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Labial Adhesions
Background: Adhesion of the labia is a common disorder in the female pediatric population. The disorder usually is asymptomatic and is first noticed during a routine physical examination. Treatment of labial adhesions is straightforward, but a host of other pediatric vaginal disorders—including an imperforate hymen or a septate vagina—must be excluded prior to treatment.

Pathophysiology: The etiology of labial adhesions probably relates to vaginal inflammation or irritation. Once the superficial epithelium of the labia is denuded, subsequent healing leads to fibrous adhesions between the labia.

Frequency:

  • In the US: This relatively common disorder occurs in 1-2% of females aged 3 months to 6 years. A recent study noted a 5% incidence rate in the pediatric female population.
  • Internationally: Incidence of labial adhesions worldwide is unknown but presumably similar to US incidence.

Mortality/Morbidity: Labial adhesions are generally asymptomatic and not a common cause of urologic or gynecologic morbidity. Labial adhesions occasionally cause outflow obstruction, leading to vaginal reflux of urine and subsequent vaginal leaking when the child stands after voiding.

Race: No strong evidence exists for a racial predilection.

Sex: Labial adhesion is a female pediatric disorder.

Age: Labial adhesions occur most often in infants and girls aged 3 months to 6 years. If left untreated, labial adhesions usually resolve spontaneously at puberty.

History: Labial adhesion is an asymptomatic disorder usually noted during routine examination. Some patients complain of leaking urine when they stand after voiding.

Physical: Labial adhesions generally are readily apparent. Thin, pale, semitranslucent membranes cover the vaginal os between the labia minora. In severe cases, these adhesions entirely close the vaginal os.

Causes: Labial adhesions probably are caused by vaginal inflammation or irritation, which, in some cases, could be the result of sexual abuse.

Other Problems to be Considered:

Imperforate hymen and other vaginal abnormalities should not be mistaken for labial adhesions.

Lab Studies:

  • No specific laboratory tests are required to evaluate labial adhesions.

Imaging Studies:

  • No specific imaging studies are required to evaluate labial adhesions.

Medical Care: Periodically observe the patient's condition. If treatment is necessary or requested, prescribe estrogen cream application (see Medication). Once the labia separate, apply antibiotic ointment for several more weeks to allow complete healing.

Surgical Care: If medical care does not result in separation of the labia minora, consider surgical lysis. Depending upon the maturity of the child and the expectations of the parents, surgical separation can be performed in a physician's office. Use prilocaine cream and perform a blunt separation of the labia using a hemostat. Anesthetic sedation prior to the procedure is recommended in some cases.

Diet: Diet is not associated with labial adhesion formation.

Activity: Activity has no association with labial adhesions.

The primary treatment for labial adhesions is application of topical estrogen cream. Dienestrol 0.01% cream can be applied to the adhesions twice daily for 2 weeks. Adverse systemic effects from estrogen application are rare and reversible once treatment is stopped.
 

Drug Category: Topical estrogens -- Indicated for the treatment of atrophic urogenital changes (eg, atrophic vaginitis, kraurosis vulvae, or labial adhesions).

Drug Name
 		 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 Dose 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 Dose Apply to adhesions bid for 2 wk (most common dosage)
Contraindications 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
Interactions To various degrees, topical estrogens elicit all of the pharmacologic responses produced by endogenous estrogens, therefore 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
Pregnancy X - Contraindicated in pregnancy
Precautions Caution in patients with history of thromboembolism, stroke, MI (especially those aged >40 y), liver tumor, hypertension, or cardiac, renal, or hepatic insufficiency

 

Further Outpatient Care:

  • Once the labial adhesions separate, either by medical means or surgical treatment, apply antibiotic ointment for several weeks to allow the labial edges to heal without repeat adhesion formation.
  • Because labial adhesions rarely are a symptomatic or an emergent issue, follow-up care should occur in the office of the pediatrician, pediatric gynecologist, or pediatric urologist.

Deterrence/Prevention:

  • While the etiology of labial adhesions is uncertain, they probably are associated with vaginal irritation or inflammation. Advise parents of patients to avoid exposing the child to possible irritants (eg, strong detergents, bubble baths, harsh soaps).

Complications:

  • Recurrence of labial adhesions is common and may require prolonged follow-up and antibiotic ointment administration. 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. Reassure parents that hyperpigmentation normally fades after therapy ends.

Prognosis:

  • The prognosis for girls with labial adhesions is excellent. If left untreated, the condition usually resolves spontaneously at puberty.

Patient Education:

  • Parents should understand that they must continue to apply medications, even after the labia have separated, to prevent recurrence of labial adhesions.

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