List of Abbreviations
BGD – diseases of the Bartholin gland
BG – Bartholin gland
BGC – Bartholin gland cyst
BGA – Bartholin gland abscess
STI – sexually transmitted infections
PCR – polymerase chain reaction
RNA – ribonucleic acid
Terms and Definitions
Bartholin gland cyst – a unilateral or rarely bilateral formation in the area of the lower third of the vaginal vestibule, formed as a result of impaired secretion outflow from the BG [1, 2, 3].
Bartholin gland abscess – a purulent inflammation of the Bartholin gland of microbial origin [1, 2].
1. Brief information on the disease or condition
1.1 Definition of the disease or condition
Bartholin gland cyst – a unilateral formation in the area of the lower third of the vaginal vestibule, formed as a result of impaired secretion outflow from the BG [1, 2, 3].
Bartholin gland abscess – a purulent inflammation of the Bartholin gland of microbial origin [1, 4].
1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)
Bartholin gland cyst (BGC) is formed upon obstruction of the BG excretory duct due to secretion accumulation, secondary edema, or trauma [1, 2, 4].
Upon infection of the cyst, a Bartholin gland abscess (BGA) may form, which in most cases has a polymicrobial character (see Appendix G2) [1, 2, 3, 4, 5]. Most often, infectious agents enter the gland in an ascending manner through the excretory duct from the vagina or urethra during inflammatory processes, as well as from the intestine [1, 4, 5, 6, 7, 8].
1.3 Epidemiology of the Disease or Condition
Bartholin gland diseases (BGC, BGA) are most frequently detected in women of reproductive age [1, 2, 5]. The incidence of BGC and BGA reaches 2% of all gynecological visits per year [1, 2, 5]. BGAs are diagnosed approximately three times more frequently than BGCs [1, 7, 8].
1.4 Features of Coding the Disease or Condition
Diseases of Bartholin's gland
ICD-10: (N75)
Bartholin gland cyst
ICD-10: (N75.0)
Bartholin gland abscess
ICD-10: (N75.1)
Other diseases of Bartholin's gland
ICD-10: (N75.8)
Bartholin's gland disease, unspecified
ICD-10: (N75.9)
1.5 Classification of the disease or condition
not applicable
1.6 Clinical presentation of the disease or condition
Bartholin's gland abscess (BGA) and Bartholin's gland cyst (BGC) may be accompanied by the following symptoms [1, 2, 3, 11, 12]:
Perineal pain
Edema
Local hyperemia and hyperthermia
Fever or chills
Sensation of discomfort in the perineal region
Asymmetry of the labia majora
BGCs may also be asymptomatic [1, 10, 11, 12].
2. Diagnostics, medical indications and contraindications for diagnostic methods
Criteria for diagnosis.
The diagnosis of BGC or BGA is established based on the patient's complaints, physical examination, laboratory and instrumental research methods [1, 2, 3, 4, 13, 14, 15].
2.1 Complaints and Anamnesis
See section 1.6.
It is recommended that all patients with Bartholin's gland disorders undergo history taking and anamnesis collection [1, 4, 5, 12].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: When taking the anamnesis, it is necessary to obtain information on intimate hygiene habits, presence of a sexual partner, cases of unprotected intercourse, somatic history, and perineal trauma [1, 2, 7].
2.2 Physical Examination
It is recommended that all patients with Bartholin's gland disorders undergo a physical examination according to standard principles of propedeutics, as well as a visual inspection of the external genitalia [1, 2, 10, 12].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Examination reveals asymmetry of the labia majora, a mass lesion in the labium majus region that is painful on palpation, hyperemia, and tissue edema; in cases of abscess, fluctuation, local hyperemia, and hyperthermia are present.
It is recommended that all patients with Bartholin's gland disorders undergo a bimanual vaginal examination to rule out concomitant pathology [1, 2, 5, 6, 10, 12].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
2.3 Laboratory Diagnostics
It is recommended that patients with Bartholin's gland disorders undergo microscopic examination of vaginal smears to detect inflammatory diseases [1, 2, 5, 10, 12, 14].
Level CLevel 5Level of recommendation evidence C (reliability level of evidence – 5).
It is recommended that patients with BGA undergo microbiological (culture) examination of purulent discharge for aerobic and facultatively anaerobic microorganisms for the prescription and/or correction of antimicrobial therapy [1, 4, 7, 14, 16].
