Novel Insights from Clinical Practice Received: July 17, 2014 Accepted after revision: October 30, 2014 Published online: January 27, 2015
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
Recto-Bartholin’s Duct Fistula: A Case Report Young Sun Kim a Hyo Sang Han a Min Woo Seo b Woo Suk Kim b Jin Hyung Lee b Nae Kyeong Park b Jae Hong Sang a
Departments of a Obstetrics and Gynecology and b General Surgery, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
Established Facts • Rectovaginal fistula after the excision of a Bartholin gland is a rare complication.
Novel Insights • This is the first case report of a recto-Bartholin’s duct fistula that did not involve the vagina.
Key Words Bartholin’s duct cysts · Fistulous tract · Fistula-in-ano
duct fistula, performed surgical excision and fistulectomy. Postoperative treatment with antibiotics resulted in the complete resolution of all lesions at the 3-month follow-up. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0378–7346/15/0792–0136$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Bartholin’s duct cysts and gland abscesses are common problems in women of reproductive age [1]. Bartholin’s duct cysts, the most common cystic growths in the vulva, occur in the labia majora [1]. Obstruction of the distal Bartholin’s duct may result in the retention of seJae Hong Sang, MD Department of Obstetrics and Gynecology 250, Gongdan-dong Gumi, Gyeongsangbuk-do (Korea) E-Mail thorsang @ naver.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/15/2015 9:52:46 AM
Abstract Bartholin’s duct cysts, the most common growths in the vulva, occur in the labia majora. The cyst may become infected, and an abscess may develop in the gland. Rectovaginal fistula is a rare complication and its formation is secondary to Bartholin’s cyst; only 4 cases have been reported in the literature so far. In this case, the fistula was located between the rectum and a Bartholin’s duct, rather than the vagina and the rectum. We present the first case of a recto-Bartholin’s
Color version available online
Color version available online Color version available online
Fig. 1. A longitudinal incision was made in the cystic lesion because Bartolin’s duct cyst was ruptured in the right vulvar area (pin-point size).
Fig. 3. Appearance of the gross specimen of the right Bartholin’s
duct cyst.
muscle, and finally, definitive treatment of the fistula [3]. Fistulotomy is a commonly used mode of management [3] and patients with complex fistulas may require fistulectomy [2]. Rectovaginal fistula is a rare complication related to inflammatory bowel disease, obstetric trauma, pelvic surgery, radiation, and trauma [4]. Its formation is secondary to Bartholin’s cyst, with only 4 cases being reported in the literature. In the present case, the fistula was located between the rectum and a Bartholin’s duct, rather than the vagina and rectum. The purpose of this report is to present the first case of a recto-Bartholin’s dust fistula that occurred without vaginal involvement. In addition, we hope that the case presented here will be both clinically instructive and informative for obstetricians and gynecologists.
Case Report
cretions, with resultant dilation of the duct and formation of a cyst [1]. The cyst may become infected, and an abscess may develop in the gland. Fistula-in-ano is an abnormal tract connecting the anorectal mucosa to the exterior skin [2]. Fistulas typically develop after rupture or drainage of a perianal abscess [2]. Management includes infection control, assessment of the fistulous track in relation to the anal sphincter Recto-Bartholin’s Duct Fistula
A 38-year-old woman presented with recurrent Bartholin’s duct cysts during a 12-month period. The patient was G2P0A0L2 and both children were delivered by cesarean section. The patient’s last delivery occurred 2 years before this study period and her postdelivery course was uneventful. No other anorectal or vaginal procedures were reported. However, a recurrent Bartholin’s duct cyst was removed by her gynecologist 12 months prior to her presentation at our clinic. An elective excision was planned. The patient was placed in the lithotomy position and the perineal area, vagina, and rectum were prepped using the povidone-iodine solution. A longitudinal incision was made over the cyst and we detected a fistulous tract to the anorectum not involving the vagina (fig. 1, 2). Figure 3 shows the excision of the specimen. Both the external and internal sphincters were intact. A fistulectomy was performed
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
137
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Fig. 2. The second finger on the operator’s left hand is shown entering the anus and emerging through the fistulous tract.
down to the rectal wall by a general surgeon. Postoperatively, laxatives were administered to the patient and a 7-day course of oral antibiotics was prescribed. When the patient was reviewed at 3 months after the operation, both superficial and deep tissues had fully healed, with no further sepsis or fistulation.
