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. [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.)
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.
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. [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.
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, [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:
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The density of the adhesions
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The patient’s level of maturity
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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]
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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Typical appearance of labial adhesions.
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Labial adhesions before lysis.
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Labial adhesions after lysis.