Level of Evidence CGrade of Recommendation 4Level of recommendation C (level of evidence – 4).
It is recommended that patients with BGA/BGC and suspected STIs undergo molecular biological testing of discharge from the mucous membranes of the female genital organs (Chlamydia trachomatis, Neisseria gonorrhoeae, Mycoplasma genitalium) to rule out STIs [4, 7, 17-22].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comment: Diagnosis and treatment of STIs are carried out in accordance with current clinical guidelines for the respective nosologies according to ICD-10.
It is recommended that patients with BGA undergo a complete blood count (CBC) to detect signs of systemic inflammation [10, 23, 24, 25].
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
Comments: The patient may exhibit leukocytosis with a left shift of the leukocyte formula (an increase in the proportion of band neutrophils) [10, 23, 24, 25].
2.4 Instrumental Diagnostics
It is recommended that patients with Bartholin's gland disorders undergo a comprehensive pelvic ultrasound examination (transvaginal and transabdominal) to rule out concomitant gynecological pathology [10, 23, 24]
GCR CLOE 5Grade of Recommendation C (Level of Evidence – 5).
2.5 Other Procedures
Not applicable
3. Treatment, including drug and non-drug therapies, diet therapy, and pain management
3.1 Conservative Treatment
It is recommended to use antibacterial therapy as an adjunct to the surgical treatment of BGA in the presence of recurrence risk factors and signs of systemic inflammation [1, 4, 7, 12, 25].
GCR CLEL 4Grade of Recommendations C (Level of Evidence – 4)
Comment: Possible antibacterial therapy regimens are presented in Appendix A3.
Correction of antibacterial therapy should be carried out based on culture results 48-72 hours after the start of treatment if there is no improvement in clinical and laboratory parameters indicating a positive trend in the disease course and/or resistance of pathogens to the ongoing therapy [26, 27].
3.2 Surgical Treatment
It is recommended to perform surgical treatment in patients with BGC/BGA followed by pathomorphological examination of the biopsy (surgical) material [1, 2, 5, 6, 8, 12, 13, 23, 28].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
It is recommended to perform follow-up monitoring of asymptomatic cysts up to 2-3 cm in size for 3 months with subsequent ultrasound monitoring; if there is a tendency to enlargement, surgical treatment is indicated [1, 2, 4].
GRC CLEL 4Grade of Recommendation C (Level of Evidence – 4)
Comments:
Options for surgical interventions [4, 12]:
In BGA: 1. Incision and drainage
In BGC: 1. Incision and drainage of the Bartholin's gland cyst (however, this treatment method is associated with a high risk of recurrence).
2. Placement of a Bartholin's gland catheter [4, 8, 12, 29].
3. Marsupialization - the essence of the operation consists of opening the cyst cavity, excising and suturing the cyst wall to the edges of the wound [4, 12, 29].
4. Enucleation of BGC [4].
5. Removal of BGC using a surgical CO2 laser. During CO2 laser treatment, vaporization of the cyst wall or the cavity bed after wall removal is performed for additional hemostasis and prevention of recurrences. This type of treatment is associated with a minimal risk of recurrence [12, 29, 30, 31, 32, 34].
It is recommended to perform correction of antibacterial therapy after surgical treatment and receipt of microbiological (culture) test results, taking into account the sensitivity of isolated microorganisms to antibacterial drugs in BGA [1, 4, 7, 33].
GCR CLEL 4Grade of Recommendations C (Level of Evidence – 4)
4. Medical Rehabilitation and Sanatorium-Resort Treatment
There is no specific rehabilitation.
It is recommended that all patients consult a physical therapy doctor to determine a rehabilitation program [10, 35-38].
GCR CLEL 5Grade of Recommendations C (Level of Evidence – 5)
Comments: Postoperative rehabilitation using physiotherapeutic methods combined with adequate antibacterial therapy provides analgesic and anti-inflammatory effects [35-38].
The following types of physical therapy may be used after surgical treatment of a Bartholin's gland abscess:
1) contact method of a alternating magnetic field [35].
2) vaginal or contact methods of low-level laser therapy and magnetolaser therapy [35, 36].
3) contact method of an ultra-high-frequency electromagnetic field (UHF therapy) [35, 37, 38].
