Labial Adhesions


Article Author:
Dulce Gonzalez


Article Editor:
Magda Mendez


Editors In Chief:
Chaddie Doerr


Managing Editors:
Avais Raja
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Khalid Alsayouri
Kyle Blair
Trevor Nezwek
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beata Beatty
Daniyal Ameen
Altif Muneeb
Beenish Sohail
Nazia Sadiq
Hajira Basit
Phillip Hynes
Komal Shaheen
Sandeep Sekhon


Updated:
2/22/2019 6:24:06 PM

Introduction

Labial adhesion is the fusion of the labia minora or majora, and it is mostly located near the clitoris. It also may be known as synechia vulvae or labial agglutination. The exact cause for labial adhesions remains unknown. However, it is believed that a state of low estrogen may be a contributing cause. Therefore, these patients are typically managed with estrogen cream when symptomatic.[1][2][3]

Etiology

This entity is mostly an incidental finding since the majority of the patients have no symptoms. As the name implies, labial adhesion is a fusion of the labia minora or majora. The exact cause of labial fusion remains unknown. However, it is believed to occur in a low estrogen state. It is rare in the reproductive age group due to the sufficient levels of estrogen found in this population.[4][5][6]

In females who are currently in the reproductive stage, labial adhesions are rare. For those who do develop labial adhesions, there is usually a history of some sort of genital trauma or irritation to the genitalia. Examples of genital trauma may include childbirth, sexual abuse, and genitourinary surgery. Management for these patients tends to consist of lysis of the adhesion as well as applying topical estrogen cream. There have been cases of labial adhesion in the postpartum period. It is believed that a possibility may be due to breastfeeding along with the irritation and trauma that occurs during a vaginal delivery. The reasoning behind breastfeeding as a cause is that when a mother breastfeeds her baby, prolactin is increased prolactin, leading to a decrease in estrogen and resulting in a hypoestrogenic state. Management remains the same. For preventive measures, it is recommended for minimization of vulvar irritation accompanied by adequate hygiene to the perineal area. Another recommendation may be for the resumption of sexual activity.

Labial adhesions also may be found during another low estrogen stage, the postmenopausal stage. In this stage, due to the low estrogen, the genital area is susceptible to irritation and inflammation, which may lead to adhesion. In this age group, the risk of fusion increases when the patient has a history of diabetes mellitus, lichen sclerosis, or with diminished sex.

Epidemiology

Labial adhesion may affect up to 2% of prepubertal girls, with the typical age of presentation for labial adhesions at two years of age.

Pathophysiology

The condition is believed to be due to inflammation of the labia in a low-estrogen environment. It is thought to occur in a hypoestrogenic state due to it being very uncommon in the newborn period when there is maternal estrogen influence as well as during the reproductive period when there are adequate estrogen levels. The inflammation can be due to infection as well as to poor hygiene, including stool contamination.

Some studies are against the idea that labial fusion is due to a hypoestrogenic state. A study in 2007 published in "Pediatric Dermatology" that measured the serum estradiol levels of 59 prepubertal females with labial adhesion and 60 prepubertal females showed no statistically significant difference in their estrogen levels.

History and Physical

Patients usually have no clinical manifestations, and labial fusion is found incidentally on routine examination. A common location for the fusion of the labia is near the clitoris. The labial adhesion consists of thin fibrotic tissue, which can range from being a small partial fusion to a complete fusion occluding the vaginal orifice.

When clinical manifestations do occur, they usually consist of post-void dripping, hematuria, dysuria, and local inflammation in the labial area. These females may come in complaining of difficulty voiding and retention of urine. Urinary tract infections (UTIs) also may be associated with this condition, thus prompting treatment. Some studies have shown that a prepubertal female who has labial adhesion has a higher risk of having a urinary tract infection. It is of utmost importance to do a physical exam that includes evaluation of the genitourinary region. When the labial adhesions resolve successfully, the risk for an infection of the urinary tract decreases.

Evaluation

This is a clinical diagnosis. There is no need for labs or imaging. 