Discussion
Bartholin’s glands are located bilaterally at the posterior introitus and drain through the ducts that empty into the vestibule at approximately the 4 o’clock and 8 o’clock positions [1]. These normally pea-sized glands are palpable only if the duct becomes cystic or a gland abscess develops. The differential diagnosis includes cystic and solid lesions of the vulva, such as an epidermal inclusion cyst, Skene’s duct cyst, hidradenoma papilliferum, and lipoma [1]. The treatment of a Bartholin’s duct cyst also depends on the patient’s symptoms. A patient with an asymptomatic cyst may require no treatment; however, symptomatic Bartholin’s duct cysts and gland abscesses require drainage [5]. Interventions include: (1) silver nitrate gland ablation, (2) cyst or abscess fenestration, ablation, or excision using carbon dioxide (Co2) laser, (3) marsupialization, (4) needle aspiration with or without alcohol sclerotherapy, (5) fistulization using a Word catheter, Foley catheter, or Jacobi ring, (6) gland excision, and (7) incision and drainage followed by primary suture closure [6]. The most common etiology of rectovaginal fistula is obstetric injury, followed by radiation injury, Crohn’s disease, diverticulitis, ulcerative colitis, operative trauma, infectious etiologies and Neoplasm [7]. The symptoms of
a rectovaginal fistula include flatus or feces in the vagina. It may also include a purulent discharge with vaginal irritation depending on the level of the fistula [7]. Bartholin’s cyst infection is a rare cause of rectovaginal fistula formation. The treatment modality for this condition is a wide mobilization of the adjacent tissue planes, complete excision of the fistula tract, and a multilayered closure [8]. Fistulotomy is the most commonly used mode of management; however, complex fistulas may require fistulectomy [2]. Other procedures that are used include injection of fibrin glue or insertion of a bioprosthetic plug into the fistula opening [2]. Only a few cases of Bartholin’s cyst infection that caused the rectovaginal fistulas have been presented. This is the first case report of a recto-Bartholin’s duct fistula without the involvement of the vagina. We presume that the inflammation in the Bartholin’s gland was treated in the wrong way. The inflammation recurs constantly and it becomes another fat necrosis around the Bartholin’s gland. So we suppose that the inflamed fat necrosis led to fistula formation in the rectum. In conclusion, Bartholin’s cyst is a common gynecological problem that can result in complicated cases, in rectovaginal or recto-Bartholin’s duct fistula formation. Although an optimal treatment modality is yet to be determined, we performed fistulectomy, which resulted in a good outcome after 12 weeks of follow-up.
Acknowledgment This work was supported in part by Soonchunhyang University Research Fund.
References
138
4 Zoulek E, Karp DR, Davila GW: Rectovaginal fistula as a complication to a Bartholin gland excision. Obstet Gynecol 2011;118:489–491. 5 Hill DA, Lense JJ: Office management of Bartholin gland cysts and abscesses. Am Fam Physician 1998;57:1611–1616, 1619–1620. 6 Wechter ME, Wu JM, Marzano D, Haefner H: Management of Bartholin duct cysts and abscesses: a systematic review. Obstet Gynecol Surv 2009;64:395–404.
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
7 Hamilton S, Spencer C, Evans A: Vagino-rectal fistula caused by Bartholin’s abscess. J Obstet Gynaecol 2007;27:325–326. 8 Nasser HA, Mendes VM, Zein F, Tanios BY, Berjaoui T: Complicated rectovaginal fistula secondary to Bartholin’s cyst infection. J Obstet Gynaecol Res 2014; 40: 1141– 1144.
Kim/Han/Seo/Kim/Lee/Park/Sang
Downloaded by: University of Tokyo 157.82.153.40 - 5/15/2015 9:52:46 AM
1 Omole F, Simmons BJ, Hacker Y: Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician 2003;68:135–140. 2 Fox A, Tietze PH, Ramakrishnan K: Anorectal conditions: anal fissure and anorectal fistula. FP Essent 2014;419:20–27. 3 Shawki S, Wexner SD: Idiopathic fistula-in-ano. World J Gastroenterol 2011;17:3277–3285.
