All about the Bartholin gland cyst
Bartholin's cyst is a fairly common pathology among young women 30 - 35 years. If the education is small, it does not bother the woman and even remains not diagnosed. But in the case of an increase in the size of the cyst, characteristic complaints appear and a lot of inconvenience arises - from discomfort during intercourse to the inability to lead an active lifestyle. Therefore, it is necessary to conduct timely and high-quality treatment of the Bartholin gland cyst.
From anatomy course
In anticipation of the vagina there are a large number of functioning glands, whose task is to protect the vulva from infection and injury, as well as moisturizing during sexual contact. The glands of the vulva constantly produce a secret that not only moisturizes the external genitals, but also removes pathogens and various microparticles from them.
Among the vulva glands, the Bartholin glands play a huge role, which are located deep in the labia majora, mainly in the lower third of the vestibule. Bartholin glands are a paired organ, have a rounded shape and in the absence of pathology are not visible and are not palpable. In size, the Bartholin glands do not exceed 1.5 - 2 cm. The mouths of the excretory ducts of these glands are located on the inner side of the labia minora.
When the gland's excretory duct is blocked, the viscous and viscous secret that it forms begins to accumulate in the gland, stretching its walls, as a result of which a cyst is formed - a cavity filled with secretions. Features cysts Bartholin glands:
- can reach significant sizes (up to 7 - 8 cm),
- are formed more often on the one hand (bilateral cysts is a rare phenomenon),
- have a benign nature and do not degenerate into cancer,
- do not affect the course of pregnancy and the condition of the fetus,
- do not violate the hormonal balance,
- are not inherited,
- often recur.
Causes and mechanism of education
The reasons for the formation of a cyst are either its infection or the creation of a mechanical obstacle in the excretory duct of the gland.
Infection of the gland can be caused by both specific microorganisms and nonspecific. Specific pathogens include:
- ureaplasmas and other.
Nonspecific pathogens include representatives of conditionally pathogenic flora, which are activated by the action of predisposing factors:
- E. coli
- protei and others.
The following circumstances may provoke cyst formation:
- weakened immunity
- neglect of personal hygiene,
- wearing close synthetic clothes,
- the use of lubricants (clog the ducts of the glands, and not only Bartholin),
- wrong washing technique (the procedure should be performed under the stream of water from front to back),
- wearing tight clothes (tight jeans or pants),
- bacterial vaginosis
- hypothermia of the lower half of the body,
- promiscuous sex life (high risk of infection),
- rough sex
- epilation in the bikini area (skin damage),
- gynecological manipulations that damage the mucous membrane of the vagina and vulva (abortion, hysteroscopy,
- chronic gynecological (cervicitis, adnexitis, endometritis) and common diseases (tonsillitis, caries, pyelonephritis),
- immunodeficiency states
- endocrine pathology (diabetes mellitus).
When the infection enters the vulva, the vulva becomes inflamed. The infectious process also captures the outflow channels of the Bartholin glands, causing canaliculitis. At the same time the excretory opening is blocked, and the secret produced by the gland begins to accumulate inside and a cyst is formed. If the contents of the cyst suppuate, a gland abscess develops.
Perhaps the formation of cysts and without the participation of pathogenic microorganisms. In this case, there is a blockage of the excretory duct by strongly overgrown surrounding tissues, which is caused by mechanical damage to the mucosa and its subsequent healing (hyperplasia or fibrosis).
The size of the Bartholin gland cyst can vary from a pea to a chicken egg. The clinical picture develops when it reaches an impressive size, when a cyst begins to cause discomfort and disrupts the usual way of life. Small lesions are asymptomatic, and only in case of inflammation of the Bartholin gland cyst complaints appear.
Large formations cause pain when moving (walking, squats) and discomfort during sexual intercourse.
Gynecological examination reveals asymmetry of the genital slit - on the one hand, the labia majora is enlarged (a consequence of inflammatory edema). If the cyst is large, then a rounded education is defined, which rises above the unchanged skin color. On palpation, the formation is painless or sensitive, elastic consistency and mobile (not welded to the skin).
If an infection process prevails in a cyst, the clinical picture changes. Infectious agents penetrate the excretory duct of the gland, causing inflammation in it - canaliculitis. There is a narrowing of the duct, but it is not completely blocked, therefore, a few drops of pus are released when the inflamed area is compressed. The patient has complaints of minor pain in the affected area, a dense cushion is felt in the labia minora and reddening of the exit duct of the gland appears.
In the absence of a medical duct, the stenosis is completely stenosed (closed) and the release of pus to the outside becomes impossible. It begins to accumulate inside the duct, pushing the gland aside, which is called a false abscess. A characteristic clinical picture develops: a sharp pain when moving and touching the labia, their bright redness and swelling, symptoms of intoxication. False abscesses are often spontaneously opened and emptied, as a result, patients do not go to the doctor. But as the opened abscess heals, the inflammatory process goes into the category of chronic and sluggish, which leads to the final blockage of the excretory duct and the secondary formation of a cyst.
If the infection affects the Bartholin gland tissue, then its purulent fusion occurs - the formation of a true abscess with pronounced symptoms (sharp and throbbing pain, huge sizes up to 10 - 15 cm, hyperemia, intoxication).
Diagnose: "Bartholin's cyst gland" for the doctor is not difficult. A primary gynecological examination confirms suspicions (a characteristic round and elastic formation, mobile and slightly painful on palpation).
Assigned laboratory tests:
- vaginal smear,
- general blood and urine tests
- blood biochemistry
- PCR diagnostics (detection of hidden genital infections),
- bacterial seeding of the educational contents to determine the pathogen and determine its sensitivity to antibiotics.
Tactics of treatment is determined by the size of education, the presence of complaints and possible complications. If the cyst is small, no more than 2 cm, then preference is given to dynamic observation. Very often, small cysts resolve themselves. Bartholin gland cyst can be eliminated without surgery in two cases:
- the initial stage of inflammation is canaliculitis, when the process has captured only the duct of the gland, and the gland itself is not inflamed,
- small size (up to 3-4 cm) cysts in the "cold" period (no inflammatory signs).
Conservative therapy includes:
- Exercise restriction
In the case of canaliculitis, the patient is advised to move less (walk, run), since the movements further injure the inflamed lip and aggravate the inflammation.
