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Management of Labial Adhesions in Prepubertal Girls
J Pediatr Adolesc Gynecol (2000) 13:183–186
Opinions in Pediatric and Adolescent Gynecology Edited by Hatim A. Omar, MD University of Kentucky, Department of Pediatrics, Kentucky Clinic, Lexington, Kentucky
Management of Labial Adhesions in Prepubertal Girls Every year, at least one of my pediatric residents or medical students asks me why the recommended treatment for labial adhesion in prepubertal girls changes from mechanical separation to medical treatment in different books, or even in different chapters of the same book. I have seen my share of referrals with referring diagnosis, varying from sexual abuse to vaginal agenesis, that were in fact simple labial adhesion. The high incidence of this condition is a good enough reason for all primary care providers to be familiar with and comfortable in diagnosing and managing it in their patients. Despite the frequency of labial adhesion in prepubertal girls, few serious studies had addressed the issue of optimal treatment and opinions continue to differ especially between urologists and pediatric gynecologists. In my personal experience since 1985, I have not had to resort to mechanical separation in any of my patients. Hoping to decrease the confusion on this issue, we present here the views of two outstanding experts in pediatric and adolescent gynecology on management of this condition. The two opinions, while not entirely different, are not exactly the same either, but provide good arguments that I hope will help primary care providers in their decision-making regarding labial adhesion.
Labial adhesions is an acquired condition in which the labia minora are fused over the vestibule. It is estimated to occur in 0.6–3.0% of prepubertal girls.1–4 However, because many children with labial fusion are asymptomatic, the prevalence of labial adhesions may be even greater. The etiology of labial adhesions is not known, but is presumably related to the low levels of estrogens in the prepubertal child. It had been suggested that the thin skin covering the labia
could be denuded as a result of local irritation and scratching. The labia then adhere in the midline, and as reepithelialization occurs on both sides, the labia remain fused in the midline.5 The diagnosis of labial adhesions is made by the visual inspection of the vulva. The examiner can see a thin, avascular line of fusion in the midline. Not all girls with labial adhesions require therapy. Asymptomatic girls, often with minor degrees of labial adhesion, require observation only. Treatment is indicated in symptomatic girls who present with dysuria or recurrent vulvar or vaginal infections.6 On rare occasion, a child may present with urinary retention.5 For many years, topical treatment with conjugated estrogens had been the mainstay of conservative therapy, with a presumed success rate of close to 90%.6 This optimism was based on a report that such therapy resulted in resolution in 88% of patients. Unfortunately, that particular study included only 25 girls.7 However, the clinical experience over the years was mixed. Some children—particularly those with filmy adhesions—responded to topical estrogen therapy, and separation of the labia was often achieved within 7–10 days of therapy. However, some girls required a more prolonged course of therapy (6–8 weeks), and some did not respond to even that extended course of topical therapy. Girls with dense, fibrous adhesions often did not respond to topical therapy. Some of the girls who fail therapy often present with thin, filmy adhesions, which the physician is often able to separate in the office using a Q-tip and topical xylocaine. A recent study reported the experience in one clinic with topical estrogen for the treatment of labial adhesions.8 In that particular study, 259 symptomatic girls, age 1–7 years with labial adhesions were treated with topical estrogen for 10–14 days. Following the topical application, the fused labia separated in only 121 (47%) patients. Success rates were even lower in girls who underwent previous surgical separation and those with dense, fibrous adhesions.