Treatment / Management

If the patient is clinically asymptomatic, there is no need for treatment and reassurance can be provided to the family as well as education on proper hygiene. The first line in management is reassurance since most of the labial adhesions resolve spontaneously within one year. It is reported that up to 80% resolve without any treatment.[7][8][9]

When treatment is indicated, it consists of applying estrogen cream to the labial area. One of the major indications for treatment is a urinary tract infection. Some studies have demonstrated a success rate of up to 90% with the use of topical estrogen cream. Another common topical management is a topical steroid, such as beclomethasone. Even though topical estrogen is the most commonly used, studies have not shown a statistically significant difference between topical estrogen and beclomethasone.

After application of the estrogen cream on the vulvar area, side effects may include tenderness to the breast and changes to pigmentation on the area applied. Because there have been no studies on adverse effects with long-term use of topical estrogen in the pediatric population, the recommendation is to use topical estrogen cream for the shortest duration as possible that will provide effective treatment.

Other forms of management include topical betamethasone and surgical removal. With the use of betamethasone, there may be thinning of the skin as well increased the risk for infection of the hair follicle, redness, thinning of hair growth, and itchiness on the area applied.

There is not a precise length of treatment currently recommended for any form of topical treatment; therefore, the shortest duration that resolves the adhesion is recommended. Topical treatment is usually done so once or twice a day for up to six weeks. Some authors have recommended topical management for up to three months. When topical management fails, then adhesion may be managed surgically.

A few weeks of topical management is recommended before surgical management is considered. Surgical lysis of the fusion is recommended if topical management is unsuccessful. The surgical management is usually performed under general anesthesia and consists of gentle traction.

Recurrences are common in labial adhesions, regardless of the mode of treatment used. Labial adhesions may keep reforming until the female patient goes through puberty. Some studies report a rate of recurrence from 11% to 14% with either topical or surgical management. Recurrences may be managed with topical treatment or with surgical lysis of the fusion. Another treatment modality includes manual separation with a continuation of proper hygiene and cleanliness.

Enhancing Healthcare Team Outcomes

Labial adhesions are managed by a multidisciplinary team that includes the pediatrician, nurse practitioner, and primary care provider. The diagnosis is made with a clinical exam and the treatment depends on symptoms.

If the patient is clinically asymptomatic, there is no need for treatment and reassurance can be provided to the family as well as education on proper hygiene. The first line in management is reassurance since most of the labial adhesions resolve spontaneously within one year. It is reported that up to 80% resolve without any treatment.

When treatment is indicated, it consists of applying estrogen cream to the labial area. One of the major indications for treatment is a urinary tract infection. Some studies have demonstrated a success rate of up to 90% with the use of topical estrogen cream. In rare cases, surgical release of the adhesions may be required.

Recurrences are common with labial adhesions, regardless of the mode of treatment used. Labial adhesions may keep reforming until the female patient goes through puberty. Some studies report a rate of recurrence from 11% to 14% with either topical or surgical management. 


Interested in Participating?

We are looking for contributors to author, edit, and peer review our vast library of review articles and multiple choice questions. In as little as 2-3 hours you can make a significant contribution to your specialty. In return for a small amount of your time, you will receive free access to all content and you will be published as an author or editor in eBooks, apps, online CME/CE activities, and an online Learning Management System for students, teachers, and program directors that allows access to review materials in over 500 specialties.

Improve Content - Become an Author or Editor

This is an academic project designed to provide inexpensive peer-reviewed Apps, eBooks, and very soon an online CME/CE system to help students identify weaknesses and improve knowledge. We would like you to consider being an author or editor. Please click here to learn more. Thank you for you for your interest, the StatPearls Publishing Editorial Team.

Labial Adhesions - Questions

Take a quiz of the questions on this article.

