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gyn.bartholin-abscess.v1

Bartholin gland cyst / abscess (I&D + Word catheter, marsupialization for recurrent)

obstetricsacuteadultpregnancygeriatricacuteoutpatient
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Phase C new dossier — authored 2026-05-15 for shard-5-obped-id (wave 10). Bartholin gland duct obstruction → cyst → abscess (when infected); one of the more common gynecologic problems in reproductive-age women (~ 2-3 % lifetime incidence; ~ 80-90 % of vulvar abscesses are Bartholin per Berger 2012 PMID 22914407). Manifest pointer reuses prisma/seed/manifests/id.sepsis.core.v1.ts per shard precedent (id.tetanus.v1 pattern) — Bartholin abscess seed manifest authoring is out-of-shard-5 scope. Audit broken_pointers clean. Treatment hierarchy: (1) office I&D + Word catheter × 4-6 wk for uncomplicated abscess (recurrence < 5 % per Wechter 2009 PMID 19099613 vs 5-15 % with I&D alone); (2) sitz baths conservative for asymptomatic / mildly symptomatic cyst; (3) antibiotics adjunctive (NOT routine) for systemic features / cellulitis / immunocompromise / pregnancy / sepsis / STI overlap; (4) marsupialization for recurrent ipsilateral disease (≥ 2 episodes); (5) gland excision for refractory recurrent OR postmenopausal suspected malignancy. Microbiology: polymicrobial typical with E. coli + gut anaerobes (Bacteroides, Peptostreptococcus, Prevotella) ~ 60-70 %; CA-MRSA ~ 10-15 %; GC / CT < 10 % in modern series (Kessous 2013 PMID 23232761; Tanaka 2005 PMID 15634986). STI testing remains indicated for risk-factor patients (CDC 2021 PMID 34292926). Postmenopausal Bartholin mass — Bartholin gland malignancy is rare (~ 2 % of vulvar cancers) but documented; biopsy abscess wall at I&D mandatory for > 40 yr or atypical features (Visco 1996 PMID 8559513; Heller 2014 PMID 24803013). Adenocarcinoma, squamous, transitional cell, and rare entities all reported. Pregnancy considerations: drainage is safe in pregnancy; antibiotic modifications avoid TMP-SMX (1st trimester folate antagonism / late pregnancy kernicterus) and doxycycline (fetal tooth + bone effects); amox-clav OR cefuroxime + metronidazole preferred; OB co-management for symptomatic patients. Severity triggers (8): bartholin_abscess_at_diagnosis_drainage (severe — I&D + Word catheter × 4-6 wk is definitive), systemic_symptoms_or_immunocompromised (severe — antibiotics adjunctive + drainage + observation), recurrent_bartholin_abscess (moderate — marsupialization or excision; ≥ 2 episodes), postmenopausal_atypical_bartholin (severe — biopsy abscess wall + gland excision; vulvar / Bartholin malignancy rare but documented), suspected_pid_or_sti_overlap (moderate — STI testing + ddx routing to gyn.pid), word_catheter_displacement_premature (mild — replace OR marsupialization), abscess_extension_or_cellulitis (severe — broader antibiotics + surgical consult; rule out Fournier gangrene mortality 25-35 %), pregnancy_with_bartholin_abscess (severe — drainage acceptable + pregnancy-safe antibiotics + OB co-management). Three setting playbooks: outpatient (primary setting — office I&D + Word + outpatient follow-up at 4-6 wk), ED (after-hours / severe symptomatic / NF rule-out / sepsis triage), inpatient (rare — IV antibiotics for severe systemic infection / immunocompromise / pregnancy complications). Sibling differentiation: gyn.pelvic-inflammatory-disease.core.v1 (shared CDC STI testing framework; PID with overlap routes to PID dossier), id.cellulitis.core.v1 (cellulitis extension / NF / Fournier red flags), gyn.ovarian-torsion.v1 (acute female pelvic pain ddx; different anatomy). Cross-dossier routing: gyn.pid (PID overlap), id.cellulitis (NF / Fournier red flags), id.sepsis (sepsis features qSOFA ≥ 2 + skin source), gyn.ovarian-torsion (sibling ddx — different anatomy). Open gaps: (1) Phenotype matrix is documented in co-located _briefs/gyn.bartholin-abscess.v1.md but NOT a first-class TS field — schema-blocked. (2) Bayesian linkage (LRs + decision thresholds) documented in brief + research bundle but NOT a first-class TS field; ROS/DDx seed cross-cutting (shard scope forbids). (3) Vulvar / Bartholin adenocarcinoma sibling routing — gyn.vulvar-cancer.v1 does not yet exist on disk; postmenopausal route is informal via severity trigger. (4) Word 1968 original description PMID NEEDS_SOURCE_REVIEW (pre-1975 indexing). (5) CA-MRSA prevalence in Bartholin abscess series varies by region; empiric MRSA coverage decision should consider local antibiogram. (6) Pediatric prepubertal Bartholin abscess is exceedingly rare and should trigger abuse workup or alternative diagnosis routing; not encoded as separate phenotype. Status declared INTEGRATED with manifest reuse pattern (id.sepsis.core.v1 manifest) — audit gate honored. Includes design_brief + workups + decision surface (calculators + protocol + regimen_axes) + test_files + evidence + acuity-specific phases (acute: RED_FLAGS + INITIAL_WORKUP + TREATMENT + DISPOSITION). _registry.ts NOT modified this commit — refined Phase-C-wave-10 pattern; registration will be picked up in a wave-roll-up commit.

Entry points (7)

  • symptom
    Unilateral labial swelling at 4 or 8 oclock position with fluctuance — classic Bartholin abscess (Wechter 2009 PMID 19099613)
    unilateral_labial_swelling_with_fluctuance
  • symptom
    Painful vulvar mass with difficulty sitting / walking / intercourse — symptomatic Bartholin abscess (Wechter 2009 PMID 19099613)
    painful_vulvar_mass_difficulty_sitting_or_intercourse
  • symptom
    Asymptomatic unilateral labial swelling — Bartholin cyst (often incidental; observation / sitz baths if mild)
    asymptomatic_unilateral_labial_swelling
  • symptom
    Recurrent ipsilateral Bartholin abscess (≥ 2 episodes) — escalate to marsupialization or gland excision (Wechter 2009 PMID 19099613)
    recurrent_ipsilateral_bartholin_abscess
  • symptom
    Postmenopausal patient or > 40 yr with Bartholin mass / atypical features (firm, fixed, induration) — biopsy abscess wall for malignancy ddx (Visco 1996 PMID 8559513; Heller 2014 PMID 24803013)
    postmenopausal_bartholin_mass_or_atypical
  • symptom
    Bartholin abscess with fever / cellulitis / systemic toxicity / immunocompromised host — antibiotics + I&D + observation; consider IV antibiotics + admission if sepsis features (CDC STI 2021 PMID 34292926)
    bartholin_abscess_with_systemic_features
  • symptom
    Pregnant patient with symptomatic Bartholin abscess — drainage acceptable; pregnancy-safe antibiotic considerations; OB co-management (CDC STI 2021 PMID 34292926)
    pregnancy_with_symptomatic_bartholin_abscess

Required inputs (18)

  • agerequired
    demographic • used at CONTEXT
    Reproductive-age (20-30 peak) is the typical phenotype; postmenopausal > 40 yr mandates malignancy ddx + biopsy abscess wall (Visco 1996 PMID 8559513)
  • pregnancy_statusrequired
    demographic • used at CONTEXT
    Pregnancy modifies antibiotic selection (avoid TMP-SMX 1st trimester / late pregnancy; avoid doxycycline; prefer amox-clav OR cefuroxime + metronidazole); drainage itself is safe in pregnancy
  • duration_of_swellingrequired
    symptom • used at ENTRY
    Acute (hours-days) suggests abscess; subacute / chronic (weeks-months) suggests cyst or atypical entity; recurrent timeline informs escalation to marsupialization
  • pain_severity_and_functional_impactrequired