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
Recto-Bartholin’s Duct Fistula: A Case Report Young Sun Kim a Hyo Sang Han a Min Woo Seo b Woo Suk Kim b Jin Hyung Lee b Nae Kyeong Park b Jae Hong Sang a
Departments of a Obstetrics and Gynecology and b General Surgery, Soonchunhyang University Gumi Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
Established Facts • Rectovaginal fistula after the excision of a Bartholin gland is a rare complication.
Novel Insights • This is the first case report of a recto-Bartholin’s duct fistula that did not involve the vagina.
Key Words Bartholin’s duct cysts · Fistulous tract · Fistula-in-ano
duct fistula, performed surgical excision and fistulectomy. Postoperative treatment with antibiotics resulted in the complete resolution of all lesions at the 3-month follow-up. © 2015 S. Karger AG, Basel
© 2015 S. Karger AG, Basel 0378–7346/15/0792–0136$39.50/0 E-Mail [email protected] www.karger.com/goi
Introduction
Bartholin’s duct cysts and gland abscesses are common problems in women of reproductive age [1]. Bartholin’s duct cysts, the most common cystic growths in the vulva, occur in the labia majora [1]. Obstruction of the distal Bartholin’s duct may result in the retention of seJae Hong Sang, MD Department of Obstetrics and Gynecology 250, Gongdan-dong Gumi, Gyeongsangbuk-do (Korea) E-Mail thorsang @ naver.com
Downloaded by: University of Tokyo 157.82.153.40 - 5/15/2015 9:52:46 AM
Abstract Bartholin’s duct cysts, the most common growths in the vulva, occur in the labia majora. The cyst may become infected, and an abscess may develop in the gland. Rectovaginal fistula is a rare complication and its formation is secondary to Bartholin’s cyst; only 4 cases have been reported in the literature so far. In this case, the fistula was located between the rectum and a Bartholin’s duct, rather than the vagina and the rectum. We present the first case of a recto-Bartholin’s
Color version available online
Color version available online Color version available online
Fig. 1. A longitudinal incision was made in the cystic lesion because Bartolin’s duct cyst was ruptured in the right vulvar area (pin-point size).
Fig. 3. Appearance of the gross specimen of the right Bartholin’s
duct cyst.
muscle, and finally, definitive treatment of the fistula [3]. Fistulotomy is a commonly used mode of management [3] and patients with complex fistulas may require fistulectomy [2]. Rectovaginal fistula is a rare complication related to inflammatory bowel disease, obstetric trauma, pelvic surgery, radiation, and trauma [4]. Its formation is secondary to Bartholin’s cyst, with only 4 cases being reported in the literature. In the present case, the fistula was located between the rectum and a Bartholin’s duct, rather than the vagina and rectum. The purpose of this report is to present the first case of a recto-Bartholin’s dust fistula that occurred without vaginal involvement. In addition, we hope that the case presented here will be both clinically instructive and informative for obstetricians and gynecologists.
Case Report
cretions, with resultant dilation of the duct and formation of a cyst [1]. The cyst may become infected, and an abscess may develop in the gland. Fistula-in-ano is an abnormal tract connecting the anorectal mucosa to the exterior skin [2]. Fistulas typically develop after rupture or drainage of a perianal abscess [2]. Management includes infection control, assessment of the fistulous track in relation to the anal sphincter Recto-Bartholin’s Duct Fistula
A 38-year-old woman presented with recurrent Bartholin’s duct cysts during a 12-month period. The patient was G2P0A0L2 and both children were delivered by cesarean section. The patient’s last delivery occurred 2 years before this study period and her postdelivery course was uneventful. No other anorectal or vaginal procedures were reported. However, a recurrent Bartholin’s duct cyst was removed by her gynecologist 12 months prior to her presentation at our clinic. An elective excision was planned. The patient was placed in the lithotomy position and the perineal area, vagina, and rectum were prepped using the povidone-iodine solution. A longitudinal incision was made over the cyst and we detected a fistulous tract to the anorectum not involving the vagina (fig. 1, 2). Figure 3 shows the excision of the specimen. Both the external and internal sphincters were intact. A fistulectomy was performed
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
137
Downloaded by: University of Tokyo 157.82.153.40 - 5/15/2015 9:52:46 AM
Fig. 2. The second finger on the operator’s left hand is shown entering the anus and emerging through the fistulous tract.
down to the rectal wall by a general surgeon. Postoperatively, laxatives were administered to the patient and a 7-day course of oral antibiotics was prescribed. When the patient was reviewed at 3 months after the operation, both superficial and deep tissues had fully healed, with no further sepsis or fistulation.
