada



wanita usia 20-50 tahun. Riwayat menderita kista atau abses Bartholin: jika pada terapi awal tidak adekuat (misalnya kateter Word terlepas saat belum terjadi epitelisasi). Pengobatan yang berulang juga dapat menyebabkan saluran menjadi lebih sempit dan dapat menimbulkan jaringan parut,



sehingga memungkinkan terjadinya kekambuhan. Aktivitas seksual: ukuran kista tergantung pada akumulasi dari sekresi kelenjar tersebut. Semakin sering aktivitas seksual maka pembesaran



ukuran kista menjadi lebih cepat, begitu pula sebaliknya. Trauma atau operasi: kista atau abses Bartholin dapat terjadi setelah prosedur episiotomi, trauma, maupun operasi pada vulvovaginal 4.

6. Pemeriksaan Penunjang 

Kultur abses: tidak mutlak dilakukan dalam mendiagnosis abses, namun dapat membantu mengidentifikasi bakteri patogen yang dominan jika dalam pengobatan tidak terjadi resolusi setelah dilakukan insisi dan drainage. Lebih dari 80% kista dan 33% abses



yang dikultur hasilnya steril. Biopsi lesi vulva: dilakukan jika curiga keganasan berdasarkan tampilan klinis. Hal ini juga dapat dipertimbangkan pada kista atau abses Bartholin pada wanita usia >40 tahun, mengingat peningkatan kejadian kanker kelenjar Bartholin pada wanita menopause. Insiden tertinggi terjadi pada usia sekitar 60 tahun, namun harus dipertimbangkan pada semua wanita di atas 40 tahun jika ditemukan

5

pada tampilan klinis lesi nodular, irregular, dan dengan indurasi persisten 5. 7. Diagnosis Diagnosis kista bartholin dilakukan berdasarkan gejala klinis serta pada pemeriksaan inspeksi pada vulva. 

Anamnesis Kista Bartholin dapat asimptomatik dan tidak sengaja ditemukan saat dilakukan pemeriksaan panggul. Kista Bartholin sering terjadi pada wanita usia reproduksi yaitu antara 20-50 tahun. Gejala yang mungkin ditemukan seperti rasa sakit saat duduk atau berjalan, maupun saat behubungan seksual. Ukuran kista tergantung pada akumulasi sekresi kelenjar Bartholin. Pasien juga mengeluhkan perasaan seperti tertekan seiring dengan membesarnya ukuran kista. Sedangkan pada abses Bartholin biasanya ukuran membesar lebih cepat dan disertai dengan adanya nyeri. Pada sepertiga wanita yang mengalami abses Bartholin juga disertai dengan adanya demam 6.



Pemeriksaan Fisik Berdasarkan pemeriksaan fisik akan didapatkan suatu masa kistik pada bagian inferior labia mayor dan melewati labia minor. Saat terjadi infeksi maka dapat terbentuk suatu abses, yaitu suatu massa dengan konsistensi kenyal, eritema, discharge, dan disertai adanya demam4. Meskipun kanker kelenjar Bartholin jarang ditemukan (insiden <1 pada 500.000 wanita), dengan insiden tertinggi usia 60-an, namun harus

6

dipertimbangkan jika dalam pemeriksaan fisik didapatkan suatu massa dengan tepi irregular, nodular, dan indurasi persisten4. 

Pemeriksaan Penunjang Pemeriksaan darah lengkap tidak selalu dilakukan. Begitu juga dengan kultur abses maupun tes sensibilitas antibiotik tidak diperlukan dalam mendiagnosis suatu abses Bartholin. Tes tersebut dilakukan jika telah dilakukan insisi dan drainage kista maupun abses Bartholin tidak didapatkan resolusi. Tes tersebut dapat mengetahui organisme predominan serta antibiotik yang sensitif untuk organisme tersebut. Lebih dari 80% kultur pada kista Bartholin serta 33% pada abses Bartholin adalah steril. Sedangkan untuk biopsi lesi dilakukan jika kita mencurigai adanya keganasan dari pemeriksaan fisik 5.

8. Diagnosis Banding Kondisi Mucous cyst of the vestibule

Tanda dan Gejala Konsistensi lunak, diameter <2cm, letak

Vulval haematoma

superfisial Biasanya terjadi akibat trauma atau postoperasi, disertai dengan tanda-tanda inflamasi. Padat kenyal, asimptomatik, dapat terjadi

Vulval fibroma

pada labia mayor, perineum atau introitus vagina Sesuai dengan warna kulit, kenyal, pada

Vulval lipoma

7

daerah subkutan, asimptomatik, pertumbuhannya lambat, dapat terjadi pada labia mayor, abdomen bagian bawah, maupun inguinal Massa kistik yang membengkak, biasa terjadi

Cyst of the canal of Nuck

pada daerah lipatan inguinal, atau labia mayora anterior, namun tidak melewati labia minor, terjadi dari sisa-sisa peritoneum yang Epidermal inclusion cyst (sebaceous,

melewati kanalis inguinalis. Asimptomatik, ukuran kecil, multiple,

keratinous, or epidermoid cyst)

berkelompok pada labia mayor, dan berwarna

Malignant lesion of Bartholin's gland

kekuningan massa dengan tepi irregular, nodular, dan indurasi persisten, terjadi pada usia 60-an 3.

