Abstract  
The Bartholin’s glands are located bilaterally at the posterior portion of the vestibule, distal to the hymenal remnants and are secretory in function. Although not solely so, they are responsible for the natural lubrication of the vagina and vulva and are normally not palpable or visible on examination of the pelvis. Symptomatic Bartholin duct masses are a common presenting complaint in women presenting acutely to a gynaecological department and can present a therapeutic dilemma. Symptoms most often arise when an abscess forms in an obstructed duct, and unless this is draining spontaneously, it may require a degree of surgical intervention. Incision and drainage has proved to have a high recurrence rate and should thus be supplemented with the insertion of a Word catheter or the placement of sutures securing the ductal wall to the perineal epithelium, known as marsupialisation. Other methods of treatment have proved less effective. Less often malignancies can arise from the Bartholin structures and occur most frequently in women aged 40 to 70 years. It is thus mandatory to biopsy the ductal and or gland wall in women of this age presenting with a suspicious enlargement of this area of the vulva on the first visit as primary neoplasms of this origin, although rare, are highly metastatic and may require extensive surgical intervention.

Keywords: Bartholin’s gland; Bartholin’s duct; Disease

Introduction
The Bartholin glands are the female homologue of the bulbourethral glands in the male and are also known as the greater vestibular glands. Situated within the bulbocavernosus muscle on either side of the vestibule, these glands secrete small amounts of mucous draining via the Bartholin ducts into the vagina. In the absence of pathology these small structures are not palpable, but in the
event of blockage the ducts may become symptomatic, occurring in 2 to 3 % of women. Bartholin glands are rarely the site of malignancies, accounting for less than 1% of all primary female genital malignancies.1,2 Nevertheless, a host of other vulvo-vaginal lesions can mimic a Bartholin gland disorder, and this should be taken cognisance of when evaluating a mass or abscess in this region.
Anatomy, Physiology and Embryology

Originally described by the Danish anatomist Caspar Bartholin the Younger in 1677, each gland is approximately 1 cm in diameter and open into a narrow 2.5 cm duct to the surface between the labia minora and the margin of the hymen. Although the function of the gland was thought to be to provide lubrication of the vagina during sexual intercourse and maintain the normally moist surface of the vulva, removal of the gland has been shown not to compromise the surrounding epithelium.3 Embryologically, this structure shares its origin with the lower two thirds of the vagina and hymen from the urogenital sinus, a development of the cloaca. Its blood supply is thus from the external pudendal artery and lymph drains via the medial group of the superficial inguinal lymph nodes in the groin to the femoral lymph nodes, and also crosses the midline. Some lymphatics drain directly to the internal iliac
nodes. Malignancies of the vulva spread primarily via the lymphatics and may involve the deep lymph nodes of the pelvis.4

Diseases of the Bartholin Duct and Gland:
Bartholin duct cyst
Along with abscesses, cysts are the most common disorders of the Bartholin gland and affect mostly the ductal portion after distal blocking of the outlet.
Symptomatic enlargement of the duct represents a common management dilemma in gynaecology. Risk factors are similar to those associated with the risk profile of women with sexually transmitted infections (STI’s). Cysts are usually sterile and do not affect the gland.

The diagnosis is made clinically in a women presenting with the history of a unilateral labial swelling and the findings of a soft, painless mass in the area of the Bartholin gland. Larger cysts cause discomfort, typically during sexual intercourse, sitting or walking. Asymptomatic cysts, usually found on routine pelvic examination, need only be treated in women older than 40 years of age, when drainage and biopsy should be performed to exclude malignancy. Symptomatic cysts can be treated in a number of ways including drainage and excision, however no large comparative clinical trials are available to provide guidance on therapeutic decisions.5

 

