Nobody likes having severe pain in their “personal areas,” and as emergency physicians, we have an obligation to relieve these problems on both an immediate and long-term basis.
Bartholin Gland Abscess
Bartholin glands normally secrete lubrication into the vaginal vestibule via small ducts, but if they become occluded, cyst and abscess formation may follow. Draining an infected Bartholin gland is a common procedure in an emergency department, but this painful condition is likely to recur if we do not ensure that a new duct can form to allow the gland to drain normally.
There are several methods for creating a fistula from the abscess cavity, but one of the best ways is to leave a Word catheter in place for 2-4 weeks to allow a drainage channel to form.
Here’s the problem: Have you ever tried to find a Word catheter in your GYN room? They are usually right next to the fenestrated ear wicks, kryptonite dagger, and powdered unicorn horn. There are precedents for using a Foley catheter as an alternative, but telling a patient that she will have a 24-cm rubber tentacle hanging out of her groin for three weeks is a tough sell.1,2
To make your own Word-like catheter, you’ll need a pediatric Foley Catheter (8 or 10 French, since larger sizes do not work well). You should also have hemostats and scissors, cyanoacrylate tissue adhesive (such as “Dermabond”), and a PPD or insulin syringe, in addition to your usual incision and drainage equipment.
I recommend applying topical EMLA to the vaginal mucosa to relieve the pain of local anesthetic injection, and I use preservative-free or buffered lidocaine if possible.
Once you have performed the I&D, place the deflated balloon of the Foley catheter into the abscess cavity. You may need a hemostat to help, since the tip just past the balloon that must also be in the cavity. Slowly inflate the balloon with 3-4 mL of saline or sterile water. Once you are sure it’s in place, clamp the Foley firmly with a hemostat several centimeters distal to the balloon. (Picture 1).
Next, use scissors to cut the catheter 2 cm distal to the clamp site. The proximal end of the catheter will eject the fluid from the balloon inflation channel, but the balloon itself will not collapse as long as you keep the hemostat in place. When you look at the catheter in cross-section, you’ll see the large central channel where urine normally drains, and in the 6 o’clock position a much smaller channel that conducts fluid to the balloon for inflation.