Take Quiz
What is the management of labial adhesions in preadolescent girls?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Which of the following is usually the best management of labial adhesions in pre-adolescent girls?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
What is true regarding labial adhesions in prepubescent girls?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 3-year-old female is noted to have labial adhesions. Which of the following is appropriate management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
Decreased level of which hormone is believed to be involved in the etiology of labial adhesions?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up
A 15-month-old female is evaluated due to fever, decreased appetite, and vomiting. Physical examination is remarkable for an ill-appearing female, crying yet consolable, in no respiratory distress. Genitourinary exam shows a pink fibrotic tissue over the vulva. A urinalysis is remarkable for WBC 20-30/HPF, positive leukocyte esterase, positive nitrites, and moderate bacteria. This is the second urinary tract infection this year for this patient. She is discharged home on antibiotics and to follow up with her primary provider. Regarding the labial adhesion, what should be the next step in management?



Click Your Answer Below


Would you like to access teaching points and more information on this topic?

Improve Content - Become an Author or Editor and get free access to the entire database, free eBooks, as well as free CME/CE as it becomes available. If interested, please click on "Sign Up" to register.

Purchase- Want immediate access to questions, answers, and teaching points? They can be purchased above at Apps and eBooks.


Sign Up

Labial Adhesions - References

References

Singh P,Han HC, Labial adhesions in postmenopausal women: presentation and management. International urogynecology journal. 2018 Nov 28;     [PubMed]
Dowlut-McElroy T,Higgins J,Williams KB,Strickland JL, Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial. Journal of pediatric and adolescent gynecology. 2018 Oct 29;     [PubMed]
Wejde E,Ekmark AN,Stenström P, Treatment with oestrogen or manual separation for labial adhesions - initial outcome and long-term follow-up. BMC pediatrics. 2018 Mar 8;     [PubMed]
Norris JE,Elder CV,Dunford AM,Rampal D,Cheung C,Grover SR, Spontaneous resolution of labial adhesions in pre-pubertal girls. Journal of paediatrics and child health. 2018 Jul;     [PubMed]
Rubinstein A,Rahman G,Risso P,Ocampo D, Labial adhesions: Experience in a children's hospital. Archivos argentinos de pediatria. 2018 Feb 1;     [PubMed]
Fernandez S, A Pediatrician's Take on a Few Common Infant Urologic and Gynecologic Issues. Pediatric annals. 2017 Nov 1;     [PubMed]
Knudtzon S,Haugen SE,Myhre AK, Labial adhesion - diagnostics and treatment. Tidsskrift for den Norske laegeforening : tidsskrift for praktisk medicin, ny raekke. 2017 Jan;     [PubMed]
Vilano SE,Robbins CL, Common prepubertal vulvar conditions. Current opinion in obstetrics     [PubMed]
Bussen S,Eckert A,Schmidt U,Sütterlin M, Comparison of Conservative and Surgical Therapy Concepts for Synechia of the Labia in Pre-Pubertal Girls. Geburtshilfe und Frauenheilkunde. 2016 Apr;     [PubMed]

Disclaimer

The intent of StatPearls is to provide practice questions and explanations to assist you in identifying and resolving knowledge deficits. These questions and explanations are not intended to be a source of the knowledge base of all of medicine, nor is it intended to be a board or certification review of Nurse-Child Health PN. The authors or editors do not warrant the information is complete or accurate. The reader is encouraged to verify each answer and explanation in several references. All drug indications and dosages should be verified before administration.

StatPearls offers the most comprehensive database of free multiple-choice questions with explanations and short review chapters ever developed. This system helps physicians, medical students, dentists, nurses, pharmacists, and allied health professionals identify education deficits and learn new concepts. StatPearls is not a board or certification review system for Nurse-Child Health PN, it is a learning system that you can use to help improve your knowledge base of medicine for life-long learning. StatPearls will help you identify your weaknesses so that when you are ready to study for a board or certification exam in Nurse-Child Health PN, you will already be prepared.

Our content is updated continuously through a multi-step peer review process that will help you be prepared and review for a thorough knowledge of Nurse-Child Health PN. When it is time for the Nurse-Child Health PN board and certification exam, you will already be ready. Besides online study quizzes, we also publish our peer-reviewed content in eBooks and mobile Apps. We also offer inexpensive CME/CE, so our content can be used to attain education credits while you study Nurse-Child Health PN.