An abscess of the bartholin gland
Definition of the disease. Causes of the disease
An abscess of the bartholin gland (Latin abscessus — “abscess”) is an acute infectious and inflammatory disease with the formation of a purulent cavity and melting of the gland tissues located at the entrance to the vagina.
Bartholin gland abscess
The bartholin glands, as a rule, are affected on the one hand, bilateral inflammation is rare. With an abscess, a capsule is formed that restricts the focus of inflammation from healthy tissues — this is how the protective reaction of the body manifests itself [1]. The disease is manifested by painful compaction in the area of the labia majora, swelling, pain and fever. It is characterized by temporary disability and refusal of sexual activity.
The vital activity of conditionally pathogenic microorganisms, which are present in a small amount in a healthy body, leads to an abscess of the bartholin gland. The disease is often caused by E. coli, staphylococci, streptococci, less often — gonococci, chlamydia, trichomonas [5].
The prevalence of the disease in the population is about 2%, most often it is detected in women aged 20-45 years [2] [3]. The pathology is characterized by relapses — in 38% of cases, the bartholin gland abscess occurs repeatedly.
Functions of the bartholin glands:
secrete a secret that restores the microbiocenosis of the genitals;
moisturize the entrance to the vagina during sexual intercourse;
provide natural lubrication of the birth canal during childbirth [3].
Causes of bartholin gland abscess:
Frequent change of sexual partners and unprotected sexual acts, leading to the transmission of pathological microbial biofilms, which include gardnerella vaginalis. These films form on the surface of the vaginal mucosa and create an environment for the development of other pathogens: E. coli, candida albicans, Staphylococcus, etc. A conglomerate of microbes causes inflammation of the vagina, including an abscess of the bartholin gland.
Sexually transmitted infections — gonorrhea, chlamydia infection, trichomoniasis.
Ruptures of the perineum and vagina during childbirth. After suturing the ruptures, it is possible to close the duct of the bartholin gland, the formation of hematomas, and then an abscess.
Injuries of the perineum or vagina (for example, during epilation) — the infection penetrates into the duct of the bartholin gland as a result of damage to the integrity of the skin and mucosa.
Sexual intercourse during menstruation. Blood is an excellent breeding ground for bacteria, during menstruation, the acidity in the vagina decreases, which increases the amount of opportunistic flora, such as E. coli.
Inflammation of the vagina and urethra.
Non-compliance with the rules of intimate hygiene, for example, epilation on an uncleaned surface can cause the spread of infection.
Constant wearing of tight underwear contributes to the fact that the excretory ducts of the gland are squeezed, the secret is concentrated in its cavity, which leads to excessive development of microorganisms and inflammation.
Risk factors for the development of a bartholin gland abscess include:
The growth of pathogenic microflora in bacterial vaginosis and inflammation of the pelvic organs.
Ruptures of the walls of the vagina, perineum, labia in complicated childbirth and suture failure.
The presence of a foreign body (spiral, pessary, contraceptive) — with prolonged wear, irritation of the uterine and vaginal mucosa occurs, and infection joins. As a result, there is swelling, redness of the entrance to the vagina and inflammation of the bartholin gland develops.
Suppression of immunity caused by pregnancy, diseases (HIV, cancer, radiation sickness), taking medications (glucocorticosteroids, cytostatics).
Circulatory disorders (bleeding, thrombosis, etc.) — cause a change in blood volume and its exit outside the vessel. This leads to the development of inflammation, the formation of altered tissues, a decrease in oxygen in them, a decrease in the protective reaction of the body and the spread of infection with the bloodstream.
Local estrogen deficiency, leading to a decrease in glycogen levels. Glycogen is a nutrient medium for lactobacilli, which produce lactic acid, providing an acidic environment in the vagina and protection from the spread of microbes and inflammation. In menopause, when there are practically no estrogens, the mucous membrane and tissues of the entrance to the vagina become thinner, which contributes to their slight injury and infection [4] [6].
warning
If you find similar symptoms, consult a doctor. Do not self-medicate – it is dangerous for your health!
Symptoms of bartholin gland abscess
Symptoms of the disease:
the appearance of a sharply painful seal ranging in size from 1-4 to 7-10 cm in the area of the labia majora on one or two sides;
redness in the labia majora and swelling of the entrance to the vagina;
high body temperature (from 38-39 °C) and general weakness;
sharp and constant pain in the area of the external genitals, which increases with movement;
dryness and pain during sexual intercourse (dyspareunia);
enlargement of lymph nodes and pain in the lower abdomen;
pathological discharge from the genital tract with odor and pus, the color of which varies from white to cloudy gray and yellow, may be accompanied by itching and scratching;
forced body position — the pain becomes constant and increases with movement, so the patient takes a comfortable position for her (lying on her back with her legs spread);
the skin above the abscess acquires a bright red color and becomes immobile due to edema [4].
Abscess
Pathogenesis of bartholin gland abscess
An abscess of the bartholin gland occurs when bacteria infect the vulva (entrance to the vagina). Ways of infection penetration:
damaged skin of the vulva and perineum;
affected mucous membranes of the vulva and vagina, cervix, uterine body or urethra and intestines;
blood and lymphatic vessels are an extremely rare way of spreading infection from another focus of inflammation, for example, from the oral cavity with angina, tonsillitis or caries [4][5].
