eMedicine Specialties > Pediatrics: Surgery > Gynecology

Labial Adhesions: Treatment & Medication

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

Treatment

Medical Care

Labial adhesions can often be managed with periodic observation, and spontaneous resolution has been reported in as many as 80% within 1 year.7 If treatment is necessary based on symptoms or parental request, estrogen cream is indicated. It is directly applied to the labia minora can be used twice daily for 2-4 weeks (see Medication).

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 46.7-100%.8 The use of steroid betamethasone 0.05% cream has also been described.9 Parental use of the pull-down maneuver may also facilitate gentle takedown of adhesions (see Physical). Once the labia separate, apply an emollient (eg, A&D ointment, Balmex, Aquaphor) or antibiotic ointment 3-5 times a day for several months to allow complete healing and prevention of recurrence.

Surgical Care

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.

Depending on the maturity of the child and the expectations of the parents, surgical separation can be performed in a physician's office using a lidocaine and prilocaine (EMLA) cream as a topical anesthetic. Blunt separation of the labia is then performed using a lubricated probe or hemostat. Anesthetic sedation prior to the procedure can be used in select cases.

Alternatively, labial adhesions can be taken down in the operating room under general anesthesia. The adhesions separate very easily but are painful in the office without any anesthesia. Suture oversewing of the adhesions is typically not required.

The decision between the office and the operating room setting is based on the density of the adhesions, patient maturity, and 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 operating room. The procedure is short and usually just requires gentle traction by the surgeon once anesthesia has been given. Postoperatively, an emollient needs to be placed on the separated labia minorum several times each day for 3-4 months by the patient or parent to prevent recurrence.

Consultations

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

Diet

Diet is not associated with labial adhesion formation.

Activity

Activity has no association with labial adhesions.

Medication

The primary treatment of labial adhesions is application of topical estrogen cream directly on the labia minora. Estrogen vaginal cream (conjugated estrogen cream or estradiol vaginal cream 0.01%) can be applied to the adhesions 2-3 times daily for several weeks. Once the adhesions start to separate, the application frequency can be decreased. 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.

Topical estrogens

These agents are indicated for the treatment of atrophic urogenital changes (eg, atrophic vaginitis, kraurosis vulvae, labial adhesions).


Dienestrol cream 0.01% (DV Vaginal Cream, Ortho Dienestrol Vaginal)

A synthetic, nonsteroidal estrogen, compounded in a cream base and suitable for intravaginal and topically to the vulvar area.

Adult

Apply topically and, if possible, intravaginally qd/bid for 1-2 wk, then maintenance dose 1-3 times wk in postmenopausal women to prevent recurrence

Pediatric

Apply to adhesions bid for 2 wk (most common dosage)

To various degrees, topical estrogens elicit all of the pharmacologic responses produced by endogenous estrogens (monitor for potential interactions); may reduce hypoprothrombinemic effect of anticoagulants; coadministration of barbiturates, rifampin, and other agents that induce hepatic microsomal enzymes may reduce estrogen levels; pharmacologic and toxicologic effects of corticosteroids may occur as a result of estrogen-induced inactivation of hepatic P450 enzyme; loss of seizure control has been noted when administered concurrently with hydantoins

Documented hypersensitivity; women who are or may become pregnant; avoid in patients with breast cancer, estrogen-dependent neoplasia, abnormal genital bleeding, or thromboembolic disorders; adverse systemic effects are rare in children and are reversible once treatment ends

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Caution in patients with history of thromboembolism, stroke, MI (especially those aged >40 y), liver tumor, hypertension, or cardiac, renal, or hepatic insufficiency

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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