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Labial Adhesions

  • Author: Kenneth G Nepple, MD; Chief Editor: Andrea L Zuckerman, MD  more...
 
Updated: Dec 03, 2015
 

Practice Essentials

Labial adhesions (also referred to as labial agglutination) are a common disorder in prepubertal females. They are a fusion of labia minora in the midline, are usually asymptomatic, and typically can be treated conservatively. Labial adhesions must be differentiated from other pediatric vaginal or urethral disorders (eg, an imperforate hymen or a septate vagina). They most commonly occur between 3 months and 3 years of life. See the image below.

Typical appearance of labial adhesions Typical appearance of labial adhesions

Signs and symptoms

Although labial adhesions are generally asymptomatic, the following may be noted:

  • Urine pooling in the vagina with voiding and subsequent urine leakage from the vagina upon standing after voiding (postvoid dribbling or vaginal voiding)
  • Associated urinary tract infection (UTI)
  • Discomfort with voiding

The following physical findings may be present:

  • Thin, pale, semitranslucent adhesions covering the vaginal opening between the labia minora, sometimes entirely closing the vaginal opening, typically beginning posteriorly and progressing a variable distance anteriorly toward the clitoris
  • Other interlabial masses or genital anomalies
  • Signs of sexual abuse

See Presentation for more detail.

Diagnosis

Conditions to be considered in the differential diagnosis include the following:

  • Hymenal skin tags
  • Imperforate hymen
  • Introital cysts (paraurethral or Gartner duct cysts)
  • Ureterocele
  • Urethral polyp
  • Urethral prolapse
  • Vaginal atresia or müllerian agenesis
  • Vaginal rhabdomyosarcoma

Some recommend routine urine culture in children with labial adhesions, but this is usually done if patients have any urinary symptoms.

See DDx and Workup for more detail.

Management

Labial adhesions can often be managed with periodic observation; spontaneous resolution may occur and commonly occurs during puberty. Further management considerations are as follows:

  • If treatment is necessitated by symptoms or parental requests such as frequent UTIs, topical estrogen cream is indicated
  • If medical care does not result in separation of the labia minora or if urinary retention or UTIs are present, manual or surgical separation may be considered
  • Avoiding exposure to possible irritants (eg, strong detergents, bubble baths, harsh soaps) may be beneficial
  • Referral to a pediatric urologist or gynecologist may be appropriate if the provider is uncomfortable with treating labial adhesions or if medical management is unsuccessful

See Treatment and Medication for more detail.

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Background

Labial adhesions (also referred to as labial agglutination) are a common disorder in prepubertal females. This 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, müllerian agenesis, or a septate vagina, must be excluded. Labial adhesions occur most commonly in prepubertal girls, as they are hypoestrogenic. They may occur more frequently in the setting of vulvovaginitis.

Treatment of labial adhesions is typically conservative.[2] If treatment is needed, parents should be instructed to apply an emollient after the labia have separated to prevent recurrence of the adhesions. They should also be informed that the possibility of recurrence may necessitate repeated procedures or therapies.

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Pathophysiology and Etiology

Labial adhesions are fibrous adhesions between the labia majora. Low estrogen levels have been thought to play a causative role in their formation, and the protective effect of maternal estrogen makes labial adhesions uncommon during the newborn period.[3] However, a 2007 study found no statistically significant difference in serum estradiol levels between infants with labial adhesions and control subjects.[4]

Labial adhesions may also be caused by vaginal inflammation, local irritation, or tissue trauma. They have been reported to result from childhood sexual abuse and may be associated with lacerations or hematoma.[5, 6]

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Epidemiology

A prospective study of more than 1900 girls assessed through a pediatric outpatient clinic reported a 1.8% incidence of labial adhesions, whereas a review of more than 9000 female infants found no cases of neonatal labial adhesions.[3] The incidence of labial adhesions worldwide is unknown but presumably is similar to the US incidence.

Labial adhesions are, by definition, a disorder of females and occur most often in infants and girls aged 3 months to 6 years, with a peak incidence around the age of 13-23 months.[3] Labial adhesions have not been reported in the newborn period. If left untreated, labial adhesions usually spontaneously resolve at puberty as a consequence of increased estrogen levels. No strong evidence supports a racial predilection.