5. Prevention and Dispensary Observation
It is recommended that all patients with Bartholin's gland disorders (BGA, BGC) adhere to personal and intimate hygiene rules after surgical treatment to prevent recurrence [4, 10].
GDR CLE 5Grade of recommendation C (level of evidence – 5)
Comment: Compliance with personal hygiene rules, especially during menstruation, and the use of barrier contraception methods are advisable to reduce the risk of STI transmission [4, 10].
6. Organization of Medical Care
Treatment is carried out in a gynecological/surgical medical facility. For pregnant women, treatment is provided in an obstetric and gynecological medical facility.
Indications for hospital admission to a medical organization:
1) surgical treatment of BGC and BGA
Indications for patient discharge from a medical organization
─ clinical recovery
7. Additional Information
No additional information available.
Criteria for Evaluating the Quality of Medical Care
References
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Appendix A1. Working Group Composition
1. Leyla V. Adamyan – Academician of the Russian Academy of Sciences, Doctor of Medical Sciences, Professor, Deputy Director of the National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation, Honored Scientist of Russia, Head of the Department of Reproductive Medicine and Surgery at the A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Ministry of Health of Russia, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Endoscopic Gynecologists, the Russian Endometriosis Association, and the Russian Society of Obstetricians and Gynecologists.
2. Apolikhina Inna Anatolyevna - MD, Professor, Head of the Department of Aesthetic Gynecology and Rehabilitation at the V.I. Kulakovo National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health, Professor at the Department of Obstetrics, Gynecology, Perinatology and Reproductology of the Institute of Professional Education at the I.M. Sechenov First Moscow State Medical University of the Russian Ministry of Health, Professor at the Department of Obstetrics and Gynecology of the Department of Vocational Education at the V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology of the Russian Ministry of Health
3. Artymuk Natalia Vladimirovna - MD, Professor, Head of the Department of Obstetrics and Gynecology named after Professor G.A. Ushakov at Kemerovo State Medical University of the Russian Ministry of Health, Chief Freelance Specialist in Obstetrics and Gynecology of the Russian Ministry of Health in the Siberian Federal District (Kemerovo), member of the Presidium of the Board of the Russian Society of Obstetricians and Gynecologists, President of the Kemerovo Regional Public Organization "Association of Obstetricians and Gynecologists".
4. Vitaly F. Bezhenar – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics, Gynecology and Reproductology at the First Pavlov State Medical University of St. Petersburg of the Ministry of Health of Russia, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Health Committee of the Government of St. Petersburg, member of the Society for Reproductive Medicine and Surgery, the Russian Association of Endoscopic Gynecologists, and the Russian Society of Obstetricians and Gynecologists.
5. Tatyana E. Belokrinitskaya – Doctor of Medical Sciences, Professor, Head of the Department of Obstetrics and Gynecology of the Faculty of Advanced Training and Professional Retraining at Chita State Medical Academy of the Ministry of Health of Russia, Honored Doctor of the Russian Federation, Chief Non-Staff Specialist in Obstetrics and Gynecology of the Ministry of Health of Russia in the Far Eastern Federal District (Chita), member of the Russian Society of Obstetricians and Gynecologists, President of the Trans-Baikal Society of Obstetricians and Gynecologists.
6. Lyubasovskaya Lyudmila Anatolyevna — Ph.D. in Medical Sciences, Head of the Department of Clinical Pharmacology and Antimicrobial Drugs, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation.
7. Krutova Viktoriya Alexandrovna — D.Sc. in Medical Sciences, Professor, Chief Physician of the Clinic, Vice-Rector for Clinical Work at the Kuban State Medical University of the Ministry of Health of Russia, Chief Freelance Specialist of the Ministry of Health of Russia in Obstetrics, Chief Freelance Specialist of the Ministry of Health of Russia in Gynecology, Chief Freelance Specialist in Women's Reproductive Health in the Southern Federal District.
8. Malyshkina Anna Ivanovna — D.Sc. in Medical Sciences, Professor, Director of the Ivanovo Research Institute of Motherhood and Childhood named after V.N. Gorodkov, Head of the Department of Obstetrics and Gynecology, Medical Genetics of the Faculty of General Medicine at the Ivanovo State Medical Academy of the Ministry of Health of Russia, Chief Freelance Specialist of the Ministry of Health of Russia in Obstetrics, Chief Freelance Specialist of the Ministry of Health of Russia in Gynecology, Chief Freelance Specialist in Women's Reproductive Health in the Central Federal District.
