(031) Bartholin Cysts Can Be Treatable Causes of Female Sexual Dysfunction: Four Year Review of Diagnosis and Treatment Principles
Authors: Uloko M , Stearns H , Gagnon C , Minton J , Goldstein I 
Published: June 2023

Abstract

Introduction
Bartholin glands are major vestibular androgen dependent glands that release mucus secretions during sexual arousal 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.

Objectives
To review patient records of women presenting to a sexual medicine clinic over a four-year period diagnosed with and surgically treated for Bartholin cyst-associated sexual dysfunction.

Methods
Grayscale ultrasound was performed (see figure) using the Aixplorer and cyst dimensions were measured after visual sexual stimulation in the office. Vulvoscopy was performed with the Wallach Zoomscope. Bartholin cyst anesthesia testing was performed using benzocaine 20%, lidocaine 8% and tetracaine 6%. Marsupialization surgery was performed as an out-patient.

Results
We identified 11 patients (mean age 26 +/− 6 years) diagnosed with Bartholin cyst-associated sexual dysfunction between January 2019 and November.
2010 who met inclusion criteria and were surgically treated by marsupialization for unilateral (4) and bilateral (7) Bartholin cysts. Their symptoms of Bartholin cyst-associated sexual dysfunction included 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%). 55% had been treated previously at other facilities unsuccessfully, including cyst aspiration, Word catheter placement, and marsupialization. The mean cyst size on ultrasound was 2.9 +/− 1.5 cm. Bartholin cyst anesthesia testing was positive in all (4/4) that underwent this test. Surgical principles to encourage post-op mucin drainage through the Bartholin duct included visualization of the duct at surgery (see figure) and direct anastomosis of the duct to the inferior portion of the incision at 5 and/or 7 o’clock locations (see figure). Post-operative daily arousal was encouraged and mucin secretion through the marsupialized ducts was documented by placement of gauze in the introitus and observing the mucous (see figure). At the time of this review, with an average follow-up of 8 months, 15 of 18 (83%) cysts are still draining and 9/11 patients are somewhat better, much better and very much better with resolution of Bartholin cyst-associated sexual dysfunction symptoms.

Conclusions
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 locations. Post-operative daily arousal is encouraged with documentation of mucinous drainage detected.

Disclosure
No.