Heater with ice, wrapped with a cotton towel, apply to the inflamed labia for 20-30 minutes, taking breaks of 20 minutes. The cold constricts the blood vessels, which prevents the further spread of infection and reduces swelling at the site of inflammation. In addition, exposure to cold eliminates pain during inflammation.
They have an anti-inflammatory effect. It is recommended to take sessile warm baths with disinfectants (solution of potassium permanganate, chlorhexidine or miramistina). Baths take 10 - 15 minutes 4 to 6 times a day. You can also put lotions with a solution of sodium chloride on the inflamed area (dissolve 3 tablespoons of salt in a liter of warm water). Lotions are applied for 20 to 30 minutes every 6 hours. Use of ointment applications with levomekol is allowed (anti-inflammatory action). But applications with ichthyol or Vishnevsky ointment should not be used. Ichthyol and Vishnevsky ointment have a warming effect and only increase inflammation (the transition of canaliculitis into an abscess), so they are prescribed before the planned surgical intervention to accelerate the maturation of the abscess.
The blood network is well developed in the tissues of the vulva, so the infection spreads very quickly. The earlier antibiotic therapy is prescribed, the lower the risk of canaliculitis going to the suppuration of the gland. Until the results of the tank. Broad-spectrum antibiotics (fluoroquinolones, cephalosporins, macrolides, penicillins) are prescribed for sowing cyst contents. If necessary, according to the results of the analysis, a change of antibiotics is carried out. The course of treatment is standard and is 7 days.
- Nonsteroidal anti-inflammatory drugs
We recommend taking ibuprofen, indomethacin and other NSAIDs. These drugs not only reduce inflammation, but also have an analgesic effect. If necessary, other types of analgesics and antispasmodics are prescribed.
- Immunomodulators and desensitizing drugs.
To strengthen the immune system appointed Viferon, tincture of Eleutherococcus, tincture of Echinacea, thymalin and other immunomodulators. Antihistamine (antiallergic) drugs reduce swelling and itching (suprastin, claritin).
Conducted with the relief of acute inflammatory process (UV and UHF, magnetic therapy and infrared laser irradiation).
Methods of traditional medicine
Folk remedies are used simultaneously with therapeutic treatment. They help relieve swelling and reduce inflammation, as well as stimulate immunity.
Recipes for immunity:
Grind 100 - 150 gr. walnuts, a teaspoon of dill seeds and 3 - 4 cloves of garlic in a blender. Mix with half a liter of liquid honey and leave for 2 - 3 days. Mixture take 2 teaspoons three times a day before meals.
Grind 200 gr. Aloe leaves (about 20 pieces) and mix with half a liter of honey and half a liter of red dessert wine. Stir the mixture and cook in a water bath for about an hour. After that, strain the mixture and take 2 teaspoons three times a day before meals. Mixture stored in the refrigerator.
Prepare a decoction of valerian root, pine buds, nut leaves and herbal leaf (1 tablespoon of each plant per liter of boiling water, boil for 10 minutes, then infuse for 4 hours). Strain the broth and drink 1/3 cup twice a day.
For local treatment:
- warm baths of healing herbs (chamomile, calendula, eucalyptus),
- an infusion of nettle, yarrow and elderberry (pour a glass of boiling water over a tablespoon of each herb, infuse for 2 hours) - use for sedentary baths,
- Chamomile flowers and marigold pour boiling water, leave for 2 - 3 hours, drain and hold warm sit-baths.
Surgical treatment of this pathology is carried out in the case of:
- Significant size of the cyst, which causes discomfort and disrupts the usual way of life,
- the occurrence of an abscess (the operation is carried out in an emergency),
- recurrent inflammation of the cyst, which requires conservative therapy,
- at the request of the patient (education causes psychological discomfort).
In the presence of a Bartholin gland cyst, several surgical techniques have been developed and are being actively used.
The most popular operative technique is marsupialization of the cyst. It is performed under local anesthesia. The cavity of a cyst is opened and its contents are evacuated. Then the cavity is treated with antiseptics, and the walls of the formation are hemmed to the edges of the wound so that the mouth of the newly formed excretory duct is formed. Such an operation makes it possible to maintain a functioning Bartholin gland. The operation is performed on an outpatient basis and lasts about half an hour.
Peeling a cyst
Hearing a cyst is a rather complicated and traumatic operation that requires hospitalization and is performed under general anesthesia. Capturing and lifting the skin with tweezers of the labia minora, a neat incision is made without touching the capsule formation. The cyst is gently expelled from adjacent tissues entirely. But its rupture is possible, which complicates the healing of postoperative wounds. In addition, there is a high risk of large blood loss. Then the bed of education is sutured in layers. The recovery period is long, up to 3-4 weeks. A postoperative scar can cause pain, which causes pain and disrupts the appearance of the vulva. The advantage of this operation is the impossibility of re-formation of a cyst.
Unfortunately, the vaporization of a cyst by a laser is not carried out in every clinic - the method requires special equipment. The essence of the operation is to convert the light energy of the laser in contact with damaged tissue into heat. The result is that evaporation (vaporization) of the cystic contents and the release of the clogged duct. And under the laser influence, the cystic cavity collapses and is sclerosed.
- high accuracy: the laser effect only affects the damaged tissues, without touching or injuring healthy,
- bloodlessness: laser radiation immediately burns blood vessels, preventing bleeding,
- painless: laser burns nerve endings,
- regulation of the depth of penetration of the beam and its power,
- speed: the procedure lasts from 5 to 20 minutes (depending on the size of the cyst),
- hospitalization is not carried out,
- lack of cosmetic defects after treatment,
- preservation of the Bartholin gland,
- the risk of relapse is practically nil.
Installing a Word Catheter
Word catheter is an American novelty. The catheter looks like a thin silicone tube that has a small balloon at one end. The balloon can swell to a few centimeters. A small incision of about 3 to 5 mm is made above the pole of the cyst, the contents of the formation are removed, and the cavity of the cyst is washed with disinfectant solutions. A catheter is inserted into the cyst through an incision and its balloon is inflated, which prevents the catheter from falling out of the cystic cavity. Wearing a vord catheter for a long time, up to 5-6 weeks, during this period a new excretory duct is formed and epithelialized. The catheter is then removed. After the removal of the silicone tube, the walls of the resulting outflow channel can no longer grow together (they are covered with new layers of epithelium).
Manipulation is performed in 10 - 12 minutes. Such treatment is carried out only in the "cold" period and requires compliance with sexual rest during the entire time of wearing the catheter. The risk of recurrence is minimal, not more than 10%.