2000 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
1083-3188/00/$20.00
Manual Separation of Labial Adhesions in Prepubertal Girls
Discussant: David Muram, MD Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
184
Opinions in Pediatric and Adolescent Gynecology
The author reported that by applying a generous amount of Xylocaine gel to the line of fusion and the vestibule, he was able to insert a Q-tip or sound behind the fused labia. The instrument was then aligned against the line of fusion and pulled gently forward. This technique was attempted in 138 patients and was successful in 112 (81%). However, surgical separation of the labia under general anesthesia was required in the remaining 26 patients who were either noncooperative and did not permit office manipulation of the fused labia (n ⫽ 9) or in whom office separation under topical anesthesia failed (n ⫽ 17). All patients in whom the office procedure failed were 3 years of age or older, and had either dense, fibrous adhesions or long-standing fusion of the labia.8 Following mechanical separation Premarin (vaginal cream) was applied to the denuded labial edges twice daily for five days to prevent reformation of adhesions.8 Using office separation under topical anesthesia as an adjunct to topical estrogen therapy allows the physician to avoid surgery in most patients. In one study, surgical separation was needed for only 29 (11%) of 262 patients who were seen initially and for 7 (19.4%) of 36 girls with recurrent labial adhesions.8 Despite efforts to avoid general anesthesia, an operative procedure is indicated for patients with urinary retention, for patients who are noncooperative with office separation, or for those with significant scarring. Unfortunately, patients with recurrent adhesions following surgical separation are at risk to require another surgical separation should the adhesions recur. In conclusion, because of the relatively high failure rate of topical estrogen therapy, the treating physician should make arrangements for follow-up at the completion of the treatment course and be prepared to separate the labia in patients who did not respond to topical estrogen therapy. The mechanical separation may prevent prolonged exposure to estrogens in some girls and surgical intervention in others.
References 1. Benn˜ Ami T, Boichis H, Hertz M: Fused labia. Clinical and radiological findings. Pediatr Radiol 1978; 7:33 2. Huffman JW, Dewhurst CJ, Carpraro VJ: The Gynecology of Childhood and Adolescence. 2nd ed. W.B. Saunders, Philadelphia, 1981, pp. 105–107 3. Nowlin P, Adams JR, Nalle BC Jr: Vulvar fusion. J Urol 1949; 62:75 4. Capraro VJ, Greenberg H: Adhesions of the labia minora. Obstet Gynecol 1972; 39:65 5. Stovall TG and Muram D, Urinary retention secondary to labial adhesions. Adolec Pediatr Gynecol 1988; 1:203
6. Sanfilippo J, Muram D, Lee P, Dewhurst JC: Pediatric and Adolescent Gynecology. W.B. Saunders Co., Philadelphia, 1994, pp. 206–208 7. Aribarg A: Topical oestrogen therapy for labial adhesions in children. Br J Obstet Gynaecol 1975; 2:424 8. Muram D: Treatment of labial adhesions in prepubertal girls. Adoelsc Pediatr Gynecol 1999; 12:67
Pro-Conservative Management for Asymptomatic Labial Adhesions in the Prepubertal Child
Discussant: Betsy Schroeder, MD Director, Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Allegheny General Hospital, Pittsburgh, Pennsylvania
Labial adhesions are a common finding in prepubertal girls. The hypothesized etiology of the transient complete or partial fusion of the labia minora is the combination of hypoestrinism and vulvar irritation. The incidence may be as high as 21.3%1 to 38.9%2 of girls who were not known or suspected to have been sexually abused. Given the frequency of such findings, one might consider labial adhesions to be a normal finding in the prepubertal girl. Clearly not all cases are recognized and treated in a routine practice, and no long-term problems as a result of not treating these cases have been identified. Reports suggest that over 80% of cases spontaneously resolve within one year.3 Virtually all cases resolve spontaneously with the onset of puberty, and there are only case reports of persistence requiring treatment after the onset of puberty in adolescents.4,5 Once the reproductive years are reached, labial adhesions are extremely unusual, even if inciting factors such as active herpes lesions are present, until the postmenopausal period. Treatment for labial adhesions may be medical or surgical. Medical treatment involves the application of topical estrogen to the affected area. If applied sparingly and appropriately, there is minimal risk involved; however, this treatment is not completely without risk. Although transient, there may be hyperpigmentation of the labia.6 It is also well known that topical estrogen is systemically absorbed and if used in excess can cause breast development, vaginal bleeding, and ultimately true precocious puberty. Finally, successful separation as a result of estrogen cream varies from 50%7 to 88%.6 If treatment is initiated and fails, manual or surgical separation is the inevitable next step. Separation in the office has its own set of risks. Topical anesthetic agents such as eutectic mixture of local anesthetics (EMLA, Astra Belgium, Brussels) cream are considered safe but may not provide adequate anesthesia. Due to the anatomy, it is often difficult to adequately place the required occlusive