When infection and secretions from the urethra, vagina and intestines enter the duct of the bartholin gland, its blockage occurs. As a result, the secret accumulates in the gland, which leads to inflammation. At the same time, redness, swelling, pain and purulent discharge appear.
Increased inflammation and edema leads to the closure of the excretory duct of the bartholin gland and the formation of a cyst — a cavity filled with a secret. A seal appears at the entrance to the vagina from the side of the labia minora. With further inflammation, suppuration of the ducts and lobules of the gland occurs, which causes a false abscess. The seal begins to close or deform the entrance to the vagina. With further infection, a true abscess occurs — the process captures the entire gland and passes to the surrounding tissues. This usually occurs when an infection penetrates through the bloodstream. At the same time, the formation becomes sharply painful, immobile and increases in volume.
Pathogens of the bartholin gland abscess:
E. coli;
streptococci;
staphylococci;
mixed conditionally pathogenic microflora – gardnerella vaginalis, atopodium vaginalis, mycoplasma;
anaerobic infection — bacteroids and clostridia.
Pathogenic vaginal microflora
Sometimes the pathogen obtained for bacteriological research does not grow on nutrient media. This indicates unknown pathogens that were not detected by conventional examination methods.
Classification and stages of development of the bartholin gland abscess
Types of bartholin gland abscess:
false — suppuration of the contents of the ducts and lobules of the gland;
true — softening of the swelling, which indicates the formation of a purulent capsule, inflammation captures the entire gland tissue [4].
By localization, bartholin gland abscesses are divided into unilateral and bilateral.
Stages of the disease:
The onset of inflammation in the excretory duct of the bartholin gland.
Formation of a cyst in the duct area.
Inflammation of the lobules of the bartholin gland (false abscess).
The spread of inflammation to the entire gland and nearby tissues (a true abscess).
It should be known that the disease develops gradually, so the stages are conditionally allocated.
Complications of bartholin gland abscess
An abscess of the bartholin gland can lead to the appearance of hematomas, vaginal-rectal fistulas, chronic bartholinitis, dyspareunia, vulvar cancer and sepsis.
Hematomas. At the base of the bartholin gland is a large venous plexus. These vessels can be damaged when the gland is removed, resulting in bleeding with accumulation of blood in the postoperative area. Hematomas of small size resolve on their own, but large formations can open in the suture area, causing the spread of inflammation.
Vaginal-rectal fistulas are formed with a true abscess that has arisen due to the removal of the bartholin gland and damage to the vagina and intestines. A true abscess can also open itself not into the lumen of the entrance to the vagina, but inside and damage the wall of the vagina or intestines. This process can lead to inflammation of nearby tissues. In this condition, bowel emptying and sexual intercourse are accompanied by pain, fecal matter is excreted from the vagina. Fistula is detected during rectal and vaginal examinations. Treatment is carried out together with a coloproctologist.
Vaginal-rectal fistula
Chronic bartholinitis, or inflammation of the bartholin gland develops with improper, untimely treatment or its absence. The disease has periods of exacerbation and remission — unlike an abscess, which is always an acute process. This form of the disease can spontaneously worsen with the appearance of purulent discharge and pain. The improvement of the condition also occurs independently. Exacerbations can occur when infection enters clogged gland channels, with severe hypothermia and vitamin deficiency.
Chronic bartholinitis often leads to the appearance of a cyst — a benign formation that occurs more often before the age of 30, it accounts for 2% in the structure of gynecological diseases. The cyst is a cavity in the duct of the bartholin gland, which contains an accumulated secret. It is formed when the opening of the excretory duct is closed due to its inflammation. If a cyst is detected after 40 years, an additional histological examination is recommended to exclude malignant tumors [4][10].
Vulvar cancer is a rare disease that accounts for about 4% of all tumors of the female genitals. Due to a decrease in immunity and estrogen deficiency, pathology often occurs after 55 years.
Sepsis. The toxins of the pathogens of the disease can go beyond the bartholin gland, into the blood and lymphatic system, causing systemic inflammation. This is one of the most serious complications, treatment is carried out jointly by resuscitators, a surgeon and a therapist.
Diagnosis of bartholin gland abscess
Diagnostics include:
Collection of complaints and anamnesis — attention should be paid to the time of occurrence of the first complaints and the connection of the disease with the obstetric anamnesis.
Gynecological examination.
Instrumental studies — ultrasound of the pelvic organs and soft tissues of the perineum.
Ultrasound of the pelvic organs
Expanded vulvo/vaginoscopy in case of suspected malignant process is a method of examining the vulva and vagina in a gynecological chair using a microscope. During the study, the tissues are stained with acetic acid and an iodine-containing Lugol solution. If the area is covered with a white film and is not painted, then it is examined in more detail and deeper. To do this, a biopsy is performed — a study of the tissue after its excision.
Vaginoscopy
Laboratory tests — a smear from the vagina, urethra and cervix to detect inflammation and infections, general blood and urine tests, a biochemical blood test.