Bartholin duct abscess
With similar pathogenesis to a cyst, an obstructed duct may become infected, usually with multiple microbials, and presents as an abscess.6 The proportion of STI’s identified in
cultures are less than in years past, with the most common aerobic pathogens including Escherichia coli, Staphylococcus species and Streptococcus species. Bacteroides species is
the most common anaerobic bacteria present and accounts for a smaller proportion when compared to aerobic microbials.7 Neisseria gonorrhoea and rarely Chlamydia can
also be responsible for causing infection.8 In contrast to a cyst, patients with an abscess will be more likely to present with symptoms of discomfort and the affected area may be surrounded by cellulitis or lymphangitis. A spontaneous sinus may also be seen draining pus in larger abscesses. Management of a ruptured abscess can be limited to analgesia and soaking of the genital area with warm compresses or Sitz baths. If uncomplicated, antibiotic administration has shown no benefit above placebo, although studies specific to Bartholin’s abscesses are lacking.9 Signs of
a complicated infection, including cellulitis, would necessitate antibiotic use and should include appropriate agents to cover the usual causative organisms, as well as the treatment of STI’s if suspected or confirmed. An unruptured abscess should be drained. The mainstay of initial treatment remains surgical incision and drainage, although this should be supplemented with either
marsupialization or the more conservative insertion of a Word catheter to reduce recurrence rates, which can be as high as 5 – 15% or 3% respectively.10 Marsupialization, first described by Jacobson in 1950, entails a small incision made over the medial aspect of the abscess and distal to the hymenal ring, drainage of the abscess and suturing of the distal aspect of the ductal lining
to the external incision edges of the epithelium with interrupted absorbable sutures. This encourages spontaneous drainage, prevents closure and reformation of the abscess. Packing of the cavity is unnecessary. The disadvantages of this procedure include a longer and more invasive procedure when compared to more conservative methods, and it is generally conducted under general
anaesthetic, although it can be done under local or pudendal block.11 Post operative complications include pain, haematoma formation, prolonged healing, scarring and dyspareunia.
In 1964, Buford Word described his invention: a 6 cm rubber catheter with a small balloon at its tip that is filled with 3 ml of saline once the device has been placed into the abscess cavity. With the distal end placed into the introitus, to allow free drainage of pus and to prevent accidental expulsion, it is left for 4 – 6 weeks while the patient is followed-up. Although associated with pain post-insertion andthe catheter falling out before follow-up, this method is favoured for its lower recurrence rate and the fact that it is well tolerated when inserted as an outpatient procedure
under local anaesthetic.12 A modification of the Word catheter is the Jacobi ring: a rubber ring made from a 7 cm length of 8-French T-tube threaded with a 20 cm length of 2/0 silk suture that enters the abscess through two separate incisions to form a closed ring once the suture ends are tied. When compared to the Word catheter in a randomised controlled trial, the authors
postulated that there may be better patient satisfaction with the Jacobi ring although no difference in recurrence was found.13 Other methods of management include carbon dioxide
laser vaporisation where the inner wall of the cyst is vaporised after drainage; the less expensive silver nitrate ablation, associated with postoperative pain secondary to chemical burns, oedema formation, ecchymosis and scar formation; and alcohol sclerotherapy.10 Excision of the gland and duct in its entirety is a challenging procedure during the acute presentation and
should be reserved for failed marsupialisation and failed conservative attempts.

Bartholin Gland and duct carcinoma

In the light that the peak incidence of Bartholin’s gland carcinomas (BGC) occurs in women between the ages of 40 and 70 years and that the gland shrinks in postmenopausal women, it is mandatory to investigate any enlargement of the
gland that appears to be irregular, solid or fixed to underlying structures.14 Often the condition is initially misdiagnosed as a cyst or an abscess: interesting then, that
most affected women do not have a past history of benign Bartholin gland disorders and present with a painless mass. Nevertheless, primary carcinomas of the Bartholin gland are
rare and are mostly adenocarcinomas (from the glandular aspect) or squamous cell carcinoma (from the ductal portion) and account for 90% of these neoplasms. Adenoid cystic
carcinoma, transitional cell carcinomas and adenosquamous carcinoma account for the remainder. In 1897 Honan established the diagnostic criteria of primary BGC and includes the correct anatomical location of the tumour, with a primary location deep in the labia, with the overlying skin intact and the histological presence of some elements of the glandular epithelium.15 The diagnosis is made on histological examination and metastatic disease is common because of the rich vascular and lymphatic network of the vulva. Surgical excision is comprised of radical vulvectomy and bilateral inguino-femoral lymph node dissection (LND). In the event of histological confirmation on neoplasm in the nodes adjuvant chemo-radiotherapy is offered. Carcinomas
frequently extend toward the lateral wall of the vagina and ischiorectal fossa and require partial excision of the distal vagina and levator ani muscle in order to achieve histologically negative margins. This procedure is associated with postoperative pain and is not aesthetically pleasing. A partial vulvectomy and ipsilateral LND can also be considered depending on the distance of the tumour from the midline and its size. There is a promising rise in the use of sentinal lymph node biopsies in these and other vulval cancers allowing for less extensive and destructive surgery. Furthermore, in 2007 a retrospective Institutional Review Board approved study was published from Boston and concluded that primary radiation or chemoradiation therapy offers an effective
alternative to surgery in the treatment of BGC with lower morbidity and preservation of genital function.16 Despite its metastatic nature the five-year survival rate has been reported as 85%.17

Differential diagnosis of a vulvovaginal mass or abscess
There are many other conditions of the perineum that often get falsely labelled as pathology of the Bartholin’s gland. Some of these include cysts of the Gartner or Skene’s ducts,
sebaceous cysts, folliculitis, hernias, lipomas, fibromas or even anorectal abscesses. Careful diagnosis is thus imperative prior to initiation of treatment and reconsideration of diagnosis should be considered in recurrent episodes.

Conclusion
Pathology of the Bartholin’s gland can range from an asymptomatic and incidentally discovered cyst requiring no further management to an extremely debilitating abscess interfering with mere ambulation of a woman. In such cases incision and drainage is always indicated, and is best supplemented with the effective insertion of a Word catheter as an outpatient, although the common practice of marsupialisation is accepted as second-line with recurrent disease and failed Word catheter placement. All women above the age of 40 years should undergo drainage and biopsy of the duct/gland wall if presenting with Bartholin abscess to exclude the possibility of a carcinoma.

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