Introduction

The Bartholin glands are a pair of small, pea-sized glands located in the superficial perineal pouch, near the posterior end of the vestibular bulb at the 5 and 7 o’clock positions.^[1] Measuring about 0.5 cm in size, these glands play a crucial role in female reproductive health by secreting an alkaline mucus during sexual arousal. This secretion aids in natural lubrication. Each gland has an efferent duct approximately 2 cm long, which opens into the vestibule just outside the hymenal ring. These glands are homologous to the bulbourethral glands in males and generally remain non-palpable unless affected by pathological conditions.

A Bartholin cyst occurs when the duct of the gland becomes blocked, leading to fluid accumulation. This cyst presents as a firm, non-cancerous lump that may or may not cause discomfort. The size of the cyst can vary, with larger ones often resulting in pain and difficulty in movement. Although most Bartholin cysts are asymptomatic, infection can sometimes occur, leading to the formation of an abscess. A Bartholin abscess is characterized by intense pain, swelling, redness, and fever due to pus accumulation within the cyst.

In Ayurveda, this condition is described under Yonikanda, with references in classical texts such as Madhava Nidana. It is believed to arise due to factors like Diwaswapna (daytime sleep), Ati Krodha (excessive anger), Ati Vyayama (overexertion), and injuries caused by Nakha-Danta-Kshata (nails, teeth, or thorns).^[2] The aggravated Doshas lead to the formation of a protuberant structure resembling the Nikucha or Lakucha fruit.^[2] Based on the predominance of Doshas, Yonikanda is classified into four types:

1. Vataja: Characterized by a dry, rough, and discolored mass with a cracked surface, resembling an early-stage Bartholin cyst.

2. Pittaja: Marked by redness, burning sensation, and fever, indicating an acute inflammatory phase.

3. Kaphaja: Displays a bluish discoloration similar to Atasi flowers, accompanied by persistent itching, resembling a chronic cystic stage.

4. Sannipatika: A severe form combining features of all three Doshas, often corresponding to an advanced abscess with chronic infection.

Ashtavidha Pariksha

Nadi - Vata Kapha
Mala - once a day
Mutra - 3-4 times/day
Jihva - Alipta
Shabda - Prakrutha
Sparsha - Anushnasheetha
Drik - Prakrutha
Akruthi - Madhyama

Dashavidha Pariksha

Prakruti - VK
Vikruthi -
Dosha -Tridosha
Dushya - Rasa,Rakta,Mamsa
Sara - Medosara

Samhanana - Madhyama
Pramana – Madhyama
Satva - Madhyama
Satmya - Madyama
Aharashakti - Madhyama
Vyayamashakti - Madhyama
Vaya - Madhyama

Physical Examination

Weight - 84 kg
Height - 160cm
BMI - 32.8
Pulse - 80/min
BP - 110/80mmhg
Breast examination - NAD
Respiratory rate - 20/min
Pallor - Absent

Systemic Examination

Respiratory system: normal

CVS: S1, S2 heard.
CNS: Conscious and oriented
GIT: liver, spleen not palpable

Gynaecological Examination

O/E: A unilateral swelling on right labia major, measuring 5cm*3cm, reddish, & smooth surface with punctum. Previous Surgical Scar mark is noted on left side of vaginal opening. On palpation cystic mass felt with tenderness on right side.

Investigation

HB: 10 gm/dl
HIV: Non-reactive

• Sitz bath with Panchavalkala Kashaya.
• Maintain local hygiene
• Review after 7 days

Result

Follow-up:

1. On 7^th day Pain, Redness and swelling were reduced.

No discharge, no induration

Wound was healthy.

2. After 6 month - No recurrence noted.

Discussion

The history and clinical features are pathognomonic for the diagnosis of a Bartholin cyst. The primary objective in this case is to prevent recurrence, which was the patient’s primary concern. Given the patient's surgical history of left Bartholin cyst marsupialization, the only remaining option was excision of the cyst. This is an inpatient procedure that requires general or spinal anesthesia, along with a hospital stay, and is expensive. However, the patient was unwilling to bear the cost due to her multiple previous surgeries for the same condition.

To overcome the limitations of the afore mentioned contemporary techniques and highlight the potential of Ayurvedic approaches, Pratisaraneeya Kshara Karma was chosen for this case. As the pathogenesis of Yonikanda and Granti are similar, the line of management for Granti, which involves Bhedana (incision) and Visravana (drainage) was adopted, followed by Kshara Karma.^[3] In Kshara Yogya (~ who is fit for Kshara Karma), the chronicity, recurrence tendency were the key factors in choosing this intervention. Pratisaraneeya Kshara has Dahana (~cauterize), Pachana (~suppurates), Vilayana (~sloughing off), Shoshana (~to shrink/dry), Shodhana (~cleanse/ purifies), Ropana (~healing property) Karma, as its innate property.^[4] To initiate the process of Paka (maturation) as a prerequisite for the Bhedana (incision), Dashanga Lepa^[5] mixed with luke warm Tila Taila was applied. The ingredients in Dashanga Lepa - includes Shirisha, Yashti, Ela, Chandana, Jatamasi, Haridra, Daruharidra, Kushta, Tagara, and Hribera possess properties which additionally help in alleviate pain for momentary relief.