LABIAL ADHESION (LA) LABIAL ADHESION

Asst. Prof. Dr. Nurkhairulnisa Abu Ishak

is the fusion of the labia minora or majora. It starts at the back of the fourchette and moves towards the clitoris. Most often, labial adhesions are encountered in prepubertal age group due to hypoestrogenic state. It occurs most commonly between 3 months and 3 years of age. Parents most often diagnose incidentally while changing diapers. Some patients may present with symptoms involving urinary tract like dysuria, increased frequency, inability to pass urine or dribbling.

The labial adhesions may range from small partial fusion to complete fusion that can occlude the vaginal orifice. These adhesions are related to local irritation and inflammation at an age when estrogen levels are low. Other postulations of adhesions are thinning of the vulva, lack of good and proper hygiene, lichen sclerosis, vulva coming in touch with urine, local infection, and physical irritants. Diagnosis is usually clinical and there is hardly any need for detailed investigations. The differential diagnosis should include hymenal skin tags, imperforate hymen, transverse vaginal septum, and vaginal atresia. This can easily be done by careful history and detailed clinical examination.

For the parents to notice such a condition in their child is worrisome. Most of them are not convinced with the conservative treatment offered to them and demand prompt cure. Therefore, it is important to make them understand the fact that if the patient is clinically asymptomatic, there is no requirement for treatment. Initial management of every case is reassurance as most of the adhesions resolve naturally with time or with onset of puberty. It is reported that up to 80% resolve spontaneously without any treatment before puberty as estrogen levels increase and the vaginal epithelium becomes multi-layered and cornified.

Previously LA would have been treated with estrogen cream or by manual separation. Recent studies have shown that success rates for both estrogen cream and manual separation are quite low. There were concerned on the use of estrogen cream in young girls as it was associated with breast tenderness, vaginal bleeding and vulvar pigmentation. However, most studies have reported that the side effects were mild and transient. An alternative to estrogen therapy is topical betamethasone.

Surgical separation should only be reserved for those who were resistant to conservative treatment or those who presented with urinary retention. Surgical separation preferably be done under general anaesthesia to reduce the psychological trauma to these young girls. Recurrences are common with labial adhesions, regardless of the mode of treatment used. Labial adhesions may keep reforming until the female patient goes through puberty. Some studies report a rate of recurrence from 11% to 14% with either topical or surgical management.

In conclusion, despite being a benign entity, labial adhesion in prepubertal girls may be a cause of severe concern and a source of great parental anxiety. To avoid repetitive treatment, reassurance and conservative management is the best approach if the patient is asymptomatic.

References

1. Gonzalez D, Anand S, Mendez MD (2021) Labial adhesions. In: StatPearls. StatPearls Publishing, Treasure Island

2. Eroğlu E, Yip M, Oktar T, Kayiran SM, Mocan H (2011) 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 24:389–391.

3. Granada C, Sokkary N, Sangi-Haghpeykar H, Dietrich JE (2015) Labial adhesions and outcomes of office management. J Pediatr Adolesc Gynecol 28:109–113.

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Dr. Loh Sweet Yi Esther