9. Terapi  Kista asimptomatik Terapi bersifat konservatif,

jika

kista

berukuran

kecil

dan

asimptomatik dapat dilakukan kompres hangat pada kista, dengan 

tujuan melancarkan drainage 5. Kista simptomatik o Marsupialisasi Pada kista berukuran besar dapat bersifat simptomatik dan memerlukan

suatu

pengobatan.

Tujuan

dilakukan

marsupialisasi adalah membuat sambungan mukokutaneus antara dinding kista dengan dinding vagina. Sehingga, memungkinkan untuk mempertahankan patensi kelenjar dan tidak menghilangkan fungsi dari sekresinya. Marsupialisasi ini dilakukan dengan tindakan anestesi lokal sebelumnya7.

8

Setelah dilakukan marsupialisasi dapat dipasang rubber drains yang ditempatkan pada eksisi linear ke dalam rongga kista. Komplikasi pada tindakan ini dapat berupa nyeri, hematoma, penyembuhan yang lama, dan dispareunia akibat terbentuknya jaringan parut. Sedangkan untuk tingkat kekambuhan pada tindakan marsupilalisasi ini berkisar antara 25 % 7.

Gambar 4. Teknik Marsupialisasi 7  Terapi adjuvan Antibiotik broadspectrum Jika tidak didapatkan adanya selulitis, tidak perlu diberikan antibiotik, karena 80% hasil kultur kista dan 33% abses didapatkan steril. Namun, jika didapatkan adanya selulitis maka diperlukan pemberian antibiotik broadspectrum karena infeksi yang terjadi seringnya polimikrobial.

Pemberian

antibiotik

berlangsung

selama 1 minggu, tetapi untuk pilihan antibiotik secara empiris hingga saat ini masih belum jelas8. Sedangkan bagi pasien dengan riwayat diabetes dan mengalami

selulitis

diperlukan

observasi

secara

cermat, karena mereka rentan terhadap infeksi yang menyebabkan nekrosis, dan dipertimbangkan untuk

9

dilakukan perawatan di rumah sakit. Terapi antibiotik secara intravena dapat diberikan pada 48 jam pertama dan dilanjutkan dengan antibiotik secara oral, namun sampai saat ini belum ditemukan bukti untuk mendukung antibiotik tertentu8. Antibiotik lini pertama: 1. Amoksisilin/asam klavulanat: 500 mg, tiga kali sehari per oral, atau 2. cefalexin: 500 mg, empat kali sehari per oral, atau 3. ceftriaxone: 250 mg, intravena, single dose dan 4. metronidazole: 500 mg, dua kali sehari per oral Antibiotik lini kedua: Cefuroxime sodium: 750 mg, intravena setiap 8 jam8. o Drainase Kateter Drainase menggunakan kateter Word merupakan salah satu terapi alternatif selain marsupialisasi, tindakan ini aman, sederhana, serta efektif untuk pengobatan pada pasien rawat jalan. Insisi untuk kateter dilakukan pada bagian luar cincin hymen. Jika kista terlalu dalam, pemasangan kateter Word mungkin sulit atau bahkan tidak dapat dilakukan. Kateter dipasang selama 4-6 minggu untuk memungkinkan terjadinya epitelisasi saluran. Jika pasien merasa nyeri atau tidak nyaman selama 24 jam setelah pemasangan kateter, kemungkinan saat pemasangan balon yang terbentuk terlalu besar, hal ini dapat diatasi dengan menarik sedikit cairan keluar 6.

10

Gambar 5. Pemasangan kateter Word 6 o Eksisi Eksisi kista Bartholin merupakan pengobatan standar sampai akhir 1960-an. Namun, saat ini pengobatan tersebut tidak lagi dilakukan kecuali jika didapati kejadian kista Bartholin berulang.

Tidak

didapatkannya

kelenjar

bartholin

menyebabkan vulva menjadi kering, rsa gatal, terbakar, dan dispareunia7. Eksisi ini dilakukan oleh dokter ginekologi yang telah berpengalaman

dengan

anestesi

umum

karena

dapat

mengakibatkan banyak perdarahan. Eksisi akan menjadi sulit jika sebelumnya pasien memiliki riwayat kista Bartholin berulang dan telah dilakukan drainase namun sudah terjadi adhesi. Komplikasi dari tindakan eksisi meliputi perdarahan, hematoma, selulitis, sepsis, kerusakan pada rektum, cacat kosmetik, dan pembentukan jaringan parut7.

