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Labial Adhesions Treatment & Management

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

Approach Considerations

Labial adhesions can often be managed with periodic observation, and spontaneous resolution has been reported in as many as 80% within 1 year.[11]  Most will resolve once endogenous estrogen production begins.

If treatment is necessitated by symptoms or blockage of most of the vaginal opening, topical estrogen cream is indicated. If medical care does not result in separation of the labia minora, manual or surgical separation may be considered. Other reasons to consider intervention include severe fibrous dense adhesions or rare cases with urinary retention.

Because labial adhesions may be associated with modifiable factors, including vaginal irritation or inflammation, avoiding exposure to possible irritants (eg, strong detergents, bubble baths, harsh soaps) may be beneficial.

Referral to a pediatric gynecologist or urologist can be made by providers uncomfortable with treating labial adhesions and in cases resistant to medical management.

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Topical Agents and Emollients

Primary treatment of labial adhesions consists of applying topical estrogen cream (conjugated estrogen cream or estradiol vaginal cream 0.01%) directly onto the area of adhesions of the labia minora. The cream can be applied to the adhesions two or three times daily for several weeks. Once the adhesions start to separate, the application frequency can be decreased and application of an emollient added.

A literature review performed in 2007 reported that the success rate of topical estrogen intervention in girls with labial adhesions is typically about 90%, with published success in case series reports ranging from 46.7% to 100%.[7] Adverse systemic effects from estrogen application are rare and include local irritations, vulvar pigmentation, and breast enlargement. These effects are reversible once treatment is stopped.

The use of steroid betamethasone 0.05% cream has also been described, with a reported success rate of 68%.[12] However, a single-institution retrospective series reported success rates of only 15% with topical estrogen, 16% with topical betamethasone, and 29% with combination therapy; there were no statistically significant differences between treatments.[13] Another study of 151 patients noted that a shorter duration of treatment was required with betamethasone ointment.[14]

Parental use of the pull-down maneuver may also facilitate gentle takedown of adhesions but may be painful for the child. Once the labia separate, an emollient (eg, A+D Original Ointment [MSD Consumer Care], Balmex [Chattem], or Aquaphor [Beiersdorf]) should be applied three to five times daily for several months to allow complete healing and minimize the chances of recurrence.

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Manual or Surgical Separation

Depending on the maturity of the child and the expectations of the parents, surgical separation may be performed in a physician’s office, with a lidocaine and prilocaine (EMLA) cream employed as a topical anesthetic. Blunt separation of the labia is then performed by gently pulling the labia laterally or with a lubricated probe, hemostat, or cotton-tipped swab. In selected cases, anesthetic sedation before the procedure may be warranted.

Alternatively, labial adhesions may be taken down in the operating room (OR) with the patient under general anesthesia. The adhesions separate very easily, but the process of separation is painful in the office without any anesthesia.[2] Suture oversewing of the adhesions is not required.

The decision whether to perform the procedure in the office or in the OR is based on the following considerations:

  • The density of the adhesions
  • The patient’s level of maturity
  • The patient’s ability to tolerate an in-office procedure

Most young patients who require manual separation for failure of estrogen cream treatment tolerate the procedure best in the OR. The procedure is short and usually requires only gentle traction by the surgeon once anesthesia has been provided. Postoperatively, to prevent recurrence, the patient or a parent must apply an emollient to the separated labia minora several times daily for 3-4 months.

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Long-Term Monitoring

Once the labial adhesions have been separated, either by medical means or through surgical treatment, an emollient (eg, antibiotic ointment or diaper rash cream) should be applied several times a day for several months to allow the labial edges to heal without repeat adhesion formation.

Because labial adhesions are usually asymptomatic and rarely constitute an emergency, follow-up care should be provided in the office of the pediatrician, a pediatric gynecologist, or a pediatric urologist.

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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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