Puncture of a cyst has only a temporary effect. The skin over the formation is anesthetized with local anesthetics, and then a cyst is punctured with a thin and long needle. Content drained. This technique is used during pregnancy, when it is impossible to perform other surgery. After puncture after a while the cyst forms again (ductal patency is not restored).
It is also a relatively new treatment method. The principle of the technique coincides with the installation of the vord catheter. Only instead of a silicone tube, a ring is inserted into the incisions above the cyst. When piercing the formation, 2 channels are created immediately, which reduces the probability of a relapse by 2 times. The procedure is not painful and does not cause inconvenience when wearing a ring.
The operation "extirpation of the gland" means its complete removal. This is a radical method and is performed with the inefficiency of other operational techniques.
Disadvantages and risks of extirpation of the gland:
- requires hospitalization
- performed under general anesthesia
- increases the risk of bleeding during surgery,
- the formation of postoperative fistulas or hematomas is not excluded,
- requires the imposition of internal and external seams,
- expensive operation.
The positive point of this operation is 100% - a guarantee of recurrence (no gland - the possibility of cyst formation is excluded). But the removal of the gland significantly reduces the quality of intimate life, especially in young women (vaginal dryness, lack of lubrication, trauma to the perineum, and pain during intercourse).
После оперативного удаления кисты необходимо пройти послеоперационный курс лечения, который включает:
- противовоспалительные препараты,
- прикладывание холода к ране в первые часы и дни после операции (купирует боль, уменьшает отек),
- обработка швов 2 – 4 раза в день антисептиками,
- dressings with levomekol (wound healing and anti-inflammatory effect),
- physiotherapeutic procedures (in 1 - 2 weeks after surgery).
Further (the next 4 weeks) a number of recommendations should be followed:
- sexual rest,
- refusal to take baths and visit baths and saunas,
- wearing non-cotton underwear,
- intimate hygiene.
I have a Bartholin gland cyst about 3 cm. Does not bother. Do I have to delete it?
If there are no complaints and there are no signs of inflammation, then we can observe the formation, but taking into account the course of antibiotics and anti-inflammatory therapy.
I plan a pregnancy, passed all tests. A gynecologist discovered a Bartholin gland cyst about 5 cm in diameter. What to do?
It is necessary to get rid of a cyst before conception, and moreover, in an operational way. During pregnancy, it can fester (reduced immunity), which will require emergency surgery and antibiotics, which are not always safe for the fetus.
When are sutures removed after surgery for a Bartholin gland cyst?
Stitches are removed for 6 - 7 days.
What are the contraindications for surgical treatment of vulvar cysts?
The operation is not carried out with acute or exacerbation of the chronic process of the urogenital system and with skin diseases in the perineal region.
Near the entrance to the vagina are the sebaceous and sweat glands, which are necessary to produce a secret that moisturizes the mucous membrane of the genital organs and protects the vulva from the effects of pathogenic microbes and microorganisms.
The largest is Bartholin gland, which is a paired organ, reaching about 1-2 centimeters in size. In normal operation, it can not be felt, and it does not cause discomfort.
This neoplasm has several features. Only one-sided formation of a cystic tumor is noted. Bilateral lesion is diagnosed in extremely rare cases.
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In addition, the tumor can grow to the size of 10 centimeters in diameter.
Also a feature of such a cyst is that during its development no hormonal disturbances occur.
The neoplasm has a tendency to relapse.
Among all the provoking factors of cyst, infection of the external genital organs comes first, which is accompanied by an inflammatory process.
But it is worth noting that most bacteria are constantly present in the genitals of women and do not cause the development of cysts of this type. That is why experts have identified the characteristic causes of the disease.
- decline immune systems that
- hypothermia genital external organs,
- improper compliance hygiene especially in the period of the menstrual cycle, when there is a rare replacement of tampons and gaskets,
- lots of genitalia partners,
- development dysbacteriosis mucous,
- injuries epidermis during abortion, sexual intercourse or when making medical manipulations,
- infectious and inflammatory processes affecting the organs of the female reproductive system,
- use of various synthetic grease during intercourse.
In some cases, the development of Bartholin cyst may be promoted by the rapid growth of connective tissue.
Symptoms of cyst will largely depend on the stage of the disease, which may be accompanied by inflammatory processes and suppuration. In this case, the site of its localization can only be the area before the exit channel, or it can spread to the glandular tissue.
Experts have identified three stages of pathology.
This condition is characterized by inflammation, which is limited only by the excretory channel. Observed swelling of the ductal walls, narrowing of the lumen.
It is worth noting that in this case there is no violation of the outflow of mucus. The course of pathology is not characterized by increased severity. Also, no final formation of cystic neoplasm is observed.
Pathological process is accompanied by such signs as:
- minor edema labia,
- mild pain while pushing.
In addition, during intercourse, in a sitting or walking position, discomfort may occur.
This state is characterized by adhesion of the walls of the discharge channel. As a result, overflow of mucus occurs. At the same time the gland continues to work without disturbances
Pathogenic microorganisms penetrate the flow walls, which provokes the appearance of inflammation in the form of edema. This leads to a further narrowing of the lumen of the exit channel, against the background of which the disease is even more aggravated. Symptoms characteristic of the first stage, becomes more pronounced.
A distinctive feature of this degree is suppuration and the development of purulent Bartholinitis. This stage is one of the most severe, as the gland's tissues are destroyed by pathogenic bacteria as a result of an infectious-inflammatory transition.
The acute stage of the disease is accompanied by:
- puffiness labia, which turn purple in color with a dense consistency inside,
- swollen vulvar cysts, its suppuration, an increase in size, pronounced pain syndrome,
- boost temperatures body up to 40 degrees
- manifestation of signs intoxication (chills, headaches, nausea) amid poisonous toxins from cell debris entering the blood fluid,
- an increase lymphatic nodes in the groin area.
When self-opening cystic formation occurs a large amount of fluid flowing out of a greenish-yellow color (pus). A wound is formed at the site of the neoplasm, which takes a long time to heal.
Can develop into cancer
A Bartholin cyst is a neoplasm of benign nature, which does not have a predisposition to degeneration into a cancer.
When choosing the tactics of therapeutic measures, it is necessary to pay attention to the size of the neoplasm and the factors that contributed to its formation.