    symptom • used at ENTRY
    Severity drives intervention urgency; mild / asymptomatic cyst → conservative; severe pain + functional impact → I&D + Word
  • fluctuance_on_examrequired
    symptom • used at CONTEXT
    Fluctuance is the clinical determinant for abscess vs cyst — abscess with fluctuance → drainage; non-fluctuant cyst → observation / sitz baths
  • temperaturerequired
    vital • used at RED_FLAGS
    Fever suggests systemic infection / cellulitis extension / sepsis; uncomplicated Bartholin abscess is typically afebrile
  • sbprequired
    vital • used at RED_FLAGS
    Hypotension flags sepsis pathway; rare in uncomplicated abscess but possible with NF / Fournier extension
  • hrrequired
    vital • used at RED_FLAGS
    Tachycardia + fever raises sepsis suspicion + SIRS / qSOFA component
  • sexual_activity_and_sti_risk_factorsrequired
    history • used at CONTEXT
    STI risk factors (younger, multiple partners, prior STI, mucopurulent cervicitis) drive NAAT for GC/CT + HIV + syphilis screen per CDC 2021 PMID 34292926
  • prior_bartholin_diseaserequired
    history • used at CONTEXT
    Recurrent disease (≥ 2 ipsilateral abscesses) → marsupialization or gland excision; document number of prior episodes + prior interventions (Wechter 2009 PMID 19099613)
  • immunocompromise_or_diabetesrequired
    history • used at CONTEXT
    Immunocompromised host (HIV / DM / steroid / chemotherapy / transplant) → broader antibiotic coverage + lower admission threshold; CA-MRSA risk increased
  • antibiotic_allergyrequired
    history • used at TREATMENT
    Drives empiric antibiotic selection — penicillin anaphylaxis avoids amox-clav + cefuroxime; consider clindamycin + ciprofloxacin OR TMP-SMX + metronidazole alternative
  • cellulitis_extension_or_nf_red_flagsrequired
    symptom • used at RED_FLAGS
    Pain out of proportion / crepitus / bullae / rapid spread / systemic toxicity → necrotizing fasciitis / Fournier gangrene (mortality 25-35 %); route to id.cellulitis.core.v1 / surgical emergency
  • wbc
    lab • used at INITIAL_WORKUP
    Leukocytosis with systemic features informs severity tier; not required for uncomplicated office I&D
  • gc_ct_naat
    lab • used at INITIAL_WORKUP
    NAAT for Neisseria gonorrhoeae + Chlamydia trachomatis when STI risk factors present; CDC 2021 routine recommendation (PMID 34292926)
  • wound_culture_with_susceptibility
    lab • used at INITIAL_WORKUP
    Wound culture at I&D when systemic features OR recurrent disease OR immunocompromised host OR MRSA suspected — guides targeted antibiotic narrowing
  • hiv_and_syphilis_screen
    lab • used at INITIAL_WORKUP
    Routine STI screen for risk-factor patients per CDC 2021 (PMID 34292926)
  • pelvic_ultrasound_if_complex_or_pid_overlap
    imaging • used at BRANCHING_WORKUP
    Bedside ultrasound is rarely needed for clinical Bartholin diagnosis; useful if mass is atypical / deep / extension suspected / PID overlap (TOA ddx routing to gyn.pid)

12-phase flow (12)

  1. 1FRAME
    Bartholin gland duct obstruction → cyst → abscess (when infected). Spectrum: asymptomatic cyst (observation / sitz baths) → symptomatic enlarging cyst (sitz baths +/- conservative) → fluctuant uncomplicated abscess (office I&D + Word catheter × 4-6 wk) → abscess with systemic features (antibiotics + drainage + observation) → recurrent disease (marsupialization or gland excision) → postmenopausal atypical (biopsy abscess wall for malignancy ddx). Partition by clinical state (cyst vs abscess vs recurrent vs atypical) + population (reproductive-age vs pregnancy vs postmenopausal vs immunocompromised) + severity (mild / moderate / severe / atypical) (Wechter 2009 PMID 19099613).