11

o Aspirasi / insisi dan drainase rongga kista Aspirasi kista memberikan kesembuhan hingga 85% . Insisi dan drainase memiliki kelebihan lebih cepat dan mudah dilakukan, memberikan kesembuhan lebih cepat, namun teknik ini memiliki tingkat kekambuhan yang tinggi. Selain itu jika terbentuk

jaringan

parut,

akan

mempersulit

tindakan

marsupialisasi maupan pemasangan Word kateter selanjutnya, 

sehingga tindakan ini tidak dianjurkan1. Perkembangan Terapi Terbaru o Laser Karbon Dioksida Laser karbon dioksida digunakan untuk membuat defek hemostatik pada kista tanpa menggunakan jahitan dan dapat menjadi alternatif pengobatan yang aman dan efektif untuk marsupialisasi. Tingkat kekambuhan tampaknya rendah untuk pengobatan kista namun lebih tinggi untuk pengobatan abses. Keuntungan lain dari tindakan ini adalah menggunakan anestesi lokal, waktu yang singkat, meningkatkan hemostasis, serta pembentukan bekas luka yang lebih kecil. Kerugiannya prosedur ini sangat mahal9. o Silver-nitrate Cauterisation Tindakan ini merupakan tindakan yang sederhana, bakterisida dengan biaya yang lebih murah, serta agen sklerosing kimia. Digunakan dalam pengobatan kista maupun abses. Penelitian randomised control trial menemukan bahwa penggunaan silver-nitrate cauterisation dengan marsupialisasi sama-sama efektif dengan pembentukan luka yang lebih kecil pada

12

penggunaan silver-nitrate. Keuntungan lainnya berupa tingkat kekambuhan yang rendah dan tidak memerlukan jahitan. Komplikasi yang terjadi meliputi luka bakar pada labia dan mukosa sekitarnya, edema labia, discharge purulent maupun haemoragik10. o Alcohol Sclerotheraphy Alcohol sclerotheraphy mengurangi waktu perawatan dengan tingkat kekambuhan yang rendah. Alkohol disuntikkan untuk menghindari nekrosis pada dinding kista. Dibandingkan dengan silver-nitrate, penggunaan alkohol lebih efektif dengan komplikasi yang lebih sedikit dan waktu penyembuhan yang lebih cepat, dan setelah follow-up selama 24 bulan tidak terjadi kekambuhan11.

10. Komplikasi 

Dispareunia Dapat terjadi setelah terapi akibat pembentukan jaringan parut, kekeringan vulva, maupun kecemasan psikologis. Komplikasi ini jarang terjadi, namun jika hadir menimbulkan ketidaknyamanan. Resiko pembentukan jaringan parut meningkat pada tindakan yang



berulang-ulang, atau eksisi kelenjar dan diseksi yang terlalu dalam7. Fistula Bartholin-rektal

13

Kejadian ini jarang dilaporkan namun terjadinya fistula dapat dipertimbangkan pada wanita yang mengalami drainase purulen persisten dan granulasi jaringan yang melibatkan duktus Bartholin12. 11. Prognosis Pengobatan berhasil pada 85% pasien (ditandai dengan tidak adanya pembengkakan, ketidaknyamanan, maupun aliran bebas dari kelenjar) terlepas dari metode yang digunakan. Sedangkan, kista maupun abses yang berulang lebih sulit untuk ditangani. Jika dilakukan eksisi pada kelenjar kemungkinan akan timbul efek jangka panjang berupa kekeringan pada vagina dan dispareunia.

Daftar Pustaka 1. Pundir J, Auld BJ. 2008. A review of the management of dissease of the Bartholin’s gland. Journal Obstetri Gynaecology. 28:161-165 2. Soydinç HE, Sak ME, Evsen MS, Çaça FN. 2012. Heterotopically Located Bartholin’s Cyst. Eur J Gen Med. (Suppl 1):36-38. 3. Omole F, Simmons BJ, Hacker Y. 2003. Management of Bartholin’s Duct Cyst and Gland Abscess. Morehouse School of Medicine, Atlanta, Georgia. www.aafp.org/afp 4. Kaufman RH, Faro S, Brown D. 2005. Benign dissease of the vulva and vagina. Philadelphia: Elsevier Mosby 5th ed. 240-249 5. Scott PM. 2003. Draining a cyst or abcess in a Bartholin’s gland with a Word catheter. JAAPA. 16: 51-52 6. Haider J, Condous G, Kirk E, et al. 2007. The simple outpatient management of Bartholin’s abcess using the Word catheter: a preliminary study. Aust N Z J Obstery Gynaecology. 47: 137-140.

