Labial Adhesions

Labial adhesions (also referred to as labial agglutination) are a common disorder in prepubertal females.[1] This disorder is usually asymptomatic and is often first noticed by parents or during a routine physical examination.[2] A host of other pediatric vaginal or urethral disorders, including an imperforate hymen, müllerian agenesis, or a septate vagina, must be excluded.[3] 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.[4] 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.

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.[5] However, a 2007 study found no statistically significant difference in serum estradiol levels between infants with labial adhesions and control subjects.[6]

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.[7, 8]

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.[5] 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.[5] 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. They also occur in older women, albeit rarely.[9, 10]

No strong evidence supports a racial predilection.

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[11, 12] ; however, the true recurrence rate may be higher with longer follow-up.[13]  A study by Wejde et al suggested that manual separation may yield better overall final outcomes than topical estrogen.[14] One report noted a decreased recurrence rate when topical estrogen was used after manual reduction of labial adhesions.[12] 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,[11]  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.

Labial adhesions are an asymptomatic disorder usually noted by parents or during routine examination. Some patients experience urine pooling in the vagina with voiding, 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.

The physical examination is aided by positioning the child in a frog-leg position (if the patient is younger than 18 months) or a dorsal lithotomy position (if he or she is older than 18 months) and using a pull-down procedure in which the labia majora are gently retracted caudally and laterally to permit better visualization of the vagina. Pulling too hard can cause pain to the child and may lead to difficult examinations in the future.

Generally, labial adhesions are readily apparent as thin, pale, semitranslucent membranes covering the vaginal opening between the labia minora (see the images below). In severe cases, these adhesions entirely close the vaginal introitus.

Typical appearance of labial adhesions.

Labial adhesions before lysis.

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 (eg, fusion of the labia majora, which can occur with differences [disorders] of sex development [DSDs]).

One study reported that 18% of girls with labial adhesions had asymptomatic bacteriuria, compared with 0% of control subjects; accordingly, the authors made the recommendation for routine urine culture in children with labial adhesions.[15]  However, if the patient is asymptomatic, there is no need to send a urine culture.

No specific imaging studies are required to evaluate labial adhesions.

Labial adhesions can often be managed with periodic observation, and spontaneous resolution has been reported in as many as 80% within 1 year.[16]  Most will resolve once endogenous estrogen production begins.[4]

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 or if labial adhesions are severe and associated with urinary retention, manual or surgical separation may be considered. Other reasons to consider intervention include severe fibrous dense adhesions or rare cases with urinary retention. (See the images below.)

Labial adhesions before lysis.

Labial adhesions after lysis.

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

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.[4, 17] 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%.[11] 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%.[18] 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.[19] Another study of 151 patients noted that a shorter duration of treatment was required with betamethasone ointment.[20]

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.

Depending on the maturity of the child and the expectations of the parents, surgical separation may be performed in a physician’s office,[21] 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 or in a sedation center. The adhesions separate very easily, but the process of separation is painful in the office without any anesthesia.[4] 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

In many cases, young patients who require manual separation for failure of estrogen cream treatment will tolerate the procedure best in the OR or under sedation. 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. A study by Morin et al cited a recurrence rate of 9% (2/22) after surgical treatment of labial adhesions (median follow-up, 4.3 mo).[22]

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.

The primary treatment of labial adhesions is direct application of topical estrogen cream to the labia minora. 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.

Class Summary

Topical estrogens are indicated for the treatment of atrophic urogenital changes (eg, atrophic vaginitis, kraurosis vulvae, and labial adhesions).

Estradiol, topical (Estrace)

Topical estrogens may reduce pH levels and mature the vaginal and urethral mucosa after 12 weeks of therapy, thereby improving mucosal atrophy. The cream 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.

Conjugated estrogens, vaginal (Premarin Vaginal Cream)