In the case when the tumor has not reached a large size and has arisen not on the background of inflammation, expectant tactics are chosen. This decision is due to the fact that under certain conditions, the cyst has a predisposition to self-dissolving.
Depending on the course of the disease, experts apply two main methods of treatment.
Treatment of a cyst without surgery is prescribed in two cases:
- the size - less than four centimeters, there is no inflammatory process,
- inflammation extends only to the excretory canal, the gland is not inflamed.
Non-surgical therapy involves several methods.
With the development of canaliculitis, it is necessary to limit physical activity. It is recommended to perform fewer movements, because when running or walking increases the risk of injury to the affected organ.
It is possible to attach a heating pad filled with ice to the labia. Before it must be wrapped in a towel.
The duration of the session should not exceed 20 minutes, after which a break in half an hour is made. This procedure contributes to the narrowing of blood vessels, removal of swelling and prevent further spread of inflammation.
In addition, the cold helps to reduce the manifestation of discomfort.
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A solution of manganese, Chlorhexidine or Miramistin, which contribute to the disinfecting action, is well suited for the procedure.
The duration of one procedure is 10-15 minutes. You can repeat up to 6 times a day.
It is also important to remember that you can not apply Vishnevsky ointment and ichthyol, because they can only complicate the process.
If the cyst appeared due to infection, while there is a rapid spread of infection, it is advisable to carry out treatment with antibiotics. Such an event reduces the likelihood of cystic formation suppuration.
As a rule, this medication has a wide range of actions. The course of therapy is 1 week.
If the pathological process is accompanied by inflammation and pain in the affected area, the doctor prescribes nonsteroidal anti-inflammatory drugs. If the cyst is not susceptible to the inflammatory process, then analgesics or antispasmodics can be taken to relieve pain.
Antihistamines and immunomodulators
To eliminate itching and swelling at the site of injury, the use of antihistamines (Cetrin, Claritin and others) is recommended. In order to create favorable conditions when the body is able to fight the disease itself, it is necessary to pay much attention to strengthening and maintaining the immune system.
To do this, it is advisable to take Timalin, Viferon, as well as tincture of Eleutherococcus or Echinacea.
The indications for surgery to remove a cyst are:
- big dimensions neoplasms
- periodical inflammation, requiring drug therapy
- desire sick when appears psychological the discomfort,
- development abscess
Several methods can also be used to perform surgery.
Briefly about cystic formation
On the eve of the vagina, special glands are located, the main function of which is to protect the vagina from infection and injury, in addition, these glands secrete a special secret that moisturizes the labia during sexual contact and removes various pathogens and harmful particles from them. The glands are located in the lower third of the vestibule. They represent a paired body of a round shape, which, under normal health conditions, is not even detectable, the more so it cannot be seen with the naked eye. The size of the glands does not exceed a couple of centimeters. The mouth of their excretory ducts are located on the inside of the labia minora.
If the ducts of these glands are blocked, the viscous viscous secret produced by them begins to accumulate inside, stretching the walls of the organ, which causes the formation of a cyst. This cystic formation has its own characteristics:
- capsule diameter can be up to seven to eight centimeters,
- most often it is a unilateral cyst, bilateral occur very rarely,
- not subject to malignancy,
- do not affect pregnancy and the fetus in the womb,
- do not violate the hormones,
- often recur, but not inherited.
This formation occurs due to infection of the gland or mechanical obstruction of the excretory duct. Infectious agents may be gonococci, chlamydia, ureaplasma, and also conditionally pathogenic microflora, which develops under the influence of certain factors (E. coli, streptococci, staphylococci, etc.).
Such factors can provoke Bartholinitis:
- reduction of protective functions of the body,
- improper hygiene,
- tight, synthetic underwear and clothing,
- clogging of the glandular ducts with lubricants,
- bacterial vaginosis
- stressful conditions
- rudeness during intimacy,
- a large number of sexual partners, while increasing the chances of infection,
- skin injuries during epilation in the bikini area,
- gynecological manipulations and pathologies.
Of the main symptoms of pathology, visualization of a tumor on the labia can be called, the size from a pea to a chicken egg, pain when walking and squatting and discomfort during sex. Without adequate treatment, there is a high likelihood of an inflammatory process in the cyst, followed by decay and the onset of a true abscess.
Indications for surgery
Only the attending physician can accurately determine whether to remove a cystic formation, usually an operation to remove a Bartholin gland cyst is prescribed in such cases:
- the significant diameter of the cystic capsule causes discomfort to the woman and disrupts her lifestyle,
- an abscess develops,
- there are periodic inflammatory processes in the tumor,
- if there is a fistula in the place of spontaneous opening of an abscess,
- when the diameter of the formation is rapidly increasing,
- if the tumor delivers psychological discomfort to the patient.
Surgical intervention prescribed after prior antibiotic therapy, which will help remove infectious and inflammatory processes of the genital tract. Initially, a doctor under general anesthesia opens the cystic cavity and cleans the contents collected in it, but this method does not always allow to get rid of the tumor once and for all, and it often recurs.
Radical therapy is the complete removal of the gland in the run-up to the vagina, this type of surgery is prescribed only in cases where all other methods have been ineffective. When a cystic formation is removed along with the gland, the quality of the sexual life may decrease, since due to the functioning of only one gland, less moisturizing secretion will be released during sex. Before agreeing to an operation, you need to clearly understand all the possible complications after the manipulation:
- the formation of a fistula or hematoma in the operable zone at the site of the suture,
- blood loss during surgery due to accidental vascular damage,
- high probability of recurrence when only cysts are removed.
The modern technique of surgical treatment of cystic formation on the eve of the vagina is aimed not only at opening the tumor and removing the accumulated exudate from it, but also at forming a new excretory flow. Consider the basic methods of surgical intervention in more detail.
It is not always the cavity with the problematic fluid makes itself felt immediately after birth. If the stage of suppuration has not yet arrived, then the girl may feel in the intimate area just a bump or unusual puffiness. But since suppuration sometimes develops in a matter of days or even hours, it is better to immediately make an appointment with a gynecologist rather than wait for the worst possible course of events.
As soon as the immunity begins to weaken, it will speak about the launch of a secondary infection. The cavity with biological material will be filled with purulent formations, raising the temperature of the body, and also signaling a sharp deterioration in the situation by other signs. When the suppuration mechanism starts, the woman will already face a Bartholin gland abscess, which in the medical classification indicates a complicated form of the disease.