Discussion
Bartholin’s glands are located bilaterally at the posterior introitus and drain through the ducts that empty into the vestibule at approximately the 4 o’clock and 8 o’clock positions [1]. These normally pea-sized glands are palpable only if the duct becomes cystic or a gland abscess develops. The differential diagnosis includes cystic and solid lesions of the vulva, such as an epidermal inclusion cyst, Skene’s duct cyst, hidradenoma papilliferum, and lipoma [1]. The treatment of a Bartholin’s duct cyst also depends on the patient’s symptoms. A patient with an asymptomatic cyst may require no treatment; however, symptomatic Bartholin’s duct cysts and gland abscesses require drainage [5]. Interventions include: (1) silver nitrate gland ablation, (2) cyst or abscess fenestration, ablation, or excision using carbon dioxide (Co2) laser, (3) marsupialization, (4) needle aspiration with or without alcohol sclerotherapy, (5) fistulization using a Word catheter, Foley catheter, or Jacobi ring, (6) gland excision, and (7) incision and drainage followed by primary suture closure [6]. The most common etiology of rectovaginal fistula is obstetric injury, followed by radiation injury, Crohn’s disease, diverticulitis, ulcerative colitis, operative trauma, infectious etiologies and Neoplasm [7]. The symptoms of
a rectovaginal fistula include flatus or feces in the vagina. It may also include a purulent discharge with vaginal irritation depending on the level of the fistula [7]. Bartholin’s cyst infection is a rare cause of rectovaginal fistula formation. The treatment modality for this condition is a wide mobilization of the adjacent tissue planes, complete excision of the fistula tract, and a multilayered closure [8]. Fistulotomy is the most commonly used mode of management; however, complex fistulas may require fistulectomy [2]. Other procedures that are used include injection of fibrin glue or insertion of a bioprosthetic plug into the fistula opening [2]. Only a few cases of Bartholin’s cyst infection that caused the rectovaginal fistulas have been presented. This is the first case report of a recto-Bartholin’s duct fistula without the involvement of the vagina. We presume that the inflammation in the Bartholin’s gland was treated in the wrong way. The inflammation recurs constantly and it becomes another fat necrosis around the Bartholin’s gland. So we suppose that the inflamed fat necrosis led to fistula formation in the rectum. In conclusion, Bartholin’s cyst is a common gynecological problem that can result in complicated cases, in rectovaginal or recto-Bartholin’s duct fistula formation. Although an optimal treatment modality is yet to be determined, we performed fistulectomy, which resulted in a good outcome after 12 weeks of follow-up.
Acknowledgment This work was supported in part by Soonchunhyang University Research Fund.
References
138
4 Zoulek E, Karp DR, Davila GW: Rectovaginal fistula as a complication to a Bartholin gland excision. Obstet Gynecol 2011;118:489–491. 5 Hill DA, Lense JJ: Office management of Bartholin gland cysts and abscesses. Am Fam Physician 1998;57:1611–1616, 1619–1620. 6 Wechter ME, Wu JM, Marzano D, Haefner H: Management of Bartholin duct cysts and abscesses: a systematic review. Obstet Gynecol Surv 2009;64:395–404.
Gynecol Obstet Invest 2015;79:136–138 DOI: 10.1159/000369456
7 Hamilton S, Spencer C, Evans A: Vagino-rectal fistula caused by Bartholin’s abscess. J Obstet Gynaecol 2007;27:325–326. 8 Nasser HA, Mendes VM, Zein F, Tanios BY, Berjaoui T: Complicated rectovaginal fistula secondary to Bartholin’s cyst infection. J Obstet Gynaecol Res 2014; 40: 1141– 1144.
Kim/Han/Seo/Kim/Lee/Park/Sang
Downloaded by: University of Tokyo 157.82.153.40 - 5/15/2015 9:52:46 AM
1 Omole F, Simmons BJ, Hacker Y: Management of Bartholin’s duct cyst and gland abscess. Am Fam Physician 2003;68:135–140. 2 Fox A, Tietze PH, Ramakrishnan K: Anorectal conditions: anal fissure and anorectal fistula. FP Essent 2014;419:20–27. 3 Shawki S, Wexner SD: Idiopathic fistula-in-ano. World J Gastroenterol 2011;17:3277–3285.