    inputs: age, pregnancy_status
    advance: clinical state + population + severity tier tagged
  2. 2ENTRY
    Recognise via unilateral 4 or 8 oclock labial swelling with or without fluctuance + pain + functional impact (difficulty sitting / walking / intercourse). Asymptomatic cyst is common incidental finding. Acute fluctuant abscess presents over hours-days. Recurrent ipsilateral disease (≥ 2 episodes) escalates management. Postmenopausal > 40 yr or atypical features (firm, fixed, induration) mandate biopsy. Pregnant patient — drainage acceptable; antibiotic considerations modified (Wechter 2009 PMID 19099613; Visco 1996 PMID 8559513).
    inputs: duration_of_swelling, pain_severity_and_functional_impact
    advance: Pre-test clinical probability + cyst-vs-abscess decision documented
  3. 3CONTEXT
    Age (reproductive-age vs postmenopausal — malignancy ddx > 40 yr), pregnancy status (antibiotic modifications), STI risk factors (NAAT for GC/CT + HIV + syphilis screen per CDC 2021 PMID 34292926), prior Bartholin disease (recurrent → marsupialization), immunocompromise / diabetes (broader coverage + lower admission threshold), antibiotic allergy (penicillin anaphylaxis modifies regimen).
    inputs: age, pregnancy_status, fluctuance_on_exam, sexual_activity_and_sti_risk_factors, prior_bartholin_disease, immunocompromise_or_diabetes, antibiotic_allergy
    advance: Risk-factor profile + STI testing decision + recurrence-tier + antibiotic-tier captured
  4. 4RED_FLAGS
    Fever / cellulitis / systemic toxicity / sepsis features (qSOFA ≥ 2 or SIRS positive) → antibiotics + I&D + observation; consider IV antibiotics + admission. Necrotizing fasciitis / Fournier gangrene red flags (pain out of proportion / crepitus / bullae / rapid spread / systemic toxicity) → emergent surgical consultation; Fournier mortality 25-35 % — route to id.cellulitis.core.v1 / surgical emergency (IDSA 2014 SSTI framework adapted to vulvar / perineal source).
    inputs: temperature, sbp, hr, cellulitis_extension_or_nf_red_flags
    actions: calc.qsofa
    advance: Severity tier set; NF features ruled out or routed; sepsis pathway activated if positive
  5. 5INITIAL_WORKUP
    Office I&D for uncomplicated abscess does not require labs. For systemic features / recurrent disease / immunocompromised host: CBC + BMP + lactate if sepsis features. NAAT for GC/CT + HIV + syphilis screen for STI risk-factor patients (CDC 2021 PMID 34292926). Wound culture at I&D when systemic features / recurrent / immunocompromised / MRSA suspected. Biopsy of abscess wall if postmenopausal OR > 40 yr OR atypical features (Visco 1996 PMID 8559513).
    actions: panel.cbc, panel.inflammation, panel.ua
    advance: Office I&D feasibility decision OR escalation to ED / OR established; STI screen sent if risk factors
  6. 6BRANCHING_WORKUP
    Pelvic ultrasound if mass is atypical / deep / extension suspected / PID overlap (TOA ddx — route to gyn.pid). MRI rarely needed; reserved for suspected malignancy with complex anatomy (gyn-onc directed). Biopsy of abscess wall at I&D if postmenopausal OR > 40 yr OR atypical features — sent for histopathology (Visco 1996 PMID 8559513; Heller 2014 PMID 24803013).
    actions: workup.pelvic_pain
    advance: Branching workup complete; malignancy / PID / NF mimics excluded or routed
  7. 7DIFFERENTIAL
    Bartholin abscess vs labial inflammatory cyst vs vulvar epidermal inclusion cyst vs hidradenitis suppurativa (recurrent labial / inguinal nodules) vs vulvar lipoma vs vulvar leiomyoma (rare) vs vulvar malignancy (rare; postmenopausal-driven priority) vs Skene gland abscess (periurethral location) vs vulvar abscess (more diffuse / not localized to 4-8 oclock). PID with TOA overlap if mucopurulent cervicitis + lower abdominal pain + CMT — route to gyn.pid.
