Surgery

Bartholin glands disorders (Bartholin cyst / Bartholin abscess)

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The Bartholin gland is located on either side of the vaginal opening, on the inner aspect at about 5 and 7 o’clock position. The glands secrete a fluid (mucus) that keeps the vagina moist and helps lubricate the vaginal area during sexual activity. The gland is not visible or palpable unless it is swollen.

Common disorders of the Bartholin glands are:

  • Bartholin cyst – this is a swelling of the area at the Bartholin gland, usually due to a blocked duct. The obstruction results in the accumulation of glandular secretion and cystic dilation of the duct. This usually occurs on one side. Sometimes, both sides can form cysts at the same time but is uncommon. It can vary from a small pea to a large egg-like size.
  • Bartholin abscess – Bartholin abscess is an infection of the Bartholin gland, with a collection of pus.

Causes of Bartholin cyst and abscess 

Causes include infection; congenital causes, and trauma such as a laceration or after episiotomy.

Symptoms and signs

  • Bartholinitis – the common symptom is usually pain, especially during intercourse. There will be redness and tenderness over the area. Swelling is usually minimal.
  • Bartholin cyst – the cyst, as opposed to the abscess, is generally not painful. Depending on the size of the cyst, some women may not be aware of the cyst at all. Large cysts may cause discomfort or pain and are easily palpable. The examination will reveal a cystic, unilateral (usually), non-tender mass. The cyst may burst and the discharge may be clear, cloudy, or yellow in colour.
  • Bartholin abscess – most abscesses develop over a period of a few days. The collection of pus inside the swelling will cause pain. The pain can be severe enough to interfere with walking, sitting or intercourse. In severe cases, there may be fever and feelings of unwell. The skin around the opening of the gland may be red and swollen. The abscess is usually hot, swollen, and tender. If ruptured, pus discharge will be seen. The inguinal lymph node may be swollen and the area will be painful.

Diagnosis

The diagnosis is obvious, with the presence of a swelling in the lower half of the labia corresponding to the area of the Bartholin gland. The size varies from 1 cm to a few centimeters.

Investigation

Specimens for cultures and sensitivity testing should be obtained from all draining cysts to help identify the organisms and to guide appropriate antibiotic therapy.

Treatment

  • Bartholinitis – needs antibiotics therapy.
  • Bartholin cyst- if the cyst is small, it can be left alone since there is a possible chance that the cyst may resolve when the duct becomes unblocked. If the cyst is large or causes symptoms, then a surgical procedure is required. This usually involves opening the cyst wall, removing the content, and then placing a few absorbable sutures at the opening to keep the cyst open to drain the remaining contents. This is called the marsupialization procedure and preserves the function of the gland. This is usually done in the operating theatre.
  • Bartholin abscess – surgical drainage is required for relief. Sometimes spontaneous rupture of the abscess may occur but recurrence is higher in such instances. The procedure is marsupialization, similar to the cyst. Antibiotics are usually given.

Post marsupialization advise:

  • Avoid intercourse or use of tampons for  3 to 4 weeks. The wound usually takes 2 to 3 weeks to heal.
  • Soaking in warm water is helpful. Sitz baths (two to three times a day) can ease discomfort, promote drainage of the cyst fluid, and aid the healing process. Alternatively, applying a warm compress to the area several times a day can be helpful.
  • Treatment in the acute phase should consist of bed rest, and medication to relieve pain.
  • Most women feel better within 24 hours after a Bartholin’s abscess has drained.
  • If antibiotics have been prescribed, the full course must be completed.

Outcome

The outcome is excellent. There is usually no lasting effect from it if adequately treated. You should be able to resume your daily activities after 24 to 48 hours. However, the recurrence of cysts or abscesses is still possible in some women.

Complications of Bartholin gland infection

  • Persistent chronic inflammation may cause blockage of the duct and leads to cyst formation. Although complications after marsupialization are rare, they can include:
  • Approximately 5 to 15 percent of Bartholin’s cysts or abscesses recur after marsupialization.
  • Rarely, there may be bleeding, hematoma (blood collection), infection, and dyspareunia (painful sex).

Prevention

There is no proven effective method to prevent Bartholin cysts or abscesses. It is important to maintain good personal hygiene and practice safe sexual practices using adequate precautionary methods to reduce the chance of infection or trauma to the area. The use of lubricant during sexual activity can help reduce friction and prevent irritation or trauma to these areas. Avoid using harsh soaps or douches as these can disrupt the natural balance of the area around the vaginal opening.

 

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Cervical Polyps

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A cervical polyp is a benign fleshy growth on the cervix. The cervix is the part of the uterus that is visible during the speculum examination. It is also called the neck of the uterus. Cervical polyp arises from cells, either from the cervical canal (this type is also called an endocervical polyp) or from the outer surface of the cervix.