Opinions in Pediatric and Adolescent Gynecology
dressing over the anesthetic agent, so it may not work as effectively as it does on other sites. A study by Smith and Smith8 found that EMLA was less effective in controlling pain in labial separation than in meatotomy for meatal stenosis and newborn circumcision. According to parents of children who had undergone this procedure under EMLA, 7 children had mild discomfort, 5 had moderate discomfort, and 2 had severe discomfort. One of the rules of pediatric gynecology is to avoid traumatizing the child; a 50% chance of moderate to severe discomfort is too great a risk. The only other alternative to treat these girls is to take them to the operating room for separation under general anesthesia or local anesthesia plus sedation. In this situation, the risk of discomfort during the procedure is minimal, but the anesthetic risks are much greater. In a retrospective chart review, 26 of 138 (19%) girls failed office separation using topical anesthesia and required surgical separation in the operating room.7 Once separation does occur, whether by medical or surgical means, there is a high rate of recurrence. In one study of 14 girls who had undergone labial separation in the office, the recurrence rate after 16 months (range 1–32 months) was 17%.8 In Muram’s study7 36 of 259 (14%) girls who had been treated for labial adhesions had recurrences requiring separation in the office or in the operating room. To reduce the likelihood of recurrence, the parent must be extremely diligent with the child’s vulvar hygiene, but this still may not be effective. The risks from not treating labial adhesions are minimal. There is a chance that they will become symptomatic. This is most likely to occur with more extensive adhesions. Symptoms may include recurrent vulvovaginitis,9 urinary tract infections and urethritis,10 or leaking of urine that has pooled behind the adhesions.3 With complete occlusion, urinary retention may result. Longitudinal studies of patients with asymptomatic labial adhesions to determine the frequency of development of symptoms are lacking.
185
Anecdotal information suggests that this is infrequent. Clearly, the risks incurred from treating asymptomatic labial adhesions are low. There is no question that adhesions should be treated if symptoms are present or if the adhesions are extensive, making it likely that urinary symptoms will develop in the near future. If there are no symptoms, simple hygienic measures should be adequate, and these adhesions will in all likelihood resolve spontaneously during early puberty. Sitz baths and a little reassurance can go a long way to make a concerned parent happy, and there is no risk to the child at all with that.
References 1. Berenson AB, Heger AH, Hayes JM, et al: Appearance of the hymen in prepubertal girls. Pediatrics 1993; 89:387 2. McCann J, Wells R, Simon MD, Voris J: Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86:428 3. Pokorny SF: Prepubertal vulvovaginopathies. Obstet Gynecol Clin North America 1992; 19:39 4. Evruke C, Ozgunen MD, Kadayifci O, et al: Labial fusion in a prepubertal girl: a case report. J Pediatr Adolesc Gynecol 1996; 9:81 5. Emans SJ, Laufer MR, Goldstein DP: Pediatric and Adolescent Gynecology. Philadelphia, LippencottRaven, 1998 6. Aribarg A: Topical oestrogen therapy for labial adhesions in children. Br J Obstet Gynecol 1975; 82:424 7. Muram D: Treatment of prepubertal girls with labial adhesions. J Pediatr Adolesc Gynecol 1999; 12:67 8. Smith C, Smith DP: Office pediatric urologic procedures from a parental perspective. Urology 2000; 55:272 9. Sanfilippo JS, Muram D, Lee PA, et al: Pediatric and Adolescent Gynecology. Philadelphia, W.B. Saunders, 1994 10. Starr NB: Labial adhesions in childhood. J Pediatr Health Care 1996; 10:26
Opinions in Pediatric and Adolescent Gynecology Edited by Hatim A. Omar, MD University of Kentucky, Department of Pediatrics, Kentucky Clinic, Lexington, Kentucky
Management of Labial Adhesions in Prepubertal Girls Every year, at least one of my pediatric residents or medical students asks me why the recommended treatment for labial adhesion in prepubertal girls changes from mechanical separation to medical treatment in different books, or even in different chapters of the same book. I have seen my share of referrals with referring diagnosis, varying from sexual abuse to vaginal agenesis, that were in fact simple labial adhesion. The high incidence of this condition is a good enough reason for all primary care providers to be familiar with and comfortable in diagnosing and managing it in their patients. Despite the frequency of labial adhesion in prepubertal girls, few serious studies had addressed the issue of optimal treatment and opinions continue to differ especially between urologists and pediatric gynecologists. In my personal experience since 1985, I have not had to resort to mechanical separation in any of my patients. Hoping to decrease the confusion on this issue, we present here the views of two outstanding experts in pediatric and adolescent gynecology on management of this condition. The two opinions, while not entirely different, are not exactly the same either, but provide good arguments that I hope will help primary care providers in their decision-making regarding labial adhesion.
