Bartholin glands are major vestibular androgen dependent glands that release mucus secretions during sexualarousal through a 2.5 cm duct that drains at the 5 o'clock and 7 o'clock positions of the vestibule. Bartholin's glands are innervated by a branch of the pudendal nerve; mucous secretion is activated by the efferent pelvic nerve.
Unilateral or bilateral obstruction of the Bartholin's ducts may occur (e.g. from trauma, infection,surgery, or idiopathic), however as long as innervation is intact, Bartholin glands continue to produce mucus despite outlet ductal occlusion. This leads to dilation of the duct with subsequent cyst formation that can result in Bartholin cyst-associated sexual dysfunction symptoms.
At San Diego Sexual Medicine we have managed numerous women presenting with Bartholin cyst-associated sexual dysfunction. Some of the Bartholin cyst-associated sexual dysfunctions include dryness with sexual arousal (73%), pain with sexual arousal (82%), pain with orgasm (36%), spontaneous drainage (18%), and a mass at the introitus interfering with penetration (45%).
The majority of our patients with Bartholin cyst discomfort or pain have been treated previously at other facilities unsuccessfully, including cyst aspiration, Word catheter placement, and marsupialization. We have successfully diagnosed and surgically treated these women with Bartholin cyst-associated sexual dysfunction using contemporary diagnosis and treatment Principles. For example, we use Grayscale ultrasound to record cyst dimensions after visual sexual stimulationi n the office. In our patients, the mean cyst size on ultrasound is 2.9 +/- 1.5 cm. We use vulvoscopy to examine the cyst and other aspects of the vulva, vestibule and vagina with the Wallach Zoomscope. We use Bartholin cyst anesthesia testing where we apply benzocaine 20%, lidocaine 8% and tetracaine 6% to the cyst wall to assess if there is clinically significant symptom reduction.
Marsupialization surgery as an out-patient procedure. Surgical principles to encourage post-op mucin drainage through the Bartholin duct include visualization of the duct at surgery and direct anastomosis of the duct to the inferior portion of the incision at 5 and/or 7 o’clock locations. This is best achieved by allowing a new drainage area within the Bartholin cyst so that the lubricating fluid can continue to be released into the vestibule after sexual arousal and aid pain-free vaginal penetration. The process of surgically establishing drainage of a Bartholin cyst is called marsupialization. Marsupialization has the least chance of recurrence of the Bartholin cyst. Marsupialization is best performed under general anesthesia in an operating room. Marsupialization involves suturing the walls of the Bartholin cyst directly to the inner surface of the labia minora. The sutures dissolve over in 4-6weeks. Post-operative regular arousal is encouraged and mucin secretion through the marsupialized ducts is documented by placement of gauze in the introitus and observing the mucous.
Bartholin cysts are a sexual dysfunction that can be successfully treated. Diagnosis involves an ultrasound after sexual arousal and a positive Bartholin cyst anesthesia test. Treatment involves marsupialization with visualization and anastomosis of the Bartholin duct to the inferior portion of the incision at the 5:00 and 7:00 o’clock locations. Post-operative regular arousal is encouraged with documentation of mucinous drainage detected.