Bacterial culture from the vagina to clarify pathogens and identify their sensitivity to antibiotics.
Bacteriological examination of the contents of the abscess (pus).
An abscess capsule biopsy is performed with a lumpy, unevenly compacted abscess structure to exclude adenocarcinoma during menopause or perimenopause.
The diagnosis is usually obvious and is established during a gynecological examination and with the help of ultrasound of the soft tissues of the perineum. The bartholin gland abscess looks like a formation with smooth walls, smooth contours and liquid contents inside. The skin above the abscess is bright red. The main sign of a true abscess is a symptom of fluctuation. Fluctuation (lat. fluctuatio — “excitement”) is called the fluctuation of the fluid in the cavity. To detect fluctuations, the fingers of one hand are pressed on the area under study, feeling a shock in the form of a wave with the fingers of the other hand.
Symptoms of a false abscess:
weakness and an increase in body temperature to 38 ° C;
pain in the perineum and during sexual intercourse;
seal in the area of the entrance to the vagina;
pathological discharge from the genital tract.
A true abscess is manifested by more vivid symptoms:
body temperature up to 40 °C;
limitation of mobility due to pain in the perineum;
forced position in bed with legs apart;
pronounced weakness;
the seal at the entrance to the vagina can increase to 6 cm or more;
the skin above the seal is hot and still;
fluctuation during palpation.
Identification of a true abscess requires immediate hospitalization [4][7].
Treatment of bartholin gland abscess
Treatment of bartholin’s gland abscess is always surgical. Sometimes the operation is combined with drug therapy (broad-spectrum antibiotics, antimicrobial and anti-inflammatory drugs) and physiotherapy treatments that prevent relapses and improve immunity.
It is believed that if the patient has no signs of a systemic inflammatory reaction (sepsis), phlegmon, multiple abscesses, suppression of immunity, then there is no need for antibiotics. In the presence of the above pathologies, while waiting for the results of bacteriological seeding, therapy with a broad-spectrum antibiotic active against several pathogens is prescribed.
Treatment of a false abscess is carried out on an outpatient basis or in a day-stay hospital. Therapy of a true abscess requires only inpatient treatment [7][12].
Types of surgical treatment of bartholin gland abscess.
Excision and drainage of the abscess. A surgical scalpel incision of the abscess capsule is performed, the contents of the abscess are removed with a syringe. Then the abscess cavity is washed with antiseptics and a rubber drainage is installed. In the future, the gland cavity is treated daily with antiseptics, drainage is changed, sterile dressings with antibacterial ointment or antimicrobial gel are used.
The opening of the abscess and the formation of a new opening of the duct of the bartholin gland. To prevent the abscess from repeating, a new opening of the duct of the bartholin gland is formed. To do this , perform one of the operations:
Laser treatment (vaporization) for false abscesses. The abscess is removed without traumatizing healthy tissue using a laser beam. The method is non-contact, does not cause bleeding and scarring, promotes rapid recovery of tissues and gland functions. The operation is performed on an outpatient basis [15].
Installation of a Word catheter — a small inflatable balloon with saline solution. The catheter is located in the cavity of the bartholin gland for 4-6 weeks, by which time the duct of the bartholin gland should be formed. The method is used after the resolution of inflammation [11]. You can read about the treatment with a Word catheter in a clinical case.
Marsupialization — the edges of the wall of the cavity of the bartholin gland are sewn to the border of the surgical wound with the formation of an artificial duct opening and left open until healing.
Word catheter installation and marsupialization
The opening of the abscess by the radio wave method is not painful, does not leave a burn, and after treatment — scars. A small incision is performed, there is no bleeding during the operation, the tissue is quickly restored [15].
Puncture aspiration is the removal of the contents of an abscess by means of a puncture. It is carried out when the disease is detected in pregnant women.
Removal of the bartholin gland is indicated if a malignant process is suspected (the bumpy surface of the abscess capsule), with edema that does not pass after surgical treatment for more than a month, with relapses of the disease more than twice. With true or recurrent abscesses of the bartholin gland, the formation is removed together with the gland. The procedure can cause complications in the form of fistula formation between the rectum and the vagina, sepsis and bleeding. When the bartholin gland is removed, the function of moistening the labia is assumed by the paraurethral glands [7].
Paraurethral glands
Small abscesses can regress without treatment, independently maturing and opening up. The elevated position of the lower extremities, local procedures using ozonated saline solution and ultrasonic cavitation with antiseptic solutions will help to accelerate the resolution of inflammation.
After the operation, physiotherapeutic treatment is recommended — magnetotherapy, blood irradiation with an infrared laser (VLOK) or ultraviolet light (UFOK), treatment and restoration of the acidic environment of the vagina with antiseptic solutions using ultrasonic cavitation [7][12][14].
Blood irradiation with an infrared laser (VLOK)
Forecast. Prevention
The outcome of an abscess of the bartholin gland depends on the chosen method of therapy. With the formation of a new opening of the excretory duct, treatment, as a rule, ends with complete recovery and restoration of the functions of the gland after 14 days. With other methods, the recurrence rate reaches 15% [8].
