eMedicine Specialties > Pediatrics: Surgery > Gynecology

Labial Adhesions

Author: Kenneth G Nepple, MD, Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Coauthor(s): Christopher S Cooper, MD, FACS, FAAP, Associate Professor of Urology, Director of Pediatric Urology, University of Iowa, Children's Hospital of Iowa; Associate Dean for Student Affairs and Curriculum, University of Iowa Carver College of Medicine; Madhu Alagiri, MD, Director of Pediatric Urology, Associate Clinical Professor, Department of Surgery, University of California at San Diego
Contributor Information and Disclosures

Updated: Mar 23, 2009

Introduction

Background

Labial adhesions are a common disorder in prepubertal females. The disorder is usually asymptomatic and is often first noticed by parents or during a routine physical examination.1 A host of other pediatric vaginal or urethral disorders, including an imperforate hymen or a septate vagina, must be excluded. Treatment of labial adhesions is typically conservative.

Typical appearance of labial adhesions

Typical appearance of labial adhesions

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Typical appearance of labial adhesions

Typical appearance of labial adhesions


Pathophysiology

Labial adhesions are fibrous adhesions between the labia majora. Labial adhesions are due to low estrogen levels in prepubertal girls and contact with irritants.

Frequency

United States

A prospective study of over 1900 girls assessed through a pediatric outpatient clinic reported a 1.8% incidence of labial adhesions, whereas a review of over 9000 female infants found no cases of neonatal labial adhesions.2

International

Incidence of labial adhesions worldwide is unknown but presumably similar to US incidence.

Mortality/Morbidity

Labial adhesions are generally asymptomatic and not a common cause of urologic or gynecologic morbidity. Labial adhesions can rarely cause urinary outflow deflection or obstruction, leading to vaginal reflux of urine and subsequent vaginal leaking when the child stands after voiding.

Race

No strong evidence supports a racial predilection.

Sex

Labial adhesions are a female pediatric disorder.

Age

Labial adhesions occur most often in infants and girls aged 3 months to 6 years, with a peak incidence around the age of 13-23 months.2 Labial adhesions have not been reported in the newborn period. If left untreated, labial adhesions usually spontaneously resolve at puberty, likely as a result of increased estrogen levels.

Clinical

History

Labial adhesions are an asymptomatic disorder usually noted by parents or during routine examination. Some patients experience urine pooling in the vagina with voiding, and then experience subsequent urine leakage from the vagina when they stand after voiding (postvoid dribbling, also called vaginal voiding). Occasionally labial adhesions may also be noted in children with urinary tract infection. Children may note discomfort with voiding.

Physical

The physical examination is aided by positioning the child in a frog-leg position and using a pull-down procedure where the labia majora are grasped and gently retracted caudally and laterally to better visualize the vagina. Labial adhesions are generally readily apparent as thin, pale, semi-translucent membranes cover the vaginal os between the labia minora. In severe cases, these adhesions entirely close the vaginal os. Typically the adhesions begin posteriorly and progress a variable distance anteriorly toward the clitoris. A careful examination should also evaluate for other interlabial masses or genital anomalies, such as fusion of the labia majora that can occur with intersex disorders. Signs of sexual abuse may include lacerations or hematoma.

Causes

Low estrogen levels have been thought to play a causative role in the formation of labial adhesions, and the protective effect of maternal estrogen makes labial adhesions uncommon during the newborn period.2 However, a more recent study found no statistically significant difference in serum estradiol levels between infants with labial adhesions and controls.3 Labial adhesions may be caused by vaginal inflammation, local irritation, or tissue trauma. Labial adhesions have been reported as the result of childhood sexual abuse and may be associated with lacerations or hematoma.4,5

More on Labial Adhesions

Overview: Labial Adhesions
Differential Diagnoses & Workup: Labial Adhesions
Treatment & Medication: Labial Adhesions
Follow-up: Labial Adhesions
Multimedia: Labial Adhesions
References
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References

  1. Gaudens DA, Moh-Ello N, Fiogbe M, et al. [Labial fusion in the paediatric surgery department of Yopougon University hospital (Cote d'Ivoire): 108 cases]. Sante. Jan-Mar 2008;18(1):35-8. [Medline].

  2. Leung AK, Robson WL, Tay-Uyboco J. The incidence of labial fusion in children. J Paediatr Child Health. Jun 1993;29(3):235-6. [Medline].

  3. Caglar MK. Serum estradiol levels in infants with and without labial adhesions: the role of estrogen in the etiology and treatment. Pediatr Dermatol. Jul-Aug 2007;24(4):373-5. [Medline].

  4. McCann J, Voris J, Simon M. Labial adhesions and posterior fourchette injuries in childhood sexual abuse. Am J Dis Child. Jun 1988;142(6):659-63. [Medline].