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Heavy Menstrual Bleeding (HMB)

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menstrual bleedingHeavy menstrual bleeding or HMB (previously called menorrhagia) is a significant cause of morbidity in women of reproductive age. It often involves soaking through ten or more sanitary napkins in a day, a menstrual flow that lasts for seven to 14 days or even longer. The presence of “flooding” or clots is indicative of heavy bleeding. Normal menstrual blood flows freely without clotting. This is because of the presence of an anti-clotting agent produced by the uterus. However, if the bleeding is excessive and far exceeds the amount of anti-clotting agent available, then the remaining blood that flows out will form clots. Bleeding between menstrual cycles is also abnormal. The presence of other clinical signs such as anaemia will further support the diagnosis and indicate the severity of the bleeding

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Endometrial polyps

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Endometrial polyps are growths that arise from the inner walls that lined the uterine cavity. It is sometimes called uterine polyps. It is believed to arise from the overgrowth of endometrial tissue. It may range in size from a few millimetres only to a few centimetres. Sometimes, there can be several polyps present at the same time. It may have a long stalk and can extends through the cervix into the vagina.
An endometrial polyp is usually a non-cancerous growth. However, in a small proportion of women, some of these polyps can lead to cancer (called pre-cancerous type). The risk of cancer in a polyp is increased in post-menopausal women. It can arise at any age but rarely occur in women under 20 years old.

Cause and risk factors

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Loop Electrosurgical Excision Procedure (LEEP/LLETZ) for CIN

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Loop electrosurgical excision procedure (LEEP), also known as large loop excision of the transformation zone (LLETZ), is a procedure for further diagnosis and treatment of cervical intraepithelial neoplasia (CIN). CIN lesion is an abnormal growth in the cervix. The CIN lesion is usually diagnosed during a routine Pap smear (or called Thin Prep) test. LEEP is a very safe way to remove abnormal tissue from the cervix that might otherwise progress to cancer. It minimizes the amount of tissue removed in order to preserve childbearing ability.

Reason for the procedure

• Presence of CIN lesions from the colposcopy evaluation and confirmed via cervical biopsy. Some types of CIN can progress to cervical cancer if not treated. This can be used as a treatment for CIN lesions.
• Unsatisfactory colposcopic evaluation whereby the whole transformation zone cannot be visualized or the cervix appeared abnormal and requires a bigger tissue specimen for a more accurate diagnosis to exclude cancer changes.

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Endometrial biopsy (Endometrial sampling or curettage)

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Endometrial biopsy is a procedure that involves the removal of tissues from the endometrium, which is the inner lining of the uterus.

Reason for the procedure

It is done to diagnose endometrial cancer or hyperplasia (with or without atypia). Endometrial hyperplasia is a potentially precancerous condition. This procedure is indicated in a woman with abnormal uterine bleeding. This includes bleeding between menstrual periods, excessive bleeding during a menstrual period, or bleeding after menopause. It is also done to exclude endometrial cancer in post-menopausal  women with abnormal endometrial finding on ultrasound scan of the uterus.

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Vasectomy – Male contraception

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Article contributed by Dr Peter Ng and Dr Beatrice Chua Yoong Ni

The aim of a vasectomy is to prevent sperm from reaching the semen by disconnecting the sperm duct. The resulting ejaculate is therefore sperm-free, eliminating the risk of pregnancy. Sort of like a cheap shark fin soup without the shark fins (sperms).

Vasectomy is the contraception of choice for 6%–8% of married couples worldwide. Vasectomy is a minor procedure that provides effective and permanent contraception. In fact, it is far more effective than many other methods of contraception, including female sterilization.

Prior to a vasectomy, it is important and both husband and wife be present together to be counseled by a specialist on the implications of the procedure. It is important that the completeness of family is ascertained and that both husband and wife had discussed beforehand and agreed that it is the husband who should undergo a vasectomy to attain permanent contraception.

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Benign ovarian cysts

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The ovaries are the female reproductive organs that contain eggs and will release them on a regular basis (usually monthly in the majority of the women). It also produces female and male hormones. An ovarian cyst is abnor¬mal growth in the ovary and can be either solid or cystic. It can be divided into either a benign (non-cancerous) or malignant (cancerous) type. Benign or non-cancerous cysts do not invade neighboring tissue the way malignant cyst does. The exceptionally large ovarian cyst often turns out to be benign.

The term ovarian cyst refers to abnormal growth in the ovary that contains mainly fluid, although occasionally some solid component may be present as well.

Symptoms and signs

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