The fact that the patient has a high chance of encountering a cyst in a short period of time is evidenced by several indirect factors. They are not one hundred percent precursors of collecting a secret in an educated cavity, but they are called aspects of increased risk. The list includes the following diseases:
- gonococcus infection,
- urogenital candidiasis, which is popularly called simply thrush,
Another item at risk is poor hygiene of the genitals. It is this nuance that expands the range of potential patients, since even teenage girls can become victims of cysts.
It is not necessary that after finding even a large cyst, the victim will be redirected to the oncology center. As soon as it is confirmed that the neoplasm does not wear oncological deposits, there is no need to worry. In the planned conduct of surgical intervention, ancillary tests and other examination options are additionally prescribed if necessary. Only after the doctor is convinced that the surgery is the optimal solution will a cyst be removed.
Moreover, various clinics offer their basic services package for a given question. Today, most private medical centers use laser removal of an overgrown cavity, which has an internal capsule during prolonged retardation of treatment. The radio wave treatment, which is less traumatic than the classical scalpel procedure, has proven itself successfully.
The ladies who have been manipulated note that modern technologies not only provide for less pain, but also guarantee a more aesthetic final result without losing the sensitivity of part of the genitals. Also, innovative techniques guarantee a shortened postoperative period, which will appeal to those victims who can not leave work for a long time.
The cost of the operation depends on the format of the excision, as well as the type of anesthesia, the included preliminary examination, and consultation services for the period after removal. The cost also varies depending on the reputation of the selected medical center and the qualifications of the gynecologist-surgeon.
Signs of the formation of a problem cavity are most clearly seen in the area of the gland itself. If the cyst is still small, then it does not cause significant discomfort even when having sex. But at the stage of suppuration, it can grow literally before our eyes.
The most characteristic symptoms of the fact that you should immediately contact the attending gynecologist are:
- swollen labia,
- rounded bump of any size
- soreness during movement or prolonged stay in a fixed sitting position.
Things get worse when the Bartholin gland becomes susceptible to infection, which leads to the rapid development of Bartholinitis. Such a turn becomes possible if pathogenic microorganisms that have a negative effect on the vaginal microflora and external genital organs have already fallen into an already sore zone.
When a cyst becomes infected, starting to collect pus, the labia swell up several times, and if you feel the area that is not aesthetically appealing, the victim experiences acute pain. Walking, even slowly, becomes almost impossible. Some patients note that in the supine position, things get even worse.
The appearance of an abscess is accompanied by a sharp increase in temperature by several degrees simultaneously with a rapid increase in the cyst up to eight centimeters in diameter.
At the final stage, there is a high percentage probability of self-opening of the lesion with accumulated secret and purulent accumulations. Such an outcome threatens with possible infection of the nearest organs and tissues, so in emergency situations the patient may even be hospitalized in an ambulance in intensive care.
Why remove the Bartholin glands
Cyst growth causes pronounced pain, provokes the development of tumors of the labia minora. The neoplasm inhibits blood circulation, therefore inflammatory processes are activated in the Bartholin glands, and sepsis can develop if the cyst ruptures.
Radical removal of glands 100% guarantees a favorable prognosis in such situations, but the result of the operation is the complete loss of the natural “lubrication” function of the vagina.
If Bartholinitis occurs during pregnancy, you need to remove the glands immediately. Infection can get into the amniotic fluid and affect the development and health of the child both in the womb and after birth.
Bartholin gland removal
The operation is carried out after evaluating the results of the tests - special attention is paid to hemostasis indicators, detection of genital infections, so you need to donate blood for biochemistry, Rh factor, HIV and smear for the microflora.
- The doctor cleans small labia from pus, eliminates inflammation.
- Local anesthesia is performed, but if the doctor has concerns about the complexity of the intervention, general anesthesia is used.
- Performed an incision on the labia minora.
- The adhesions between the cyst wall and the surrounding tissues are cut.
- Iron is carefully removed.
- To stop bleeding, the excision site is electrocoagulated.
- A drainage tube is removed from the wound, and the gland bed is sutured.
If an abscess has become the reason for the operation, after the procedure its contents are sent to backwater. According to the composition of the bacteria is selected antibiotic therapy.
The advantages of surgical removal of the Bartholin gland cyst in the "SM-Clinic"
Our gynecologists perform operations with jewelry accuracy, which provides a high cosmetic effect
The use of modern surgical equipment and technologies allows for operations with minimal damage to surrounding tissues.
The operation does not require hospitalization - after a few hours you will be able to leave the hospital, and after 2 weeks to normal life
Indications for removal of the Bartholin gland cyst
In our Center, planned surgery to remove a Bartholin gland cyst is performed in the following cases:
- When diagnosed with a cyst with a diameter of more than 3 cm
- If a cyst occurs after the treated Bartholin's abscess
- With frequent recurrences of inflammation of the cyst
In addition, we perform emergency surgical interventions in case of rupture or acute inflammation of the cyst.
Preparations for the removal of the Bartholin gland cyst
In our Center, the operation is carried out in the absence of exacerbation of the disease. Also, if the examination revealed vaginal secretions of the III – IV degree of purity, the doctor will prescribe a preliminary anti-inflammatory therapy to achieve the I – II degree.
Complex preoperative preparation will help to objectively assess your condition. The first stage is a complete gynecological examination, which includes:
- examination by a gynecologist,
- smear on the purity of the vagina,
- bacterial culture of the vagina with the definition of sensitivity to antibiotics,
- smear on sexually transmitted infections.
If necessary, your doctor may order a pelvic ultrasound.
The second stage is a set of standard preoperative examinations, which includes:
- consultation of an anesthesiologist (if necessary, the use of total intravenous anesthesia), the therapist,
- radiography of the chest and ECG,
- complex of laboratory analyzes of blood and urine.
According to the results of all examinations, the doctor decides on the possibility of the operation at the moment, determines the method of intervention and the type of anesthesia.
Surgical removal (hulling) of a Bartholin gland cyst
The cyst is formed as a result of inflammation of the excretory duct of the Bartholin gland. The contents of the cyst is a mucinous fluid and inflammatory exudate, including purulent.
When a cyst is removed, the gynecologist carefully treats the surgical area, the patient receives the necessary anesthesia. The doctor then performs an incision in the skin and subcutaneous tissue. The next stage is husking, that is, cleansing the cyst and gland from the contents. After that, the surgeon stops bleeding in the bleeding vessels and sucks in the cyst bed. The operation is completed by stitching. A removed cyst with a capsule and gland is sent for morphological examination. In the presence of a purulent process, bacterioscopic and bacteriological studies are carried out to prescribe adequate drug therapy.