  5. Muram D. Labial adhesions in sexually abused children. JAMA. Jan 15 1988;259(3):352-3. [Medline].

  6. Leung AK, Robson WL. Labial fusion and asymptomatic bacteriuria. Eur J Pediatr. Mar 1993;152(3):250-1. [Medline].

  7. Pokorny SF. Prepubertal vulvovaginopathies. Obstet Gynecol Clin North Am. Mar 1992;19(1):39-58. [Medline].

  8. Tebruegge M, Misra I, Nerminathan V. Is the topical application of oestrogen cream an effective intervention in girls suffering from labial adhesions?. Arch Dis Child. Mar 2007;92(3):268-71. [Medline].

  9. Myers JB, Sorensen CM, Wisner BP, Furness PD 3rd, Passamaneck M, Koyle MA. Betamethasone cream for the treatment of pre-pubertal labial adhesions. J Pediatr Adolesc Gynecol. Dec 2006;19(6):407-11. [Medline].

  10. Soyer T. Topical estrogen therapy in labial adhesions in children: therapeutic or prophylactic?. J Pediatr Adolesc Gynecol. Aug 2007;20(4):241-4. [Medline].

  11. Schober J, Dulabon L, Martin-Alguacil N, Kow LM, Pfaff D. Significance of topical estrogens to labial fusion and vaginal introital integrity. J Pediatr Adolesc Gynecol. Oct 2006;19(5):337-9. [Medline].

  12. Baldwin DD, Landa HM. Common problems in pediatric gynecology. Urol Clin North Am. Feb 1995;22(1):161-76. [Medline].

  13. Hoebeke P, Depauw P, Van Laecke E, Oosterlinck W. The use of Emla cream as anaesthetic for minor urological surgery in children. Acta Urol Belg. Dec 1997;65(4):25-8. [Medline].

  14. Leung AK, Robson WL, Kao CP, Liu EK, Fong JH. Treatment of labial fusion with topical estrogen therapy. Clin Pediatr (Phila). Apr 2005;44(3):245-7. [Medline].

  15. Merguerian PA, McLorie, GA. Disorders of the female genitalia. In: Kelalis P, King L, Belman AB. Clinical Pediatric Urology. 3rd ed. Philadelphia: Elsevier; 1992.

  16. Nurzia MJ, Eickhorst KM, Ankem MK, Barone JG. The surgical treatment of labial adhesions in pre-pubertal girls. J Pediatr Adolesc Gynecol. Feb 2003;16(1):21-3. [Medline].

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Further Reading

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Keywords

labial adhesions, labial agglutination, adherent labia, labial fusion, synechia vulvae, imperforate hymen, outflow deflection, outflow obstruction, vaginal reflux, urine pooling, vaginal voiding, urinary tract infection, intersex disorders, sexual abuse, hematoma, tissue trauma, labial lacerations

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Contributor Information and Disclosures

Author

Kenneth G Nepple, MD, Resident Physician, Department of Urology, University of Iowa Hospitals and Clinics
Kenneth G Nepple, MD is a member of the following medical societies: Alpha Omega Alpha and American Urological Association
Disclosure: Nothing to disclose.

Coauthor(s)

Christopher S Cooper, MD, FACS, FAAP, Associate Professor of Urology, Director of Pediatric Urology, University of Iowa, Children's Hospital of Iowa; Associate Dean for Student Affairs and Curriculum, University of Iowa Carver College of Medicine
Christopher S Cooper, MD, FACS, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American College of Surgeons, American Medical Association, American Urological Association, International Children's Continence Society, Phi Beta Kappa, Society for Basic Urologic Research, Society for Fetal Urology, and Society for Pediatric Urology
Disclosure: Nothing to disclose.

Madhu Alagiri, MD, Director of Pediatric Urology, Associate Clinical Professor, Department of Surgery, University of California at San Diego
Madhu Alagiri, MD is a member of the following medical societies: American Academy of Pediatrics and American Urological Association
Disclosure: Nothing to disclose.

Medical Editor

Elizabeth Alderman, MD, Director of Fellowship Training Program, Director, Adolescent Ambulatory Service, Clinical Professor, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Montefiore Medical Center
Elizabeth Alderman, MD is a member of the following medical societies: Ambulatory Pediatric Association, American Academy of Pediatrics, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Paul D Petry, DO, FACOP, FAAP, Consulting Staff, Freeman Pediatric Care, Freeman Health System
Paul D Petry, DO, FACOP, FAAP is a member of the following medical societies: American Academy of Osteopathy, American Academy of Pediatrics, American College of Osteopathic Pediatricians, and American Osteopathic Association
Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD, Assistant Professor of Obstetrics/Gynecology and Pediatrics, Tufts University School of Medicine; Division Director, Pediatric and Adolescent Gynecology, Tufts Medical Center
Andrea L Zuckerman, MD is a member of the following medical societies: American College of Obstetricians and Gynecologists, Association of Professors of Gynecology and Obstetrics, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine
Disclosure: Nothing to disclose.

 
 
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