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Prognosis

The prognosis for girls with labial adhesions is excellent. If left untreated, the condition usually resolves spontaneously at puberty.

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

Recurrence of labial adhesions is common and has been reported in as many as 11.6-14% of cases[7, 8] ; however, the true recurrence rate may be higher with longer follow-up.[9] One report noted a decreased recurrence rate when topical estrogen was used after manual reduction of labial adhesions.[8] It is important to counsel the parents to use an emollient several times a day for several months.

Adverse systemic effects of estrogen cream are rare and reversible once medication is discontinued. Estrogen cream application often causes temporary hyperpigmentation of the skin in the area of application; patients should be reassured that this hyperpigmentation normally fades after therapy ends. Another reported side effect is breast tenderness or enlargement,[7]  which resolves when use of the cream is stopped.

To decrease the risk that labial adhesions will recur after having been opened either by use of estrogen cream or by manual separation, an emollient should be used several times a day for several months.

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Contributor Information and Disclosures
Author

Kenneth G Nepple, MD Assistant Professor, Department of Urology, University of Iowa Hospitals and Clinics

Kenneth G Nepple, MD is a member of the following medical societies: Alpha Omega Alpha, American Urological Association

Disclosure: Nothing to disclose.

Coauthor(s)

Christopher S Cooper, MD, FACS, FAAP Professor with Tenure and Vice Chair, Department of Urology, Professor, Department of Pediatrics, Associate Dean for Student Affairs and Curriculum, Children's Hospital of Iowa and University of Iowa, Roy J and Lucille A 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 Medical Association, Phi Beta Kappa, Society for Pediatric Urology, Society for Fetal Urology, International Children's Continence Society, American College of Surgeons, American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Andrea L Zuckerman, MD Associate Professor of Obstetrics/Gynecology, 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, Massachusetts Medical Society, North American Society for Pediatric and Adolescent Gynecology

Disclosure: Nothing to disclose.

Acknowledgements

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.

Elizabeth Alderman, MD Director of Fellowship Training Program, Director of Adolescent Ambulatory Service, Professor of Clinical Pediatrics, Department of Pediatrics, Division of Adolescent Medicine, Albert Einstein College of Medicine and Children's Hospital at Montefiore

Elizabeth Alderman, MD is a member of the following medical societies: American Academy of Pediatrics, American Pediatric Society, North American Society for Pediatric and Adolescent Gynecology, and Society for Adolescent Medicine

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center; Chairman, Pediatric Institutional Review Board, Mercy St Vincent Medical Center, Toledo, Ohio

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.

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. 2008 Jan-Mar. 18(1):35-8. [Medline].

  2. Bacon JL, Romano ME, Quint EH. Clinical Recommendation: Labial Adhesions. J Pediatr Adolesc Gynecol. 2015 Oct. 28 (5):405-9. [Medline].

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

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

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

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

  7. 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. 2007 Mar. 92(3):268-71. [Medline].

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

  9. 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. 2006 Oct. 19(5):337-9. [Medline].

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

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

  12. 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. 2006 Dec. 19(6):407-11. [Medline].

  13. Eroglu E, Yip M, Oktar T, Kayiran SM, Mocan H. How should we treat prepubertal labial adhesions? Retrospective comparison of topical treatments: estrogen only, betamethasone only, and combination estrogen and betamethasone. J Pediatr Adolesc Gynecol. 2011 Dec. 24(6):389-91. [Medline].

  14. Mayoglou L, Dulabon L, Martin-Alguacil N, Pfaff D, Schober J. Success of treatment modalities for labial fusion: a retrospective evaluation of topical and surgical treatments. J Pediatr Adolesc Gynecol. 2009 Aug. 22(4):247-50. [Medline].

  15. Gibbon KL, Bewley AP, Salisbury JA. Labial fusion in children: a presenting feature of genital lichen sclerosus?. Pediatr Dermatol. 1999 Sep-Oct. 16(5):388-91. [Medline].

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Typical appearance of labial adhesions
 
 
 
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