Labial adhesions is an acquired condition in which the labia minora are fused over the vestibule. It is estimated to occur in 0.6–3.0% of prepubertal girls.1–4 However, because many children with labial fusion are asymptomatic, the prevalence of labial adhesions may be even greater. The etiology of labial adhesions is not known, but is presumably related to the low levels of estrogens in the prepubertal child. It had been suggested that the thin skin covering the labia
could be denuded as a result of local irritation and scratching. The labia then adhere in the midline, and as reepithelialization occurs on both sides, the labia remain fused in the midline.5 The diagnosis of labial adhesions is made by the visual inspection of the vulva. The examiner can see a thin, avascular line of fusion in the midline. Not all girls with labial adhesions require therapy. Asymptomatic girls, often with minor degrees of labial adhesion, require observation only. Treatment is indicated in symptomatic girls who present with dysuria or recurrent vulvar or vaginal infections.6 On rare occasion, a child may present with urinary retention.5 For many years, topical treatment with conjugated estrogens had been the mainstay of conservative therapy, with a presumed success rate of close to 90%.6 This optimism was based on a report that such therapy resulted in resolution in 88% of patients. Unfortunately, that particular study included only 25 girls.7 However, the clinical experience over the years was mixed. Some children—particularly those with filmy adhesions—responded to topical estrogen therapy, and separation of the labia was often achieved within 7–10 days of therapy. However, some girls required a more prolonged course of therapy (6–8 weeks), and some did not respond to even that extended course of topical therapy. Girls with dense, fibrous adhesions often did not respond to topical therapy. Some of the girls who fail therapy often present with thin, filmy adhesions, which the physician is often able to separate in the office using a Q-tip and topical xylocaine. A recent study reported the experience in one clinic with topical estrogen for the treatment of labial adhesions.8 In that particular study, 259 symptomatic girls, age 1–7 years with labial adhesions were treated with topical estrogen for 10–14 days. Following the topical application, the fused labia separated in only 121 (47%) patients. Success rates were even lower in girls who underwent previous surgical separation and those with dense, fibrous adhesions.
