Labial Adhesions - Parts, Causes, Symptoms, Diagnosis, and Management

Introduction:

The labial adhesions are also known by the terms “labial agglutinations” and “synechia vulva.” It is when the two inner lips or labia minora are fused. The female external genitalia has a large outer lip (labia majora) and a small inner lip (labia minora). These labia minora are seen on the sides of the vagina and get joined near the clitoris. But in the case of fused labia, the minora muscles get attached. This is a common finding in children between three months to six years of age. The exact cause of this fusion is still unknown. It is thought to be due to low estrogen levels that are common during early childhood and also before puberty.

What Are the Parts of the Female External Genitalia?

The external genitalia consists of the following.

• Vaginal opening.

• Urethral opening.

• Folds of the skin around the vagina and urethra. The outer lips or fold is called labia majora and the inner lips or fold is called labia minora.

• Clitoris - the small sensitive structure at the junction of the two inner lips. This usually becomes sensitive during sexual activity.

What Are the Physiologic Changes in Labial Adhesions?

Generally, the inner lips or labia minora run around the vagina and urethra and join at one particular area called the clitoris. But in the case of labial adhesions, the inner lips are fused. In some cases, the fusion is seen along the entire length, which may interfere with urination, but they do not interfere with the fertility of the baby.

What Is the Incidence of This Condition?

• It is seen in female babies between three months to six years of age.

• It affects about 2 in 1000 children.

What Causes Labial Adhesions?

The exact cause is still unclear. However, it is thought that several reasons may contribute to this condition. They are:

• Hypoestrogenic state- Relatively low levels of estrogen that are common during early childhood and before puberty.

• Irritations to the external genitalia might also cause the fusion to occur. The irritants are:

• Labial injuries, trauma, or genitourinary surgery.

• Inflammation and infection that results in vulvitis (inflammation of the soft tissue around the vagina) and atopic dermatitis (a skin condition that causes redness and itching.)

• Poor hygiene and fecal soiling might result in chronic inflammation.

• Use of strongly perfumed powders, lotions, and soaps.

• Diaper irritation, rashes, and unchanged wet diapers.

• Sexual abuse results in local tissue damage.

• Pinworm infection.

How Do They Manifest Clinically?

• They are usually asymptomatic and noticed during the general examination and often by the parents during a diaper change.

• Pain may be seen in the genital area.

• Difficulty in voiding and painful urination.

• In severe cases, dribbling of urine even after urination may be seen.

• Retention of urine.

• Vulval soreness and itching.

• Recurrent bladder and urinary tract infections are seen in severe cases.

What Is the Differential Diagnosis for Labial Adhesions?

There are a few conditions that look similar to these labial adhesions. They are:

• Hymenal Skin Tags: The hymen layer is swollen in newborns due to maternal estrogen.

• Imperforate Hymen: Hymen covers the entire opening of the vagina.

• Introit Cysts: They are small grape-like clusters of cysts arising from the hymen layer and seen on either side of the vagina

• Ureterocele: A small swelling seen at the bottom of the uterus.

• Urethral Prolapse: The urethra gets pushed into the vaginal canal.

• Vaginal Atresia: Vagina is either closed or absent.

• Vaginal Rhabdomyosarcoma: It is a tumor that arises from the bladder or vagina.

How to Diagnose Labial Adhesions?

Labial adhesions are diagnosed clinically through physical examination, and they are most often noticed by the parents during diaper changes. The doctor checks for genital abnormalities such as a closed hymen which is usually seen as a white line in the vulval area. The vaginal and the urethral openings may be partially or fully covered. Generally, labial adhesions do not require special tests for their diagnosis. However, urine tests and voiding cystourethrogram may be performed occasionally.

• Urine Tests: They are performed to rule out infections of the urinary tract.

• Voiding Cystourethrogram: This test checks for the enlargement of the bladder and the kidneys.

How Are Labial Adhesions Managed?

Most of the patients are asymptomatic and require no treatment. About 80 % of the cases resolve without any treatment. However, if the child is symptomatic and requires treatment, then the treatment plan depends upon the severity.

1. Mild Cases: The the vaginal opening remains intact and symptoms such as pain are not seen, then no specific treatment is required. This may resolve on its own.

2. Moderate Cases:The lower part of the vagina may be obstructed. The treatment includes the application of mild ointment for several weeks and is gently separated.

The medications used are:

• Vaseline: Applied in the vulvar areas with gentle pressure on the fused areas. This separates the fused areas when the medication is applied for a longer duration.

• Estrogen Ointments (Premarin Cream): This results in the softening of the vulvar areas when applied for a longer period. However, these estrogen creams may cause some side effects, such as the development of pubic hairs, breast tenderness and budding, and genital irritation. These side effects may subside soon after the medication is stopped. As this medication has resulted in adverse effects in the pediatric population, they are recommended only for a short period.

• Topical Steroids: They are similar to estrogen creams. Steroids such as Beclomethasone and Betamethasone may be applied to the adhesions, and this relieves the symptoms of pain and inflammation. However, this may also result in itchiness and redness on the applied area and an increased risk of infection.

3. Severe Cases: In severe cases, if they do not respond to the topical medications, then surgical management is the only option. The surgical lysis of the adhered tissue is done. If the adhesions are thick, then it is performed under general anesthesia in an operating theater, and if the adhesions are thin, then topical or local anesthesia may be sufficient for the procedure. After the surgical management, it is important to apply vaseline on either side so that they do not replace while healing.

Do Labial Adhesions Recur?

Yes, they have a high recurrence rate irrespective of the mode of treatment. The recurrence is common until the child attains puberty, when the estrogen levels rise. Hence topical ointments and lubricants may be prescribed to keep the labia open.

Conclusion:

Labial adhesion is not a serious condition to worry about in your child. When the estrogen levels increase nearing pubertal age, the condition gets rectified. If your baby is asymptomatic, then no treatment is required. All that you have to do is to keep the private parts of your baby clean. Wipe them properly after urination and bowel movements. Only if your child is suffering from pain or any other symptoms, then talk to the doctor and get treated. Also, the parents should be informed that even the best treatment could cause the condition to relapse and resolve on its own.