Thanks to the use of modern medical technologies, healthy tissues of the gland are injured minimally - during the operation only cystic formation is removed. Our operating gynecologists are experienced specialists who always strive to preserve the healthy tissues and organs of the woman as much as possible.
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Rehabilitation after removal of the Bartholin gland cyst
In our Center, hospitalization, surgery and discharge after cyst removal are performed on the same day. The recovery period on average takes about a month. For this period, it is necessary to abandon sexual intercourse, limit thermal procedures, exercise, sports. For a successful recovery, be sure to follow the doctor's recommendations for taking medications. Also, the doctor will set the date for the follow-up visit and perform blood and urine tests.
Bartholin gland cyst removal in the Center of Surgery "SM-Clinic" is experienced specialists, modern techniques and the ability to quickly to the usual life. To make an appointment with a gynecologist call: +7 (495) 777-48-49.
Surgical treatment of gynecological diseases is carried out in clinics at m. "Tekstilshchiki"
Volgogradskiy Prospect, 42, bld. 12
Mon-Fri from 9:00 to 22:00
Sat, Sun from 9:00 to 21:00 2 operating 40 beds in the in-patient department of the Voikovskaya metro station
st. Clara Zetkin, 33 Bldg. 28
Mon-Fri from 8:00 to 22:00
Sat, Sun from 9:00 to 21:00 3 operating18 beds in the hospital of the metro station "VDNH"
st. Yaroslavskaya, house 4,
Mon-Fri from 9:00 to 22:00
Sat, Sun from 9:00 to 21:00 5 operating rooms 43 beds in the in-patient department of Dynamo
per. Raskovoy, d. 14/22
Mon-Fri from 8:00 to 21:00
Sat, Sun from 9:00 to 21:00 1 operating 6 beds in the hospital
Symptoms and diagnosis of Bartholin gland cyst
As a rule, cysts do not have specific symptoms.
While some of them may cause pain while walking, sitting or having intercourse (dyspareunia).
Often a woman does not even suspect the presence of education, which the doctor discovers during a gynecological examination.
Cysts of a large size often manifest pain, rather than small ones.
Additionally, there may be swelling, redness, discomfort in the vulva.
Most of the formations are one-sided.
It is important to differentiate a cyst from an abscess, other benign or malignant tumors.
For example, lipomas, papilliform hydradenomas, epidermal cysts, carcinomas, etc.
In women older than 40 years of age, cyst formation is an absolute indication for biopsy.
When pregnancy occurs, an existing large cyst may become infected.
Therefore, it is important to remove education at the planning stage.
With the development of an abscess are noted:
- fever, chills,
- severe pain
- severe redness and swelling,
- discharge from the gland.
False abscess (the so-called canaliculitis) is triggered by an inflammatory lesion of the duct of the gland with its subsequent blockage.
Without treatment can be chronized.
In a true abscess, the glandular tissues are infected with an infection, which is accompanied by a significant increase in symptoms.
This form is not cured by spontaneous breakthrough and can lead to the development of sepsis.
It is very important when increasing the intensity of the manifestations of the disease as soon as possible to seek medical help!
The diagnosis is established on the basis of the inspection according to the following criteria:
- puffiness on the one hand
- the genital gap is asymmetrical,
- the presence of elastic education, not very painful when probing.
Additionally, laboratory tests are conducted:
- I. vaginal smear,
- Ii. bacteriological seeding
- Iii. PCR.
Bartholin gland cyst treatment
Bartholin's cyst gland (or large gland vestibule of the vagina) is called the papule resulting from the accumulation of secreted secretion when the ductal gland is blocked. Bartholin gland is responsible for moisturizing the mucous membrane of the genitals. The cyst manifests as swelling in the lower part of the labia majora.
Symptoms of a Bartholin gland cyst
The main symptoms of a cyst are:
- Swelling at the base of the labia on one of them (there are two glands in total, one on each sexual lip)
- At the initial stage, swelling does not give negative sensations and is not painful. However, in later stages, the cyst can be painful on palpation.
- The cyst begins with swelling, which is not noticeable to the patient on his own, and then, if left untreated, may reach 10 cm in diameter
Causes of cyst
Bartholin's cyst occurs when the duct is blocked and the secret is accumulated inside. Known causes of cysts are:
- Chronic inflammation of the Bartholin gland (Bartholinitis) caused by sexually transmitted infections of the urogenital system (chlamydia, ureoplasmosis, candidiasis, trichomoniasis, etc.). Pathogenic microorganisms enter the ducts of the gland, causing inflammation and subsequent blockage of the duct.
- Trauma to the duct of the gland during surgical or gynecological procedures.
- Injury of the skin of the gland during intimate hygiene, close underwear or during sexual intercourse.
Bartholin cyst: complications
If untreated, a Bartholin gland cyst can cause complications such as inflammation of the cyst when the accumulated secret begins to inflame. This inflammation is accompanied by fever, painful sensations when pressing on the region of the labia and intoxication of the body occurs. In some cases (when a cyst breaks), the inflammation may develop into a Bartholin gland abscess, with tissue necrosis and an open wound. Given the location close to the entrance of the vagina, the breakthrough of the cyst and the formation of an abscess are likely to be complicated by the spread of infection to other urinary organs.
Installing the word - catheter
This is a new method of treatment, in which, after opening and processing the cavity of the cyst, a silicone catheter is inserted into it, which is a tube with a bag. It prevents the accretion of the walls of the cyst and blocking the duct. After three to four weeks, the cavity of the cyst acquires epithelial cells and does not grow together, after which the catheter is removed. This method also showed its effectiveness and the absence of complications.
How painful is the surgery to remove a Bartholin gland cyst?
All methods of treatment of Bartholin gland cyst are quite painful. The gynecologist-surgeon needs to process the cyst cavity well and restore the gland duct. Therefore, the operation is done under anesthesia, which makes it painless for the patient. Discomfort can also bother in the first one or two days after surgery.
