CYSTS
A Bartholin cyst results from the occlusion of the excretory duct or one of its subdivisions. Etiologic factors include specific or nonspecific infections and accidental or operative trauma. Most often an infection in one or both Bartholin glands results in swelling and/or abscess formation. Usually the acute process is unilateral and marked by pain and swelling. Systemic symptoms are minimal except in advanced cases. Once the acute infection has passed, stenosis and scarring of the duct may result in the formation of a chronic cyst.
The cyst appears as fluctuant swelling in the posterior aspect of the
labia. When palpated between the thumb and index fingers, it is quite movable
beneath the overlying skin. The cysts may be clear, yellow or bluish in color,
and the size may vary from that of a marble to that of a large egg. Unless
secondarily infected, they cause little or no discomfort. (More than 80% of
cultures of material from Bartholin gland cysts are sterile.) The contents of
the cyst are usually clear and mucoid. Microscopic examination usually reveals
evidence of the transitional cell epithelium, derived from the duct wall, and
Bartholin gland tissue. The cyst lining is usually transitional epithelium, but
the pathologic diagnosis is made by the additional presence of compound
mucinous glands in the wall.
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| Plate 6-15 |
Asymptomatic cysts in women below the age of 40 do not need treatment.
(Above this age, biopsy is indicated.) Excision of the gland is often difficult
and is associated with significant risk of morbidity, including intraoperative
hemorrhage, hematoma formation, secondary infection, scar formation, and
dyspareunia. Therefore, excision is not generally recommended. When treatment
must be instituted, marsupialization of the cyst is usually the best course: A
1- to 2-cm vertical or “stab” incision is made, usually within the hymenal
ring; sutures are generally not required. A Word catheter should then be placed
through the incision and inflated with a few milliliters of saline. The catheter
is left in place for 6 weeks. As an alternative, iodoform gauze packing may be
placed within the cavity with a 2- to 3-cm tail left outside the incision to
facilitate eventual removal. Unless cellulitis is present, antibiotic therapy
is not required.
The labia majora and minora contain numerous sebaceous glands. When
occlusion of a duct occurs, a cystic enlargement may result from retention
within the gland of sebum and epithelial debris. Sebaceous cysts are usually
small but may reach the size of a walnut. They may be single or multiple. They
are moderately firm, quite movable, and may be asymptomatic when uninfected.
When secondary infection occurs, the cyst becomes tense,
red, swollen, tender and painful, resembling a furuncle.
Inclusion cysts are sometimes noted in the perineum, at the fourchette,
and within the vagina. They are usually quite small, varying in size from a pea
to a walnut. They may result as an aftermath of a reparative operation for
perineal laceration. When a portion of epithelium is buried beneath the
surface, it usually becomes encysted, with an accumulation of desquamated and
degenerated epithelium.
A cyst of the canal of Nuck refers to a cystic dilation of an
unobliterated peritoneal pouch, the analogue to the processus vaginalis in the
male. This may extend for a varying distance along the round ligament, which
this pouch accompanies during fetal life. The cyst may develop in the upper
half of the labium majus with a pedicle leading into the inguinal canal. An
excised specimen may present a wall composed of fibrous and muscular tissue. A
lining epithelium of low cuboidal or cylindrical cells (persistent endothelium) may
or may not be present.