2000 North American Society for Pediatric and Adolescent Gynecology Published by Elsevier Science Inc.
1083-3188/00/$20.00
Manual Separation of Labial Adhesions in Prepubertal Girls
Discussant: David Muram, MD Eli Lilly and Company, Lilly Corporate Center, Indianapolis, Indiana
184
Opinions in Pediatric and Adolescent Gynecology
The author reported that by applying a generous amount of Xylocaine gel to the line of fusion and the vestibule, he was able to insert a Q-tip or sound behind the fused labia. The instrument was then aligned against the line of fusion and pulled gently forward. This technique was attempted in 138 patients and was successful in 112 (81%). However, surgical separation of the labia under general anesthesia was required in the remaining 26 patients who were either noncooperative and did not permit office manipulation of the fused labia (n ⫽ 9) or in whom office separation under topical anesthesia failed (n ⫽ 17). All patients in whom the office procedure failed were 3 years of age or older, and had either dense, fibrous adhesions or long-standing fusion of the labia.8 Following mechanical separation Premarin (vaginal cream) was applied to the denuded labial edges twice daily for five days to prevent reformation of adhesions.8 Using office separation under topical anesthesia as an adjunct to topical estrogen therapy allows the physician to avoid surgery in most patients. In one study, surgical separation was needed for only 29 (11%) of 262 patients who were seen initially and for 7 (19.4%) of 36 girls with recurrent labial adhesions.8 Despite efforts to avoid general anesthesia, an operative procedure is indicated for patients with urinary retention, for patients who are noncooperative with office separation, or for those with significant scarring. Unfortunately, patients with recurrent adhesions following surgical separation are at risk to require another surgical separation should the adhesions recur. In conclusion, because of the relatively high failure rate of topical estrogen therapy, the treating physician should make arrangements for follow-up at the completion of the treatment course and be prepared to separate the labia in patients who did not respond to topical estrogen therapy. The mechanical separation may prevent prolonged exposure to estrogens in some girls and surgical intervention in others.
References 1. Benn˜ Ami T, Boichis H, Hertz M: Fused labia. Clinical and radiological findings. Pediatr Radiol 1978; 7:33 2. Huffman JW, Dewhurst CJ, Carpraro VJ: The Gynecology of Childhood and Adolescence. 2nd ed. W.B. Saunders, Philadelphia, 1981, pp. 105–107 3. Nowlin P, Adams JR, Nalle BC Jr: Vulvar fusion. J Urol 1949; 62:75 4. Capraro VJ, Greenberg H: Adhesions of the labia minora. Obstet Gynecol 1972; 39:65 5. Stovall TG and Muram D, Urinary retention secondary to labial adhesions. Adolec Pediatr Gynecol 1988; 1:203
6. Sanfilippo J, Muram D, Lee P, Dewhurst JC: Pediatric and Adolescent Gynecology. W.B. Saunders Co., Philadelphia, 1994, pp. 206–208 7. Aribarg A: Topical oestrogen therapy for labial adhesions in children. Br J Obstet Gynaecol 1975; 2:424 8. Muram D: Treatment of labial adhesions in prepubertal girls. Adoelsc Pediatr Gynecol 1999; 12:67
Pro-Conservative Management for Asymptomatic Labial Adhesions in the Prepubertal Child
Discussant: Betsy Schroeder, MD Director, Division of Pediatric and Adolescent Gynecology, Department of Obstetrics and Gynecology, Allegheny General Hospital, Pittsburgh, Pennsylvania
Labial adhesions are a common finding in prepubertal girls. The hypothesized etiology of the transient complete or partial fusion of the labia minora is the combination of hypoestrinism and vulvar irritation. The incidence may be as high as 21.3%1 to 38.9%2 of girls who were not known or suspected to have been sexually abused. Given the frequency of such findings, one might consider labial adhesions to be a normal finding in the prepubertal girl. Clearly not all cases are recognized and treated in a routine practice, and no long-term problems as a result of not treating these cases have been identified. Reports suggest that over 80% of cases spontaneously resolve within one year.3 Virtually all cases resolve spontaneously with the onset of puberty, and there are only case reports of persistence requiring treatment after the onset of puberty in adolescents.4,5 Once the reproductive years are reached, labial adhesions are extremely unusual, even if inciting factors such as active herpes lesions are present, until the postmenopausal period. Treatment for labial adhesions may be medical or surgical. Medical treatment involves the application of topical estrogen to the affected area. If applied