NASPAG

Adhesions

By Janice L. Bacon, MD

 

 

drawings of normal anatomy and anatomy with labial adhesion present

Labial adhesions, also called labial agglutination, describes the changes in anatomy of the external genitalia of female infants and children in which the labia minora (small lips) and the edges of the vestibule appear joined in the mid-line—see illustration above—instead of remaining separated.

Diagnosis

The diagnosis of labial adhesions or agglutination is customarily made by close inspection of the external genitalia. A mid-line joining (called a raphe) of the labia minora and vestibule is noted. This may be thin and translucent or appear to be thick. The other female genital structures are completely within normal limits.

The adhesions may involve the entire length of the labia minora or only a portion, and below the labia minora, the edges of the vestibule. The area of external anatomy covered by a complete adhesion or agglutination is called the vestibule. When partial occlusion of the vestibule is present, it is usually the lower portion (posterior), and the opening may obscure the entrance to the vagina. When the labia minora and vestibule are completely adhesed, the openings to the vagina and to the bladder (urethra) are covered and only a tiny pinpoint opening is usually seen. In some girls, no opening is clearly visible.

The skin over the clitoris is also frequently adhesed or agglutinated. This is a normal finding in female children before puberty.

Frequency

Labial agglutination occurs most frequently in younger pre-pubertal girls ages 3 months to 6 years, though it may begin at any age and persist or reoccur until puberty. This problem is rarely seen after girls begin their pubertal growth (breast development, pubic, and axillary hair) due to production of estrogen by their ovaries. Estrogen, one of the two female hormones produced by the ovaries, provides a protective affect to the genital tissue making adhesions less likely to occur.

Etiology

Labial adhesions or agglutination are most commonly thought to be a result of some inflammation or irritation of the external genitalia, though in most circumstances no specific event can be described.

The finding may be asymptomatic and noticed at the time of a routine office visit or identified by a health care provider evaluating symptoms of urinary tract (bladder) infection, abnormal urinary emptying (stream of urine), vaginal discharge, or pain in the genital area. Pain may be especially prominent when performing straddle activities (riding a bicycle, teeter-totter, etc.). The presence of adhesions may also cause urine to be trapped in the vagina, resulting in dribbling after urination is thought to be complete.

Treatment Options

Asymptomatic girls
Symptomatic girls
  • No treatment may be needed
  • Topical estrogen
  • Manual separation

Treatment

Since labial agglutination in girls without symptoms may be an incidental finding, therapy may not be needed. Eventually the child’s own estrogen at the time of puberty will assist with spontaneous resolution.

Symptomatic children with suspected urinary tract infection, urinary retention, abnormal urinary stream, or recurrent vaginal infection may need to have the agglutination treated in order to resolve the condition or prevent future medical problems.

Sometimes concerns by family members, care takers, or day care workers may also play a role in the decision to continue to observe the adhesions or proceed with therapy.

Treatment options outlined in the accompanying table

When therapy is indicated but not emergent, an estrogen cream or ointment is usually the first medication chosen.

This topical cream or ointment is most successful in resolving the adhesions when applied to the mid-line raphe of the labia with a fingertip or Q-tip. Gentle traction at the time can be performed by the patient or parent and is helpful in assisting separation.

This therapy is customarily utilized for several weeks in order to provide adequate time for success.

Failed medical therapy indicates the need for manual separation of the labia. This should NOT be done forcefully without anesthesia.

Separation in the office may be accomplished with local anesthesia (topical jelly or ointment) or under sedation administered by an anesthesia team in an outpatient surgical setting.

At the time of separation, careful inspection for normal anatomy of the vagina and urethra is made.

Side Effects of Therapy

Forceful separation without adequate topical or systemic anesthesia may hurt the child’s relationship with the healthcare provider and compromise future exams.

Estrogen preparations may occasionally cause side effects, especially if used for prolonged periods longer than a few weeks. These include:

  • small amounts of breast budding or breast enlargement,
  • local irritation,
  • vaginal spotting or bleeding after the estrogen is discontinued. Breast budding or local irritation also resolve spontaneously when the medication is discontinued.

Following manual separation, use of estrogen cream for 1-2 weeks followed by use of a bland emollient (white petroleum jelly or other diaper rash preparation) for an indefinite period of time is indicated in order to prevent recurrence of the adhesions.

Recurrence

Recurrent adhesions of the labia minora may occur. Treatment of recurrences is based on the patient’s symptoms and findings at the time of recurrence and may not be the same treatment as that required for the original diagnosis.

Summary

Labial adhesions or agglutination are a common event in prepubertal girls. Their presence may warrant therapy if associated with pain or urinary symptoms. Topical estrogen is most common first line of treatment. Recurrence is possible, but rare after puberty.


Dr. Bacon is associate professor of obstetrics and gynecology. South Carolina School of Medicine, Columbia, SC.