    advance: Differential narrowed; primary diagnosis documented
  8. 8RISK_STRATIFICATION
    Mild (cyst only, asymptomatic / mild) → conservative (sitz baths, observation). Moderate (uncomplicated abscess) → office I&D + Word catheter × 4-6 wk. Severe (cellulitis / sepsis / immunocompromised / pregnancy with complications) → antibiotics + I&D + observation, consider IV / admission. Atypical (postmenopausal / suspicious mass) → biopsy abscess wall + gland excision + gyn-onc referral if malignant. Recurrent (≥ 2 ipsilateral) → marsupialization OR gland excision (Wechter 2009 PMID 19099613).
    inputs: age, pregnancy_status, fluctuance_on_exam, prior_bartholin_disease, immunocompromise_or_diabetes
    actions: calc.qsofa
    advance: Severity tier + intervention tier + setting tier documented
  9. 9TREATMENT
    Bartholin cyst (asymptomatic) → sitz baths 15-20 min QID × 3-4 d + observation; surgical drainage only if symptomatic / enlarging. Uncomplicated Bartholin abscess (fluctuant) → office I&D + Word catheter × 4-6 wk dwell time + sitz baths adjunctive. Abscess with systemic features / immunocompromise / pregnancy / sepsis → antibiotics (TMP-SMX 1-2 DS PO BID + metronidazole 500 mg PO TID OR amox-clav 875/125 mg PO BID + I&D + Word; consider IV ceftriaxone 2 g IV daily + metronidazole 500 mg IV q8h if hospitalised). STI-positive (GC/CT NAAT positive) → ceftriaxone 500 mg IM single + doxycycline 100 mg PO BID × 7 d (CDC 2021 PMID 34292926). Recurrent (≥ 2 ipsilateral) → marsupialization (office or OR) OR gland excision. Postmenopausal atypical → biopsy abscess wall + gland excision + histopathology + gyn-onc referral if malignant (Visco 1996 PMID 8559513). Pregnancy modifications: avoid TMP-SMX 1st trimester + late pregnancy; avoid doxycycline; prefer amox-clav OR cefuroxime + metronidazole.
    inputs: antibiotic_allergy
    advance: Intervention performed (drainage / marsupialization / excision); antibiotics started if indicated; pathology ordered if atypical; STI treated if positive
  10. 10DISPOSITION
    Office discharge after I&D + Word for uncomplicated abscess; outpatient follow-up at 4-6 wk for Word removal + recurrence assessment. ED disposition: discharge with PCP / gyn follow-up if uncomplicated; admit if sepsis / immunocompromised / pregnancy with complications / NF features. OR for marsupialization or gland excision in recurrent / refractory / suspected-malignancy cases. Inpatient (rare) for IV antibiotics + observation if severe systemic features (Wechter 2009 PMID 19099613).
    inputs: temperature, sbp
    advance: Disposition documented; follow-up appointment booked; return precautions counselled
  11. 11MONITORING
    Word catheter dwell × 4-6 wk for epithelialization; catheter check at 1-2 wk to confirm position + monitor for displacement (replace if displaced premature). Sitz baths 15-20 min QID × 1-2 wk post-I&D for symptomatic relief. Outpatient assessment at 4-6 wk for Word removal + recurrence evaluation. Pathology review at 1-2 wk for biopsied abscess wall (postmenopausal / atypical). For hospitalised systemic infection: vitals q4h + repeat CBC + wound check + antibiotic streamline based on culture susceptibility.
    advance: Word catheter removed; epithelialization confirmed; pathology benign or gyn-onc routed if malignant; systemic infection resolved if hospitalised
  12. 12FOLLOWUP
    Outpatient gyn follow-up at 4-6 wk for Word catheter removal + recurrence assessment + STI test result review + treatment of asymptomatic partner if STI positive (CDC 2021 PMID 34292926). Counsel on recurrence risk + early presentation for recurrent symptoms (route to marsupialization). Pathology review for postmenopausal / atypical biopsy — gyn-onc referral if malignant (Heller 2014 PMID 24803013). Counsel on safer-sex practices if STI testing positive; HIV / syphilis screen review. Reproductive planning + contraception counseling unchanged. Postpartum coordination if peripartum.
    advance: Word removed; STI follow-up complete; pathology reviewed; recurrence + safer-sex counseling documented