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7. Marzano DA, Haefner HK. 2004. The Bartholin gland cyst: past, present, and future. Journal of Lower Genital Tract Dissease. 195- 204 8. Bhide A, Nama V, Patel S, et al. 2010. Microbiology of cysts/abcesses of Bartholin’s gland: review of empirical antibiotic therapy againts microbial culture. Journal Obstetry Gynaecology. 30: 701-703 9. Figueirido AC, Duarte PE, Gomes TP, et al. 2012. Bartholin’s gland cysts: management with carbon dioxide laser vaporization. Rev Bras Ginecology Obstery. 34: 550-554 10. Ozdegirmenci O, Kayikcioglu F, Haberal A. 2009. Prospective Randomised Study of Marsupialization Versus Siver Nitrate Application in Management of Bartholin Gland Cysts and Abcesses. Journal Minim Invasive Gynecology. 16: 149-152 11. Cobellis PL, Stradella L, De Lucia E, et al. 2006. Alcohol sclerotheraphy: a new method of Bartholin gland cyst treatment. Minerva Gynecology. 58: 245-248 12. Zoulek E, Karp DR, Davila GW. 2011. Rectovaginal fistula as complication to a Bartholin gland excision. Obstery Gynecology. 118: 489-491

15

16

1

17

.

2. 2.

Definisi:

A Bartholin's duct cyst is a non-infectious occlusion of the distal Bartholin's duct, with resultant retention of secretions. The paired Bartholin's ducts are located at the posterior vestibule

and

provide

a

conduit

for

the Bartholin's

glands.

A Bartholin's

secretions duct cyst may

from be

asymptomatic if thecyst is small. It typically presents as a medially protruding mass at the inferior aspect of the labia

18

majora, in the posterior introitus, and is crossed by the labium minus. Duct cysts and gland cysts are indistinguishable, and the terms are used interchangeably. A Bartholin's duct abscess may be primary (from bartholinitis) or secondary (from

infection

of Bartholin's cyst).

Etiologi : Bartholin's cysts arise in the duct system of the Bartholin's gland and are typically the result of occlusion of the main duct into the vestibule. The glands are believed to provide a lubricating function during sexual intercourse and a moisturising effect on the vulval surfaces. While ductal obstruction is an essential aetiological factor, the cause of obstruction is typically obscure. [6] It may occur secondary to mucus or trauma, or from infection and oedema compressing the duct. [10] [11] The size of the cyst depends on accumulation of gland secretions, and is exemplified by rapid enlargement during sexual activity and shrinkage or stability of cyst size in women with diminished sexual activity. It is typically identified when the cyst is 1 to 4 cm in diameter.

19

Previous Bartholin's cyst increases the risk of another cyst, especially if prior treatment was incomplete. Prior treatment may cause scarring and stenosis of the duct opening. A Bartholin's abscess more commonly results from polymicrobial non-gonorrhoeal infection of the cyst fluid rather than primary infection of the gland or duct. One proposed entry mechanism is ascending infection through a stenotic opening that is too small to allow emission of thick Bartholin's gland mucous secretion. [6] While cultures may reveal no growth, or presence of a 'sterile abscess', infections tend to be polymicrobial with anaerobic, facultative, and aerobic members of the vaginal flora. [1] [12] [13] One study involving 219 women found that 38.2% of Bartholin's gland abscesses were sterile, while 61.8% were culture-positive, with Escherichia coli being the single most common pathogen, followed by polymicrobial infections,Staphylococcus aureus, group B streptococci, and Enterococcus species. [14] Rarely, Bartholin's cyst or abscess occurs after episiotomy, trauma, or vulvovaginal surgery.

Patofisiologi The paired Bartholin's glands are situated deep in the perineal compartment, between the deep and superficial fascia of the urogenital diaphragm and immediately posterior 20

to the vestibular bulbs. [16] The ducts course through loose connective tissue of the superficial compartment to exit on the vestibule distal to the hymen at the 5 and 7 o'clock positions. [8] [10] A diagnosis of Bartholin's cyst is made on clinical appearance, but the distinction between cyst of the duct and cyst of the gland can only be made on histopathology and is primarily of theoretical rather than clinical concern. The duct is lined by transitional epithelium, whereas the lining of the gland acinus is a single layer of columnar or cubical epithelium.

Gejala klinis:

vulval/perineal mass Classically a medially protruding cystic structure at the inferior aspect of the labia majora in the 5 or 7 o'clock position. It is crossed by the labium minus. Occasionally, cysts spread into the labium majus.2

vulval pressure or fullness  Cysts may create a pressure phenomenon at the introitus. [2] While small cysts may be asymptomatic,

21

women note the presence of fullness or pressure with increasing size. pain during sitting or walking (common)  Larger cysts are more likely to cause discomfort, and pain may be noted when sitting or walking. Pain can be particularly severe with abscess formation. fever (common)  About one third of women with abscess present with fever. dyspareunia (common)  With increasing cyst size, women note increasing symptoms. Larger cysts protrude medially, obscuring the introitus, and this may result in painful sexual activity. [2] vulval erythema and induration (common)  The most severely symptomatic patients present with evidence of infection or abscess formation. spontaneous rupture (uncommon)  Abscesses develop rapidly (within 2 to 3 days) and tend to rupture spontaneously. [6] Evidence of drainage and relief of pain suggests that spontaneous rupture has occurred.

