Author
Information
Madhavi J*,
Vibha More**, Satia MN***.
(*
First Year Resident, ** Assistant Professor, *** Professor.
Department of Obstetrics and Gynecology, Seth G S Medical College and
KEM Hospital, Mumbai, India).
Abstract
Complete
labial agglutination is a rare clinical entity in adults. The most
common complications of this presentation are infections of the
urinary tract and retention of urine. We present the case of a
post-menopausal woman with labial fusion who presented with
complaints of dysuria and urinary retention. It was managed
operatively with division of the labial fusion following which the
patient was able to pass urine without difficulty.
Introduction
Labial
agglutination is a condition in which labia minora are fused with
each other. It is most commonly seen in pediatric age. This condition
is also known as labial synechiae, labial fusion or labial adherence.
This condition in adult is rare and is predominantly seen in
postmenopausal women. In most of the cases, the patient is
asymptomatic or may present with post void dripping, urinary tract
infections, vaginitis, hematuria and increased urinary frequency.
Contributory factors for labial agglutination in reproductive age
group and postmenopausal women are vaginal inflammation, vaginal
laceration during childbirth, local trauma, lack of sexual activity,
recurrent urinary tract infection and hypoestrogenism.
Case
Report
A
48 year old woman, para1,
living 1,
postmenopausal since 2 years presented to the outpatient department
with a complaint
of difficulty in passing urine with pain in abdomen since 2 months.
She also gave history of burning micturition and foul smelling
discharge per vaginum since 2 months. She had taken opinion from a
private consultant and was given some local ointment without clinical
examination. She was
a known case of hypothyroidism since past 6 years on tablet Thyronorm
100 μg
once daily. On examination, she was moderately built and
well nourished. Her vital
parameters
were normal.
Cardiovascular and respiratory system
examination showed no abnormality. Her
abdomen was soft with no guarding, tenderness and rigidity. Local
examination revealed fused bilateral labia minora. Urethral opening
was not
visualized. Vaginal opening was
also not seen. On per rectal examination, a
small nodule felt. Uterine size could not be made out. There
was no evidence of any collection. Her
fasting and postprandial plasma sugar
levels were 130 and postprandial of 140
mg/dl. An
endocrinologist advised tablet Metformin
500 mg tid and
continuation of
Thyronorm 100 μg
once daily on weekdays and 200 μg
once daily on weekends. Ultrasonography showed a
normal sized uterus and no evidence of
any
collection. Patient posted for examination under anesthesia and
release of labial after all preanaesthetic work up and fitness. Under
total
intravenous anesthesia local
examination revealed both labia minora fused to each other in
midline. Urethral opening was not visualized. A small dimple was seen
in midline through which an attempt was
made to pass a
pediatric Foley's
catheter. However the effort failed.
Catheter passed
through another dimple above the first one entered
the vagina. Then a stab incision was made between the two dimple and
gentle traction was applied on both labia and the fused area was
dissected with blunt dissection successfully. Urethral opening was
visualized and urethral catheterization was
done. Vaginal opening was visualized.
Sims'
speculum was
inserted. A normal
cervix was
visualized. Bimanual examination revealed an
anteverted, atrophic uterus. Postoperatively vaginal tampons were
inserted for ten days to prevent reagglutinations and she was also
started on estradiol
cream and local antibiotic ointment. The
patient tolerated the procedure well and
was discharged on day 3 of procedure. She
had regular follow up and continued local application of
estradiol cream for six weeks.
Figure
1: Black arrow shows fused labia.
Figure
2: Black arrow shows raw area seen in bilateral labial after release
of fusion.
Figure
3: Healed labia after estradiol
therapy.
Discussion
Labial
agglutination is a state of partial or
complete adhesion of the labia minora. It generally occurs
in children or post-menopausal women, but is extremely rare in
reproductive ages.[1]In
adults including postmenopausal women, labial fusion is more
associated with recurrent urinary tract infections, vulvovaginitis,
genital trauma, hypoestrogenism and lack of sexual activity.[2]Labial
agglutination in our patient is mostly
due to the effect of vulvar hypoestrogenisation. Most
predominant accompanying symptoms of labial fusion in postmenopausal
women are vulvar soreness, pruritis and urinary symptoms such as
dysuria, urinary incontinence, retention and voiding difficulties.
Our patient presented with voiding difficulty. Due to labial fusion,
the urethral opening is smaller and cannot
stretch. It can be as small as a pinhead when labial adhesions are
severe. Symptoms may be absent or the adhesions may lead to
dribbling of urine on standing up after passing urine and
dyspareunia. Other symptoms are
itching and soreness, depending on the cause of the adhesions.
Characteristics of labial agglutination
are flat appearance of the genitalia, small or absent labia minora.
Anterior fusion is often associated with disappearance or fusion of
clitoral hood. Posterior vulval fusion may be due to scarring of
perineum. The complications secondary to complete labial
agglutination described
in literature are chronic inflammation of the genital and urinary
tract, recurrent urinary tract infection, urinary outflow
obstruction, apareunia,
acute renal failure, urocolpos, pyosalpinx and peritonitis. Most
cases are managed surgically,[3]
and require division of the labial fusion along the anatomical plane,
as was done in this case
This can done under general or
local anesthesia. In case of atrophic labial fusion, postoperative
application of topical estrogen is recommended along with topical
antibiotics to improve the healing process.[4,5]
References
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Mayoglou L, Dulabon L, Martin-Alguacil N, Pfaff D, Schober J. Success of treatment modalities for labial fusion: a retrospective evaluation of topical and surgical treatments. Journal of Pediatric and Adolescent Gynecology 2009;22(4):247–250.
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Madhavi J, Vibha More, Satia MN. Labial Agglutination In A Postmenopausal Female. JPGO Volume 2 Issue 6 Available from: http://www.jpgo.org/2015/06/labial-agglutination-in-postmenopausal.html