Adhesion of Labia Minora

Author Information

Parulekar SV
(Professor and Head. Department of Obstetrics and Gynecology, Seth G. S. Medical College and KEM Hospital, Mumbai, India.)

Abstract

Adhesion of labia minora occurs most often in infants and young girls, sometimes in postmenopausal women, and rarely in the reproductive age group. Usually it responds to topical estrogen cream application in the first two groups. A case adhesion of labia minora that developed after menarche that had to be treated surgically is presented.

Introduction

Adhesion of labia minora occurs most often in infants and young girls. It is usually associated with low estrogen levels.[1] It occurs sometimes in postmenopausal women due to hypoestrogenic state, local inflammation and lichen sclerosis.[2]. Labial adhesion in the reproductive age group is extremely rare. A case of adhesion of labia minora that developed after menarche treated surgically is presented.

Case Report

A 14 year old girl presented with inability to pass urine and menstrual blood properly for a period of two years. She had menarche at the age of 12 years, up to which time she could pass urine normally. Soon after menarche, she started having difficulty in passing urine. This progressed to such a stage that whenever she emptied her bladder, the introital area would bulge out painfully, and urine would leak out slowly over some time. The passage of menstrual blood was also not easy. Only liquefied, altered blood would escape over a few days. There was no history of local trauma, surgery, burns, or infection. Her elder sister had no such problem. Her general and systemic examination revealed no abnormality. Breasts showed Tanners stage 5 development. Axillary and pubic hair were normal. Local examination (figure 1) showed normal labia majora and clitoris. There was a continuous bridge of skin-covered tissue between the labia majora. A 1 mm sized opening was seen at its posterior end. She stated that she passed urine and menstrual blood through that opening. Introital opening and external urinary meatus were not seen. A rectal examination showed a normal uterus and no pelvic masses. Pelvic ultrasonography showed normal uterus, ovaries and vagina.


Figure 1. Appearance of adherent labia minora. The external opening (yellow arrow) and the fusion of the labia minora (green arrow) are seen.

She had undergone a radiological contrast study after insertion of a catheter through that opening before presenting to us (figure 2). The cavity opacified looked like a vagina.


Figure 2. Radiological study.

Her investigations for fitness for anesthesia revealed no abnormality. After counseling, she and her parents opted for a trial of topical estrogen therapy. She took that treatment for 5 weeks and came back for follow up. The local condition was the same as before initiation of therapy. Then they opted for surgical treatment, which was given postmenstrually. Under general anesthesia, she was placed in lithotomy position. The cavity above the closed introitus was irrigated with chlorhexidine solution, followed by normal saline until the returning fluid was clear. The cavity was visualized using a hysteroscope, using Ringer’s lactate solution for distension. The vaginal opening and external urinary meatus were visualized in their respective normal positions (figures 3 and 4).


Figure 3. Opening of the vagina (arrow).


Figure 4. External urinary meatus (arrow).

A curved hemostat was passed through the external opening to find the direction of the cavity within (figure 5).


Figure 5. A curved hemostat is passed into the cavity behind the fused labia minora.

The blades of the hemostat were opened gently to put the bridge of tissue between the labia on stretch, and then it was cut in midline in a cranial direction (figure 6). The opening of the vagina and external urinary meatus were visualized after surgical separation of the labia minora (figure 7).


Figure 6. Incision of the bridge of tissue between fused labia minora.


Figure 7. The opening of the vagina (yellow arrow) and external urinary meatus (green arrow) are seen.

The edges of the skin outside and inner epithelium of the labia minora were sutured to each other over the raw surface on each side, using simple sutures of No. 2-0 polyglactin. The end result is shown in figure 8.


Figure 8. The end result. The vaginal opening (yellow arrow), cervix (green arrow) and external urinary meatus (white arrow) are seen.

The patient made an uneventful recovery. She passed urine normally subsequently. She was discharged on the third postoperative day, with instructions to clean the sutures with chlorhexidine solution every time she passed urine, and apply povidone-iodine cream locally. She was advised to maintain local hygiene during menses. At the follow up after a month, she was passing urine normally and had passed menstrual blood normally too. The cut edges of the labia had healed well, and the vaginal opening was open. The external urinary meatus was not covered. She was well two more months later too.

Discussion

In infants, young girls and postmenopausal women, adhesion of labia minora develops due to estrogen deficiency, combined with local inflammation secondary to poor hygiene. In the reproductive age group, estrogen levels are high, and the cause of such adhesion is not hypoestrogenism, but female circumcision, herpes simplex, dermatological conditions, caustic vaginitis, local trauma, and vaginal laceration following childbirth.[3,4,5,6] The treatment is topical estrogen cream application in infants and young girls.[7] Such adhesions are associated with denser fibrosis, which often does not respond to topical estrogen therapy.[6] Topical estrogen therapy anyway would be superfluous in a woman in the reproductive age group, when she is menstruating normally. In the case presented, the girl was able to pass urine normally until after menarche, when her labia minora developed adhesion. It must have been secondary to poor menstrual hygiene and local infection. The degree of adhesion was so complete, that she was unable to pass urine normally, and the urine would distend the bridge developed by the adherent labia minora, and slowly trickle out of the very small opening left at the caudal end of the labia minora. The menstrual blood would be retained inside, and would trickle out slowly over a few days after undergoing autolysis. Topical estrogen therapy over 5 weeks failed to separate the labia, and surgical treatment had to be resorted to. Contrary to the usual recommendation of pulling on the labia in opposite directions, either digitally of by placing a hemostat inside and opening its blades, clean incision of the bridge between them and reconstruction of the cut edges was done. The end result was quite satisfactory. I recommend such surgical treatment rather than forcibly separating the labia apart, as the separation is quite traumatic, and the resultant wound is a contused lacerated wound rather than a linear surgical incision, and heals rather poorly. Recurrence occurs in 11-14% cases. [8] The patient in the case presented was taught the method of maintaining local cleanliness and hygiene, everyday and more during menstruation. She managed well and there was no recurrence in three months.

 Acknowledgment
I thank Dr Niphadkar M for photographs of the surgical steps and Dr Prasad R for the image of the radiograph.

References
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Citation

Parulekar SV. Adhesion of Labia Minora. JPGO 2015. Volume 2 No. 8. Available from: http://www.jpgo.org/2015/08/adhesion-of-labia-minora.html