22

Risk factorshide all Strong

woman of reproductive age  Most cysts occur in reproductive-age women between 20 and 50 years. [8] Bartholin's cyst has not been reported in children. previous Bartholin's cyst/abscess  A risk factor especially if the initial treatment was incomplete (e.g., if a Word catheter dislodges before complete epithelialisation). Repetitive procedures may also result in further duct orifice narrowing and scarring, making recurrence more likely. sexual activity  Cyst size depends on accumulation of gland secretions, and is exemplified by rapid enlargement during sexual activity and shrinkage or stability of cyst size in women with diminished sexual activity. 23

Weak

direct trauma or surgery  Rarely, cyst or abscess may occur after episiotomy, trauma, or vulvovaginal surgery. Pemeriksaan pnnjang

microscopy and culture of abscess material Not necessary to diagnose an abscess, but may help identify predominant organism and target antimicrobial treatment when resolution is incomplete after incision and drainage. More than 80% of cultures from cysts and about 33% of cultures from abscesses are sterile. [19]

biopsy of vulval lesion Condition

Differentiating signs/symptoms

Mucous cyst of the vestibule



Tends to be soft, <2 cm in diameter, superficial, and smooth. [15]



Usually follows trauma or intra-operative bleeding. Extravasated blood may

Vulval haematoma

of the labia and cause considerable swelling. This tense swelling is exquisit

24

Condition

Differentiating signs/symptoms

Vulval fibroma



Firm, not cystic, asymptomatic lesion typically occurring on the labia majora introitus. [15] [18]

Vulval lipoma



Skin-coloured, soft, fatty tumour of the subcutaneous tissue; typically asym growing. [11] [20] View image



Usually in the labia majora, and further lipomas may be found on the lower



Cystic swelling in the inguinal crease or anterior labia majora. Not crossed b



Arises from remnants of peritoneum as it passes through the inguinal canal

Cyst of the canal of Nuck

along the path of the inguinal canal or within the labia majora.

Epidermal inclusion cyst (sebaceous, keratinous, or epidermoid cyst)



These tend to be asymptomatic, small, and multiple, grouped together on th



May have a yellowish appearance and feel firm and knobbly. [20]



Tends to present in older women (>50 years) as an irregular nodular vulval

Malignant lesion of Bartholin's gland

ulcerations. [3] [10] View image

Should be performed if malignancy is suspected based on clinical appearance. It should also be considered in women >40 years of age with a Bartholin's cyst or abscess, given the increased incidence of Bartholin's gland cancer among menopausal women. Incidence is highest among women in their 60s but should be considered in all women over the age of 40 years and for 25

lesions with nodularity, irregularity, or persistent induration. [18] Classic presentation of Bartholin's gland cancer is an irregular, nodular mass in the region of the duct/gland. [2]

Step-by-step diagnostic approach

The diagnosis of Bartholin's cysts and abscesses is clinical and readily made on visual inspection of the vulva. Further investigations are not required to make the diagnosis. History

They may be asymptomatic and identified by chance during a pelvic exam. Most Bartholin's cysts occur in reproductive-age women between 20 and 50 years. [8] Symptoms may include pain on sitting or walking, or during sexual intercourse. [17] The size of the cyst depends on accumulation of gland secretions, and is exemplified by rapid enlargement during sexual activity and shrinkage or stability of cyst size in women with diminished sexual activity. Patients may also complain of a feeling of fullness or pressure, particularly with increasing cyst size. [10] Most abscesses usually develop rapidly and are associated with severe pain.

26

About one third of women with Bartholin's abscess present with fever. Physical examination

The classic, medially protruding cystic structure at the inferior aspect of the labia majora (in the 5 or 7 o'clock position) crossed by the labium minus is typical. View imageView image Occasionally, cysts dissect anterolaterally into the labium majus. [2] When infection is present or an abscess has formed, View image the mass is usually tender, and there may be induration, erythema, point discharge, or systemic fever. Exclusion of other causes

Any vulval mass that is not classically crossed by the labium minus at the inferior aspect of the labia is unlikely to be a Bartholin's cyst. Most other causes of vulval swellings, such as epidermal inclusion cysts, mucous cysts, or cysts of the canal of Nuck, are located in the labia majora and are not transected by the labium minus. Skene's ducts are located adjacent to the urethral meatus rather than the posterior vestibules. While treatment may also be warranted for other vulval cysts, the approach may be different, according to the aetiology. Although Bartholin's gland cancer is exceedingly rare (incidence <1 in 500,000 women), it should be considered in women presenting with an irregular/firm Bartholin's process. [6] The classic presentation of Bartholin's gland cancer is an irregular, nodular mass in the region of the 27

duct/gland.[2] The incidence is highest among women in their 60s but should be considered in all women with nodularity, irregularity, or persistent induration. [18] View imageView image Investigations