9. Olina Anna Alexandrovna — D.Sc. in Medical Sciences, Professor, Deputy Director of the Department of Medical Care for Children and Obstetrics Services of the Ministry of Health of the Russian Federation.
10. Priputnevich Tatyana Valeryevna — D.Sc. in Medical Sciences, Director of the Institute of Microbiology, Antimicrobial Therapy and Epidemiology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia
11. Smetnik Antonina Alexandrovna — Ph.D. in Medical Sciences, Head of the Department of Gynecological Endocrinology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation
12. Tabeeva Gyulyaz Iskanderovna — Ph.D. in Medical Sciences, Senior Researcher at the Department of Gynecological Endocrinology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation.
13. Teterina Tatyana Alexandrovna — Ph.D. in Medical Sciences, Obstetrician-Gynecologist at the Department of Aesthetic Gynecology and Rehabilitation, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of Russia
14. Tonoyan Narine Marzpetunovna — Ph.D. in Medical Sciences, Obstetrician-Gynecologist at the Department of Operative Gynecology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation.
15. Filippov Oleg Semenovich — D.Sc. in Medical Sciences, Professor at the Department of Reproductive Medicine and Surgery, A.I. Evdokimov Moscow State University of Medicine and Dentistry of the Ministry of Health of Russia (Moscow).
16. Shabanova Natalya Evgenyevna — Ph.D. in Medical Sciences, Associate Professor, Researcher at the Department of Clinical Pharmacology and Antimicrobial Drugs, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation
17. Yakushevskaya Oksana Vladimirovna — Ph.D. in Medical Sciences, Researcher at the Department of Gynecological Endocrinology, National Medical Research Center for Obstetrics, Gynecology and Perinatology named after Academician V.I. Kulakov of the Ministry of Health of the Russian Federation.
18. Yarmolinskaya Maria Igorevna — Head of the Department of Gynecology and Endocrinology at the D.O. Ott Research Institute of Obstetrics, Gynecology and Reproductology, Head of Gynecology Department No. 2, Head of the Center for Diagnosis and Treatment of Endometriosis, Professor at the Department of Obstetrics and Gynecology at the North-Western State Medical University named after I.I. Mechnikov of the Ministry of Health of Russia, Professor of the Russian Academy of Sciences, D.Sc. in Medical Sciences, Professor, Member of the Russian Society of Obstetricians and Gynecologists.
Conflict of interest: none declared
Appendix A2. Methodology for Developing Clinical Guidelines
Target audience for these clinical guidelines:
1. obstetrician-gynecologists
2. students; clinical residents, postgraduate students in obstetrics and gynecology
3. educators, researchers
Table 1. Levels of Evidence (LoE) grading scale for diagnostic methods (diagnostic interventions)
LoE | Definition |
|---|---|
1 | Systematic reviews of studies with reference standard control or systematic reviews of randomized controlled trials with meta-analysis |
2 | Individual studies with reference standard control or individual randomized controlled trials and systematic reviews of studies of any design, except randomized controlled trials, with meta-analysis |
3 | Studies without consecutive reference standard control or studies with a reference standard not independent of the test method, or non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case report |
5 | Only justification of mechanism of action or expert opinion is available |
Table 2. Scale for assessing the levels of evidence (LE) for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions)
LoE | Definition |
|---|---|
1 | Systematic review of RCTs with meta-analysis |
2 | Individual RCTs and systematic reviews of studies of any design except RCTs, with meta-analysis |
3 | Non-randomized comparative studies, including cohort studies |
4 | Non-comparative studies, case reports or case series, case-control studies |
5 | Only justification of the mechanism of action of the intervention (preclinical studies) or expert opinion is available |
Table 3. Scale for grading levels of recommendation certainty (LRC) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions)
GoR | Definition |
|---|---|
A | Strong recommendation (all considered efficacy criteria (outcomes) are important, all studies are of high or acceptable methodological quality, and their conclusions on the outcomes of interest are consistent) |
B | Conditional recommendation (not all considered efficacy criteria (outcomes) are important, not all studies are of high or acceptable methodological quality, and/or their conclusions on the outcomes of interest are inconsistent) |
C | Weak recommendation (lack of adequate quality evidence (all considered efficacy criteria (outcomes) are unimportant, all studies are of low methodological quality, and their conclusions on the outcomes of interest are inconsistent) |
Procedure for updating clinical guidelines.