sparingly and appropriately, there is minimal risk involved; however, this treatment is not completely without risk. Although transient, there may be hyperpigmentation of the labia.6 It is also well known that topical estrogen is systemically absorbed and if used in excess can cause breast development, vaginal bleeding, and ultimately true precocious puberty. Finally, successful separation as a result of estrogen cream varies from 50%7 to 88%.6 If treatment is initiated and fails, manual or surgical separation is the inevitable next step. Separation in the office has its own set of risks. Topical anesthetic agents such as eutectic mixture of local anesthetics (EMLA, Astra Belgium, Brussels) cream are considered safe but may not provide adequate anesthesia. Due to the anatomy, it is often difficult to adequately place the required occlusive
Opinions in Pediatric and Adolescent Gynecology
dressing over the anesthetic agent, so it may not work as effectively as it does on other sites. A study by Smith and Smith8 found that EMLA was less effective in controlling pain in labial separation than in meatotomy for meatal stenosis and newborn circumcision. According to parents of children who had undergone this procedure under EMLA, 7 children had mild discomfort, 5 had moderate discomfort, and 2 had severe discomfort. One of the rules of pediatric gynecology is to avoid traumatizing the child; a 50% chance of moderate to severe discomfort is too great a risk. The only other alternative to treat these girls is to take them to the operating room for separation under general anesthesia or local anesthesia plus sedation. In this situation, the risk of discomfort during the procedure is minimal, but the anesthetic risks are much greater. In a retrospective chart review, 26 of 138 (19%) girls failed office separation using topical anesthesia and required surgical separation in the operating room.7 Once separation does occur, whether by medical or surgical means, there is a high rate of recurrence. In one study of 14 girls who had undergone labial separation in the office, the recurrence rate after 16 months (range 1–32 months) was 17%.8 In Muram’s study7 36 of 259 (14%) girls who had been treated for labial adhesions had recurrences requiring separation in the office or in the operating room. To reduce the likelihood of recurrence, the parent must be extremely diligent with the child’s vulvar hygiene, but this still may not be effective. The risks from not treating labial adhesions are minimal. There is a chance that they will become symptomatic. This is most likely to occur with more extensive adhesions. Symptoms may include recurrent vulvovaginitis,9 urinary tract infections and urethritis,10 or leaking of urine that has pooled behind the adhesions.3 With complete occlusion, urinary retention may result. Longitudinal studies of patients with asymptomatic labial adhesions to determine the frequency of development of symptoms are lacking.
185
Anecdotal information suggests that this is infrequent. Clearly, the risks incurred from treating asymptomatic labial adhesions are low. There is no question that adhesions should be treated if symptoms are present or if the adhesions are extensive, making it likely that urinary symptoms will develop in the near future. If there are no symptoms, simple hygienic measures should be adequate, and these adhesions will in all likelihood resolve spontaneously during early puberty. Sitz baths and a little reassurance can go a long way to make a concerned parent happy, and there is no risk to the child at all with that.
References 1. Berenson AB, Heger AH, Hayes JM, et al: Appearance of the hymen in prepubertal girls. Pediatrics 1993; 89:387 2. McCann J, Wells R, Simon MD, Voris J: Genital findings in prepubertal girls selected for nonabuse: a descriptive study. Pediatrics 1990; 86:428 3. Pokorny SF: Prepubertal vulvovaginopathies. Obstet Gynecol Clin North America 1992; 19:39 4. Evruke C, Ozgunen MD, Kadayifci O, et al: Labial fusion in a prepubertal girl: a case report. J Pediatr Adolesc Gynecol 1996; 9:81 5. Emans SJ, Laufer MR, Goldstein DP: Pediatric and Adolescent Gynecology. Philadelphia, LippencottRaven, 1998 6. Aribarg A: Topical oestrogen therapy for labial adhesions in children. Br J Obstet Gynecol 1975; 82:424 7. Muram D: Treatment of prepubertal girls with labial adhesions. J Pediatr Adolesc Gynecol 1999; 12:67 8. Smith C, Smith DP: Office pediatric urologic procedures from a parental perspective. Urology 2000; 55:272 9. Sanfilippo JS, Muram D, Lee PA, et al: Pediatric and Adolescent Gynecology. Philadelphia, W.B. Saunders, 1994 10. Starr NB: Labial adhesions in childhood. J Pediatr Health Care 1996; 10:26