Routine blood tests are not required. Microbiological culture and sensitivities of abscess material are not necessary to diagnose a Bartholin's abscess. They may be helpful in identifying the predominant organism and targeting antimicrobial treatment when resolution is incomplete after incision and drainage. More than 80% of cultures from Bartholin's cysts and about 33% of cultures from Bartholin's abscesses are sterile. [19] A lesion biopsy should be performed if malignancy is suspected based on clinical appearance. It should also be considered in women >40 years of age with a Bartholin's cyst or abscess, given the increased incidence of Bartholin's gland cancer among menopausal women.

asymptomatic cyst conservative management 

A small, quiescent, asymptomatic cyst can be managed with sitz baths or warm compresses to aid drainage. [19]

28

symptomatic cyst marsupialisation 

Large cysts are more likely to be symptomatic and require treatment. The objectives of marsupialisation are to construct a new mucocutaneous junction between the wall of the cyst and the skin of the labia, and to place it in approximately the normal position. [8] [25] This allows for patency of the gland to be maintained so that secretory function is not lost. However, if infection is present, accompanied by marked inflammation and necrosis, sutures will pull through the friable tissue and marsupialisation will not be possible. It can be performed under pudendal nerve block or local anaesthetic. [10]



Variations on this technique have been described, including packing with an iodoform gauze that is removed after 1 week, using rubber drains after placing a linear incision into the cyst cavity, excising an elliptical portion of the cyst lining, or removing an oval-shaped section of tissue, called the window operation. [10] Twice-daily sitz baths are recommended post-operatively.



Complications of marsupialisation include moderate pain, haematoma formation, prolonged healing, and dyspareunia due to scarring. [1] [15] The recurrence rate is between 2% and 25%. [1] [10]

Adjunct broad-spectrum antibiotics 

In the absence of cellulitis, antibiotic therapy is unnecessary. [1] [15] More than 80% of cultures from cysts and about 33% of cultures from abscesses are sterile. [19]

29



If cellulitis is present, broad-spectrum antibiotics are recommended, as infection is often polymicrobial. A 1-week course usually suffices. However, the ideal choice of empirical antibiotics remains unclear. [13]



Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotising infection, and admission to hospital may be considered. Intravenous antibiotic therapy may then be given for the first 48 hours, followed by conversion to oral therapy. There is no evidence to support a particular antibiotic regimen.

Primary options

amoxicillin/clavulanic acid: 500 mg orally three times daily OR cefalexin: 500 mg orally four times daily OR ceftriaxone: 250 mg intramuscularly as a single dose and metronidazole: 500 mg orally twice daily Secondary options

cefuroxime sodium: 750 mg intravenously every 8 hours 1st

catheter drainage 

The Word catheter is a safe, simple, and effective outpatient treatment and is a reasonable alternative to marsupialisation. [17] The incision for the catheter should be placed just exterior to the hymen ring, within the introitus in the region of the normal duct opening. If the cyst is too deep, 30

placing the catheter is difficult and may not be possible. Clinical use is limited by the catheter's availability and tendency to dislodge.[27] 

The catheter should be left in place for 4 to 6 weeks to allow epithelialisation of a tract. [2] [6] Continuous pain or discomfort 24 hours after insertion indicates that the bulb is too large. This can be easily corrected by withdrawing some of the fluid in the bulb.



A Jacobi ring catheter creates 2 drainage tracts rather than 1 and is thought to be as effective as a Word catheter. [28] adjunct

broad-spectrum antibiotics 

In the absence of cellulitis, antibiotic therapy is unnecessary. [1] [15] More than 80% of cultures from cysts and about 33% of cultures from abscesses are sterile. [19]



If cellulitis is present, broad-spectrum antibiotics are recommended, as infection is often polymicrobial. A 1-week course usually suffices. However, the ideal choice of empirical antibiotics remains unclear. [13]



Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotising infection, and admission to hospital may be considered. Intravenous antibiotic therapy may then be given for the first 48 hours, followed by conversion to oral therapy. There is no evidence to support a particular antibiotic regimen.

Primary options

amoxicillin/clavulanic acid: 500 mg orally three times daily 31

OR cefalexin: 500 mg orally four times daily OR ceftriaxone: 250 mg intramuscularly as a single dose and metronidazole: 500 mg orally twice daily Secondary options

cefuroxime sodium: 750 mg intravenously every 8 hours 2nd

surgical excision 

Excising the cyst duct or gland was standard primary treatment of a Bartholin's cyst until the late 1960s. [1] It is no longer the preferred treatment for primary surgery but may be required for recurrent cysts. However, the absence of a Bartholin's gland may lead to dryness of the vulva, with severe itching, burning, and dyspareunia. [8] [18] [25][29]



It should be performed by an experienced gynaecological surgeon under general anaesthesia because of the possibility of excessive bleeding from the underlying venous plexus. [1] [10] [16] [18] Excision can be difficult if multiple previous attempts have been made to drain a cyst or abscess and adhesions have formed. It should not be attempted in the presence of active infection. [10] Liquid paraffin may aid dissection. [16]