Bartholin cyst during pregnancy
If you have found a cyst during pregnancy, and it doesn’t bother you, we recommend waiting until the end of the pregnancy and having surgery to remove it. However, if you have pain, and the cyst began to grow, you need to remove it. Inflammation can have a negative effect on the fetus. During pregnancy, gynecologists usually recommend removing a cyst immediately with the gland, rather than doing its recovery. This is done to minimize the risk to the fetus in case of inflammation and recurrence. When you remove one gland, the second can compensate for its function.
What kind of education
Bartholin gland is not at all large, not more than 1.5 cm in diameter. In a healthy woman, it is impossible to detect - it “merges” with the surrounding tissues. The gland has ducts (tubules) through which the secret goes outside. They open at the entrance to the vagina between the labia minora and the hymen (or its remnants).
Due to mechanical obstruction or pressure from the outside, the tubular patency is disrupted, and the resulting secret stagnates. Often cysts form on the background of chronic Bartholinitis - persistent inflammation in the structures of the gland provokes the formation of adhesions in the tubules, which leads to stagnation of the secret. A cyst gradually forms - a cavity filled with viscous liquid contents.
Bartholin gland cyst is characterized by the following:
- may be of different sizes - from 1 cm to 9-10 cm, it all depends on the intensity of the production of secretions and the duration of education,
- unilateral - Bartholin cysts are rarely found at the same time at the base of both large labia,
- benign - the cyst never degenerates into cancer, although there may be a malignant process in the gland itself,
- is of an acquired nature - the cyst is not inherited, it does not affect the course of pregnancy and childbirth,
- not associated with hormonal disorders - a cyst is a consequence of inflammation that is not related to the level of estrogen or androgen,
- there is even in girls - education occurs even in girls who do not live sexually, in this case, the inflammation is caused by nonspecific flora.
Inflammation of a cyst can occur at any time: immediately after its appearance or after many years. The following microorganisms cause it:
- non-specific flora - Escherichia coli, Streptococcus, Staphylococcus, Proteus,
- specific - chlamydia, Trichomonas, gonococci.
Who more often arises
Every woman has a Bartholin gland, however, only 10% have inflammation and only 5-7% have cyst formation. The following factors contribute to this:
- immunodeficiency states - ARVI, flu, hypothermia,
- wearing synthetics - tight clothes and tight clothes,
- neglect of personal hygiene - washing should be once or twice a day, and more often during critical days,
- regular use of lubricants - they clog the ducts,
- sexually transmitted infections - erratic communication without using a condom, as well as infection from a regular partner,
- endocrine pathology - diabetes mellitus, a malfunction of the thyroid gland increases the likelihood of cyst formation and inflammation.
Depending on whether there is inflammation in the cyst, a clinical picture of the pathology and its possible consequences develops.
In the "cold" period
If the cyst is small and not infected, the woman doesn’t really care. She may discover her by chance. The cyst is felt at the base of the labia majora as a rounded, softish formation, mobile, painless.
If the cyst is large, the external genitals are deformed on its side, the genital slit has an irregular shape. Appears "knoll" - the rise of education over the unchanged skin. With an increase in size, the tumor interferes with leading a normal sex life and even walking.
In the "acute" period
When inflammation is added, the symptoms of the Bartholin gland cyst are more pronounced. The following is marked:
- sharp or even throbbing pain in the cyst,
- under the skin will be determined painful roller,
- the labia may swell,
- hotbed to the touch
- fever, chills, weakness, lethargy.
With the progression of inflammation, a false Bartholin gland abscess may form. The contents of the cyst is filled with pus. Поднимается высокая температура, женщина отмечает пульсирующую боль в области половых губ, из-за отека и боли невозможно ходить.
Часто ложный абсцесс самостоятельно вскрывается, после чего женщине становится заметно легче. It can also develop into a true one, in which case the gland tissue itself undergoes active inflammation.
Laser removal of Bartholin gland cyst - the essence of the procedure
Laser excision of a Bartholin gland cyst is a new technology in medicine that allows dissecting and removing pathological tissues with almost no blood. The laser beam for several minutes affects the damaged area, sealing up the damaged vessels, but not damaging the nerve endings. The advantage of laser treatment of cysts in the large anterior glands lies in the fact that there are no scars after it. Usually, laser vaporization surgery is performed without anesthesia, but local patients may be given local anesthesia if necessary. So that during the rehabilitation period no complications arise, and the infection does not get inside the open cyst, laser treatment of the neoplasm is performed using silver nitrate or carbon dioxide in many clinics. The minimum duration of the procedure allows a woman to leave the hospital right on the day of surgery.
Cystic pathology of Bartholin glands
Large Bartholin glands got their name in honor of the anatomist Casper Bartolini. They are two secretory organ located in the lower part of the vestibule of the vagina in the thickness of the tissues of the labia majora. Their size does not exceed 1.5 - 2 cm. The secret secreted by the glands, grayish-transparent, has a viscous consistency due to the high content of proteins. Its function is to moisturize the surface of the labia minora. Standing out with a strong sexual arousal, the liquid provides a comfortable flow of sexual intercourse, and during labor - stretching the vaginal walls.
The secret is removed from the gland by a special duct, which has a length of about 2 cm. Under the influence of various factors, this duct can narrow or block, which makes it impossible to withdraw the synthesis product. The secret remains and accumulates in the duct or the body of the gland itself, stretching the capsule. A cystic bladder gradually forms on the inner surface of the labia majora, visible even to the naked eye. In severe cases, the formation can reach 10 cm in diameter.
A cyst is benign, but it brings a lot of inconvenience to a woman: it interferes with movement, walking, sexual intercourse. Uncomplicated pathology usually does not cause pain, but when a cyst becomes infected, a purulent abscess develops.
Causes of Bartholin Cyst
The occlusion of the secretory duct is caused by various factors, among which the main one is infection of the Bartholin gland with pathogenic microorganisms. This is possible under the following conditions:
- lack of personal hygiene, ingestion of contaminated particles to the genitals, the rectum may be a source of infection,
- lack of hygiene during sex,
- infection with sexually transmitted infections (gonorrhea, chlamydia),
- the presence of inflammation in the urogenital system (urethritis, vaginitis),
- inflammatory processes in other organs (antritis, tonsillitis, pyelonephritis),
- injuries resulting from gynecological operations (abortion, scraping), as well as during epilation of the bikini area,
- rubbing the skin of the perineum with close synthetic underwear.
The development of infectious processes is enhanced against the background of a weakened immune system, chronic systemic diseases.
In addition, blockage of the excretory duct can cause increased production of Bartholin secretion, for example, with strong sexual arousal. Thick protein product does not have time to be removed, a cork is formed.
