The Bartholin gland, also known as the greater vestibular gland, is located in the superficial compartment of the vulva, near the introitus. The gland comprised of mucinous acini, and the duct is a combination of transitional epithelium, mucinous cells, and squamous epithelium. The orifices are lined with squamous epithelium. Supplying the gland are numerous branches of the inferior pudendal artery. Deep to the gland is a thick network of anastomosing venous channels, known as the vestibular bulb. It is this erectile tissue of the vestibular bulb that contributes to the bloody nature of the Bartholin gland excision. Occasionally, during large gland excisions, other surrounding structures can be appreciated. The ischiorectal fossa is a relatively avascular area that has notorious potential for infection to manifest and spread to surrounding pelvic compartments.

Management may entail observation, sitz baths, antibiotics, silver nitrate ablation, CO₂ laser vaporization, epithelialization with Word or Jacobi ring, marsupialization, and excision. None has proven to be superior, but ideal treatment would be fast, safe, performed with local anesthesia in outpatient setting, and with low recurrence and fast healing. Observation is sufficient for the painless Bartholin duct cyst that may even reach several centimeters in size in the otherwise-healthy individual under the age of 40. If the patient has no signs of systemic infection, advise sitz baths alone for the spontaneously draining abscess or pointed abscess that is almost ready to drain. Antibiotic therapy is the first-line treatment for an abscess that is not yet matured for drainage and is the second-line therapy for an abscess that has not clinically improved after drainage. Evaluate the need for antibiotics as adjunctive treatment at the time of drainage. Patients with the following comorbidities and/or sign and symptoms should be treated with antibiotics at the time of drainage: diabetes, immunosuppression, pregnancy, high MRSA risk, recurrent infection, or signs of cellulitis or systemic infection. A broad-spectrum antibiotic that covers Gram-negative and Gram-positive organisms over anaerobes such as amoxicillin clavulanate 875 mg PO q12h for 7 days, or trimethoprim sulfamethoxazole 800/160 PO q12h for 7 days is sufficient. For augmented MRSA and Bacteroides coverage, consider adding clindamycin 300 mg PO four times a day for 7 days. An Israeli study by Kessous et al. confirmed Escherichia coli as the most common organism cultured from 43.7% of Bartholin gland infections. Empiric treatment with amoxicillin clavulanate was associated with recurrence averages between 32 and 50 months. Historically, Bartholin abscesses were attributed to sexually transmitted infections, but recently, this notion has been disproven by Hoosen, Tanaka, and Kessous. STD testing may be offered at the time of Bartholin abscess presentation but antibiotic choice should not empirically encompass Neisseria gonorrhea or Chlamydia trachomatis.

Characteristics of an abscess, that require prompt operative, rather than nonoperative management, include abscess recurrence, pain and erythema, fever, and fluctuance. Of note, although incision and drainage (I&D) may offer symptomatic relief of an acutely painful abscess, I&D alone, although described in some studies, is generally not recommended because it confers no long-term benefit and increases the risk of recurrence up to 38%. Instead, drainage with the goal of epithelializing an egress tract from the gland is preferred. This may be accomplished with silver nitrate ablation, CO₂ laser, Word catheter or Jacobi ring placement, or marsupialization. The following patients and conditions require biopsy in addition to drainage: women over 40, immune-compromised patients, history of Paget’s disease, history of any gynecologic malignancy, and those with recurrent abscess formation. Complete surgical excision should be performed instead of biopsy in postmenopausal women and when the Bartholin mass is firm and irregular.

Creating an intentional fistula, or epithelialization of a Bartholin gland abscess, is superior to simple I&D as the fistula prevents future abscess formation.