Complications of excision include haemorrhage, haematoma formation, cellulitis, sepsis, damage to the rectum, cosmetic disfigurement, and formation of scar tissue. [10][16] [18] [22]

32

Treatment approach

Treatment can be conservative or surgical, and the choice depends on symptoms, age of the patient, and whether infection is present. [1] [21] The aims of surgical management are to preserve glandular function and prevent recurrence of disease. [22] Small, asymptomatic cysts may not require any treatment. [6] [18] Larger cysts are more likely to be symptomatic. Various surgical modalities have been proposed and are aimed at creating a new ductal ostium to allow continuous drainage or destruction of the cyst wall lining. [1] The overall success rate of surgery (marked by the absence of swelling and discomfort and the appearance of a freely draining duct) is 85% regardless of the method used. None of the treatment options are contra-indicated in pregnant women, but the increase in pelvic blood flow during 33

pregnancy may lead to excessive bleeding with surgical treatment. [18] Unless the cyst obstructs the vagina (soft tissue dystocia), surgery should be delayed until after delivery in pregnant women. A meta-analysis found no clear consensus on the single best treatment. [23] Asymptomatic

A small, quiescent, asymptomatic Bartholin's cyst should be left alone and managed with sitz baths or warm compresses to aid drainage. [19] No further treatment is usually required in women <40 years of age. [2] [6] [18] Over 40 years, the possibility of malignancy must be considered and biopsy may be indicated, but simple asymptomatic cysts can be managed in the same way once malignancy has been excluded. Symptomatic

Any procedure that preserves function and prevents the formation of a cyst and abscess is preferable to excision of the gland. [6] Morbidity associated with surgical excision of Bartholin's cysts is more frequent than is generally recognised, and includes cellulitis, recurrence, intra-operative and post-operative haemorrhage, haematoma, and painful scar tissue. [6] In the absence of cellulitis, antibiotic therapy is unnecessary. [1] [15] More than 80% of cultures from Bartholin's cysts and about 33% of cultures from Bartholin's abscesses are sterile. [19] If cellulitis is present, broadspectrum antibiotics are recommended, as infection is often polymicrobial. Diabetic patients with cellulitis need careful observation, as they are susceptible to necrotising infection. Admission to hospital should be considered. 34

Marsupialisation [24]  The objectives of marsupialisation are to construct a new mucocutaneous junction between the wall of the cyst and the skin of the labia, and to place it in approximately the normal position. [8] [25] This allows for patency of the gland to be maintained so that secretory function is not lost. The same operation with slight variations can be done regardless of whether the cyst is infected, ruptured, or recurrent. [10] [25] However, if infection is accompanied by marked inflammation and necrosis, sutures will pull through and marsupialisation will not be possible. It can be performed under pudendal nerve block or local anaesthetic [10] and is the preferred treatment for many clinicians. [8]  The procedure involves making a 1.5 to 2 cm incision just distal to the hymen ring, within the introitus into the region of the normal duct opening. The cyst wall is incised and approximated to the edge of the vestibular skin with interrupted sutures. If the initial sutures pull through, a larger suture may be tried. If the larger suture also pulls through, further attempts should not be made. The aperture should be as large as possible, ideally large enough to admit 2 fingers, as it will shrink to half its size within 1 to 3 weeks. [6] [8] [25] Twice-daily sitz baths are recommended post-operatively.  Variations on this technique have been described, including packing with an iodoform gauze that is removed after 1 week, using rubber drains after placing a linear incision into the cyst cavity, excising an elliptical 35

portion of the cyst lining, or removing an oval-shaped section of tissue, called the window operation. [10] Possible advantages of the window technique include a reduction in recurrence rate. [10] [22] The use of iodine to identify the optimal site of incision for anatomical placement of the ostium has also been described. [26]  Complications of marsupialisation include moderate pain, haematoma formation, prolonged healing, and dyspareunia due to scarring. [1] [15] The recurrence rate is between 2% and 25%. [1] [10] Catheter drainage  The Word catheter is a safe, simple, and effective outpatient treatment and is a reasonable alternative to marsupialisation. [17] The incision for the catheter should be placed just exterior to the hymen ring, within the introitus in the region of the normal duct opening. If the cyst is too deep, placing the catheter is difficult and may not be possible. Clinical use is limited by availability and the catheter's tendency to dislodge. [27] The catheter is the size of a 10F Foley catheter with a 2 to 3 cm stem. A sealed stopper is attached at one end and a 5-mL capacity latex inflatable balloon at the other. [6] The catheter should be left in place for 4 to 6 weeks to allow epithelialisation of a tract. [2] [6] Continuous pain or discomfort 24 hours after insertion indicates that the bulb is too large. This can be easily corrected by withdrawing some of the fluid in the bulb.

