A number of conditions can present as perineal abscesses, the most common being a Bartholin's abscess due to blockage of the duct of the gland with the subsequent infection of the duct and/or cyst. Table 1 421 lists some of the less common conditions which can present as a perineal abscess.

A Bartholin's cyst is a cyst of the duct and not of the gland. The gland is usually compressed around the periphery of the cyst. Surgical excision of the cyst can be associated with a considerable blood loss due to the vascularity of the area. The remaining gland, which will still be functional, may reaccumulate and present as a symptomatic cyst, and need re-excision. As in other areas of the body when a cyst has become infected incision and drainage rather than attempted excision is the wiser of the available treatment options, which are:

1.Aspiration and antibiotic treatment;

2.Incision (cruciate or linear) and drainage;

Wick

Word catheter

Foley catheter

3.Marsupialization,

4.Excision.

All of these procedures can be performed under local anaesthetic except perhaps excision. However, as the abscess and the area around it are usually very tender most women will opt for general anaesthesia. These procedures are all performed with the patient in the lithotomy position.

In the very early stages of infection of a Bartholin's gland a course of antibiotic therapy may be sufficient treatment. However, once a fluctuant abscess has formed, drainage is needed. Aspiration can be performed with a 16- or 18-gauge needle under local anaesthetic. The patient should be started on a course of metronidazole and either a penicillin or a cephalosporin antibiotic. The contents of the cyst should be examined by microbiological culture. If the results of the culture suggest a particular organism not covered by the above combination then the appropriate changes should be made. Up to 80 per cent return of function of the gland with aspiration and antibiotic therapy has been reported.

Incision and drainage is the standard treatment for any abscess. The incision should be made in the vestibular area close to the hymen through an area of fluctuance (Fig. 1(a)) 1465. A drain (corrugated red rubber drain) or a wick (1.5 cm ribbon gauze) is then inserted for 24 h. Because the skin has a tendency to reseal, recurrence is common. Therefore removing an ellipse of skin (Fig. 1(b)) 1465 may help keep the edges apart and prevent this recurrence. Likewise making a cruciate incision over the area of maximum fluctuance and either suturing back or excising the skin edges may also prevent the aperture resealing.

A Word catheter or a Foley catheter can be inserted through a stab incision into the abscess cavity and the self-retaining bulb inflated with saline. The free end of the Word catheter is tucked away into the vagina (Fig. 2) 1466. In the case of the Foley catheter a ligature is placed around the catheter approximately 7.5 cm from the bulb occluding all lumens. The catheter is then cut close to the ligature. This end is placed in the vagina. The catheter is left in place for 3 to 4 weeks until the tract of the wound becomes covered with new epithelium and so forms a new duct and maintains gland function.

Marsupialization of a Bartholin's abscess also allows some gland function to be retained. An incision is made as described above, either linear or cruciate (Fig. 1b) 1465. The cyst wall is then sutured to the skin edges with interrupted plain catgut number 2/0. An effort should be made to leave a large aperture, as this will shrink as the abcess cavity shrinks.

Excision of a Bartholin's abscess can be difficult as the abscess wall is very adherent to the surrounding tissues and the usual tissue planes are not easily defined. A brisk blood loss can ensue and a drain may be needed to prevent haematoma formation and blood transfusion. A linear incision is fashioned as described above. The abscess is then enucleated using a combination of sharp and blunt dissection with curved dissecting scissors. Haemostasis must be meticulous using diathermy and fine ties. Once the abscess is removed the dead space left behind is obliterated using interrupted absorbable sutures and interrupted sutures to the skin as well (Figs. 1, 3) 1465,1467. If, while dissecting the abscess, the cavity is inadvertently opened marsupialization can be performed.

The patient should be encouraged to use the bath or bidet frequently but thereafter to keep the vulval area clean and dry. If there is a solid area within the abscess cavity a biopsy specimen should be taken and sent for histological examination to exclude malignancy. In any woman over the age of 40 malignancy should be seriously considered.

Axe S, et al. Adenomas in minor vestibular glands. Obstet Gynaecol 1986; 68: 16.

Cheetham DR. Bartholin's cyst: marsupialisation or aspiration? Am J Obstet Gynecol 1985; 152: 569–70.

Monaghan JM. Operations on the vulva. In: Monaghan JM, ed. Bonney's Gynaecological Surgery. London: Bailliere Tindall 1986: 119–21.

Nichols DH, Randall CL. Minor and ambulatory surgery. In: Nichols DH, Randall CL, eds. Vaginal Surgery. 3rd edn. New York: Williams and Wilkins 1989: 163–5.