Symptoms of Bartholin cyst
Diagnosis of pathology usually does not cause difficulties, since its symptoms are very specific. Cystic modified gland increases and looks like a one-sided (less bilateral) rounded swelling in the lower part of the labia. Pressure on the cyst is not accompanied by painful sensations. The size of the formation depends on the degree of its development and can reach the diameter of a goose egg.
If infectious agents enter the cystic bladder, a purulent abscess develops. This is a serious illness, accompanied by severe symptoms:
- throbbing sharp pain in the perineum, aggravated by movement,
- an increase in the size of the tumor,
- swelling of the labia,
- febrile temperature
- an increase in the inguinal lymph nodes
- intoxication of the body, deterioration of health.
An abscess is often spontaneously opened, while its purulent contents are released, and the condition is relieved. Often this process is mistaken for a woman as the end of the disease.
In most cases, after some time, the disease recurs.
For treatment of cysts without surgery, our readers successfully use the Irina Yakovleva Method. Having carefully studied this method, we decided to offer it to your attention. Read more.
Treatment of cysts and abscesses of Bartholin glands
Painless cystic formation of small size does not need treatment. However, its development must be controlled in order to detect signs of deterioration in time. In severe cases with abscesses, surgery to open a cystic bladder or even to remove the gland itself is shown along with the excretory duct.
First of all, it is necessary to establish the exact cause of blockage of the secretory duct. If the pathology is caused by a microbial infection, all forces should be directed to its treatment. After elimination of the pathogenic factors, the pathologies of the Bartholin glands disappear.
- Antibacterial drugs are prescribed (antibiotics, fluoroquinolones, cephalosporins and other synthetic substances).
- Local antiseptic and anti-inflammatory agents are also used (Levomekol, Miramistin, Vishnevsky ointment).
To relieve severe inflammation and alleviate the patient's condition, it is possible to use traditional medicine and herbal medicine:
- cold exposure (ice pack) on the inflamed area,
- sit trays with a decoction of medicinal herbs (calendula, chamomile).
Concurrently, restorative therapy, taking multivitamin preparations.
There are several options for surgical removal of cysts.
- Marsupialization of the gland: the opening and emptying of the cystic bladder, followed by the surgical formation of a new excretory duct.
- Installing a silicone word catheter for outgoing pus. The catheter remains in the patient's body for a month, during which time the secretory duct of the gland is fully formed.
- Puncture aspiration of the contents of a cyst or abscess (the release of fluid from the bladder using a syringe).
- Laser vaporization (evaporation of pathological tissues by laser).
- Extirpation - radical removal of the Bartholin glands along with the excretory ducts. The operation is performed under general anesthesia and is indicated only in the most severe cases of the disease with constant relapses.
Treatment of Bartholin cyst by laser vaporization
The essence of the operation is that upon contact with defective tissues, the laser's light energy is converted into heat, and as a result, the contents of the cyst literally evaporate, freeing the blocked duct. Under the influence of the laser cavity of the cystic bladder sclerosed.
- Purposefulness: only damaged tissues are affected; healthy cells are not injured or deformed.
- Adjustable depth of penetration of the laser beam and its power.
- Bloodless operation: the laser burns damaged blood vessels, so the occurrence of bleeding is excluded.
- The least painful operation, performed without anesthesia.
- Quick: the procedure takes several minutes. Duration depends on the size of the tumor.
- Hospitalization after surgery is not required.
- After vaporization, scars and scars do not remain, the patient's recovery occurs in a short time.
- Ability to save the gland.
The most significant disadvantage of the laser vaporization method is its cost, since expensive equipment is used to carry out the operation.
Restorative therapy after cyst removal includes strict personal hygiene and temporary abstinence from sexual activity. In the future, the patient is recommended to adhere to a healthy diet, lead a mobile life, monitor your sexual health, regularly visit the gynecologist.
Why are Bartholin cysts formed?
A woman in a healthy state cannot find the Bartholin gland in her, as she is small in size and “merges” with nearby tissues. In the gland there is a channel for the outflow of secreted fluid. It opens at the entrance to the vagina. The secret is moistening this area. Therefore, women always seek to preserve the gland, because there is not a single “extra” organ in the human body.
If the patency of the Bartholin gland duct is blocked, secretory secretions stagnate. This happens when using tight synthetic panties, poor hygiene or frequent inflammatory phenomena in the genital area.
Due to inflammation, adhesions appear in the gland's duct, which causes stagnation of secretions. As a result, a cyst is formed. Bartholin cyst is a cavity filled with a viscous substance - a secret.
Bartholin cyst is characterized by the following features:
- it is almost always one-sided,
- cyst sizes vary from 1 to 10 cm depending on the age of the tumor and the intensity of the synthesis of the secret,
- Bartholin cyst has a benign nature,
- it is an acquired disease that is not inherited,
- cyst can occur even in girls and girls who do not have sex,
- its appearance is associated with inflammation. No hormonal disorders lead to its formation.
A Bartholin cyst may inflame after some time or immediately after it appears.
Fig. 2. Treatment of inflammation prevents Bartholin cyst
How to treat Bartholin cyst?
If the disease is not running, the patient will be offered a conservative treatment of a Bartholin cyst:
- warm sitz baths with infusions of herbs,
- compresses with ointment.
Fig. 3 Laser vaporization of a Bartholin cyst completely eliminates the disease quickly and efficiently.
However, surgery is often required. There are new tricks for Bartholin cyst removal:
- Laser vaporization of a Bartholin cyst. The operation leaves no scars, completely painless and bloodless. The surgeon "evaporates" the contents of the cyst with a laser beam. This process allows you to save a fully working Bartholin gland. Laser vaporization of the Bartholin cyst is reliable, and the probability of recurrence is zero.
- Installing a draining catheter in the cyst. The surgeon through a small incision in the Bartholin cyst cleans the cavity from the contents and washes. Then a silicone catheter is inserted into it, which can be in place for up to a month or more. It is believed that during this time a new duct is formed, after which the catheter is removed. However, often after such treatment there is a relapse of the disease,
- Marsupialization of Bartholin cyst. The doctor opens the center of inflammation, washes, hems the incision edges to the walls of the formation. As a result, a cavity is created at the site of the Bartholin cyst, which opens onto the skin. This operation is characterized by a long healing period and severe scarring of the tissues,