The mechanism for updating clinical guidelines provides for their systematic revision at least once every three years, as well as upon the emergence of new evidence-based medicine data on the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or in the presence of justified additions/comments to previously approved clinical guidelines, but no more frequently than once every 6 months.
Appendix A3. Reference Materials
1. Order of the Ministry of Health of Russia dated October 20, 2020, No. 1130n "On Approval of the Procedure for Providing Medical Care in the Field of 'Obstetrics and Gynecology'" (Registered with the Ministry of Justice of Russia on November 12, 2020, No. 60869).
2. Protocol No. 4, Clinical Protocol for Diagnostics and Treatment "Inflammatory Diseases of the Perineum, Vulva and Vagina", approved by the Joint Commission on Quality of Medical Services of the Ministry of Health and Social Development dated June 9, 2016, Protocol No. 4. Protocol developers: Doshchanova A.M., Mireeva A.E., Tuletova A.S., Mazhitov 2) Kaufman RH, Faro S, Brown D. Benign diseases of the vulva and vagina. 5th ed. Philadelphia, PA: Elsevier Mosby; 2005:240-249.
3. Methodological Recommendations No. 38. Implementation of the Antimicrobial Stewardship Program in Surgical Departments of Healthcare Organizations of the Moscow City Healthcare System in the Provision of Medical Care. 2020. Compilers: A.V. Shabunin, M.V. Zhuravleva, R.Yu. Mayer, E.V. Kuznetsova, K.A. Pokrovsky, T.R. Kameneva, M.V. Otpuschennikova, N.A. Rezepov.
First-line antibiotic therapy regimens for bartholin gland diseases
Possible antibiotic therapy regimens [1, 4, 9].
Antibiotic therapy is administered for 3 to 5 days, followed by a decision on whether to prolong therapy based on clinical, laboratory, and microbiological data.
Treatment regimens | Dosage | |
|---|---|---|
1 | Amoxicillin+ [clavulanic acid]** | 1200 mg every 8 hours IV or 625 mg every 8 hours orally, 1000 mg every 12 hours orally |
2 | #Clindamycin ** | 300 mg every 6 hours orally |
43 | #Doxycycline** | 100 mg every 12 hours orally |
Spectrum of the most common microorganisms in Bartholin gland abscess (BGA) and Bartholin gland cyst (BGC)
Pathogen species | Frequency of detection, % |
|---|---|
Gram-negative bacilli Escherichia coli Morganella morganii Proteus spp Klebsiella pneumonia Gram-positive cocci Staphylococcus aureus: Streptococcus aeruginosa Enterococcus spp. Streptococcus mitis Anaerobes Bacteroides species Prevotella bivia Hypermucoviscous Mycoplasma spp. | 47,6 43,6 1,6 0,8 0,8 30,2 6,4 4,8 4,8 4 11,9 0,8 2,4 0,8 |
Appendix B. Physician Action Algorithms
Appendix C. Patient Information
What is a Bartholin gland cyst?
A Bartholin gland cyst is a fluid-filled lesion located in the area of the vaginal vestibule. It occurs due to impaired outflow of secretion from the gland cavity.
Why do they occur?
Frequent inflammatory conditions in the genital area caused by non-specific microflora (E. coli, staphylococci, streptococci), specific pathogens, STI pathogens, and trauma.
What symptoms develop in the presence of a Bartholin gland cyst?
Most often, patients complain of a mass in the perineal region, asymmetry of the labia majora due to swelling, and pain. Small cysts may be asymptomatic and discovered by a doctor during a routine gynecological examination. However, in some cases, they can enlarge and cause pain.
What is a Bartholin gland abscess?
A Bartholin gland abscess is a purulent inflammation of the Bartholin gland of microbial origin. It may be accompanied by fever, intoxication, and malaise. A sensation of fullness and sharp throbbing pain occur in the BGA area, which worsen with movement.
To prevent the development of BGC/BGA, it is necessary to follow preventive measures:
detect and treat STIs in a timely manner;
treat acute and chronic inflammatory diseases of the pelvic organs;
observe personal hygiene rules;
follow-up with an obstetrician-gynecologist
Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools
Not applicable