36

 Placement of a Word catheter involves the following steps: o

Identify the site for placement of the catheter (just exterior and parallel to the hymen ring).

o

Test the balloon of the Word catheter with 2 to 4 mL of sterile saline to ensure that it does not leak prior to placement.

o

Wash the site with surgical soap (e.g., povidoneiodine solution).

o

Anaesthetise the site with local anaesthetic (e.g., lidocaine 1%).

o

Make a small stab incision with a number 11 scalpel blade into the cyst cavity (parallel to the hymen ring); the stab incision should be no larger than 3 to 4 mm to prevent the catheter from falling out.

o

Introduce the Word catheter into the cyst cavity after the contents have drained.

o o

o

Fill the balloon with 2 to 4 mL of sterile saline. Tie a suture around the catheter to prevent the balloon leaking or deflating. Tuck the catheter end into the vagina.

 A Jacobi ring catheter creates 2 drainage tracts rather than 1 and is thought to be as effective as a Word catheter. [28] A similar technique has been described 37

using a small ring catheter made from butterfly Vacutainer tubing. A piece of Vicryl suture is threaded through the lumen, and the tubing is pulled through 2 small stab incisions in the cyst cavity and tied to create a loop. [27] Excision  Excision of the cyst duct or gland was standard primary treatment of a Bartholin's cyst until the late 1960s. [1] It is no longer the preferred treatment for primary surgery but may be required for recurrent cysts. The absence of a Bartholin's gland may lead to dryness of the vulva, with severe itching, burning, and dyspareunia. [8] [18] [25] [29]  It should be performed by an experienced gynaecological surgeon under general anaesthesia, because of the possibility of excessive bleeding from the underlying venous plexus. [1] [10] [16] [18] Excision can be difficult if multiple previous attempts have been made to drain a cyst or abscess and adhesions have formed. It should not be attempted in the presence of active infection. [10] Liquid paraffin may aid dissection. [16]  Complications of excision include haemorrhage, haematoma formation, cellulitis, sepsis, damage to the rectum, cosmetic disfigurement, and formation of scar tissue. [10] [16] [18] [22] Aspiration/incision and drainage of cyst cavity

38

 Aspiration of cysts has been used, with cure rates of up to 85%, but is now discouraged in favour of interventions that recreate ductal orifices. [30]Incision and drainage is quick and easy to perform, offering immediate relief, but is associated with a high incidence of recurrence. [1] [18]Additionally, as scarring can make subsequent catheter placement or marsupialisation more difficult, incision and drainage is not recommended. Emerging treatments

Carbon dioxide laser

Carbon dioxide laser vaporisation has been used to create a haemostatic cyst defect without use of suture, which may be a safe and effective alternative to marsupialisation. [24] [31] [32] [33] Recurrence rates seem to be low for the treatment of cysts but seem to be much higher when used to treat abscesses. [10] Potential advantages of laser include use of local anaesthesia, short operative time, improved haemostasis, and less scar formation. However, the procedure is expensive. [10] Silver nitrate cauterisation

Silver nitrate is a simple, cost-effective germicide and a chemical sclerosing agent. Its use has been described in the outpatient treatment of both cysts and abscesses. [10] [34] A prospective randomised controlled trial found that using silver nitrate and marsupialisation were equally effective, with less scar formation noted with the use of silver nitrate. [35] Other benefits include low rate of early and late morbidity, low

39

recurrence rate, and avoiding sutures. [34] Complications include chemical burns of the labial or surrounding mucosa, labial oedema, haemorrhagic or purulent discharge, and cyst recurrence. [10] Alcohol sclerotherapy

Compared with aspiration, instillation of alcohol for sclerotherapy reduced treatment time with a low recurrence rate. [21] Complete evacuation of the injected alcohol is essential to avoid necrosis of the cyst wall. Compared with silver nitrate, alcohol sclerotherapy was as effective, with fewer complications and a faster healing time. There were no recurrences at 24-month follow-up.

40

Complicationhide all dyspareunia

see our comprehensive coverage of Assessment of dyspareunia

May result after treatment, from scar tissue formation, vulval dryness, or psychological anxiety.

It is uncommon but, when present, the effects can be devastating.

The risk of scar tissue formation increases with repetitive procedures, and is more likely after gland excision with deep dissection.

Vulval dryness and burning is unusual after unilateral gland excision but more likely after bilateral gland excision. [8] [10][29]

Techniques to preserve the gland and recreate the ductal opening are preferred to complete gland excision, to minimise this risk.

Bartholin's-rectal fistula

Rarely reported. [4] [36] The occurrence of a fistula should be considered in women presenting with persistent purulent drainage and granulatio

tissue involving the Bartholin's duct.

Prognosis

Treatment is successful in 85% of patients (marked by the absence of swelling and discomfort, and the appearance of a freely draining duct) regardless of the treatment method used. Recurrent abscesses or cysts can be more difficult to manage. After gland excision there may be long-lasting effects of vaginal dryness and dyspareunia.

41

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