Gupta AS
Labial
adhesions or agglutination or fusion is an acquired condition that results from
the adhesions of the inner mucosal surface of the labia minora. This can be
complete or partial. When it is complete the vaginal opening cannot be seen at
all.A small opening anterior or in front of the sealed labia minora permits the
flow of urine and this sealed labia form a pocket which acts as a container to
hold the urine.Labial adhesions may be primary or secondary. Primary are
present from birth and secondary usually occur after menopause. The labial
fusion occurs in two age groups. The girl child or the adult woman.
Causes
of labial adhesions
Estrogen
deficient states: This is the commonest cause of fused labia. It affects young
girls usually aged 6 months to 6 years, women during lactation, after
menopause, following use of SERMs, aromatose inhibitors, GnRH agonists or
anatagonists or women having hyperprolactinemia. Usually at birth maternal
circulating estrogen's are present in the neonatal circulation preventing
labial adhesions. Any irritant that can cause chronic inflammation to the labia
like use of diapers, stools, urine, foreign bodies, undetected chronic sexual
abuse can lead to adhesion formation between the inner surface of the labia minora
resulting in their fusion. The condition may be detected if the girl complaints
of dribbling of the urine that leaks out of the pocket formed by the sealed
labia or it may remain undiagnosed. Most of the times it spontaneously resolves
at puberty with the surge of endogenous estrogen's. In menopausal women lack of
estrogen results in atrophic vulvovaginitis increasing the adhesiveness of the
thinned out labia and the vagina. The adult woman may present with apareunia,
dyspareunia, infertility, difficulty in introducing a vaginal tampon or
dribbling of urine or menstrual blood.
Other
causes can be inflammation due to infections like herpes genitalis, autoimmune
disorders like Behcet syndrome, pemphigoid conditions of the mucous membranes,
erosive lichen planus causing vulvovaginal gingival syndrome , or serious drug
reactions like Steven-Johnson syndrome or toxic epidermal necrolysis affecting
the vulva as a part of the systemic disorder. Inflammation and trauma following
parturition or after vulvectomy for vulval cancer or after female circumcision
can also predispose to labial adhesions.
Treatment
can be medical or surgical. Always a trial of medical treatment should be given
especially in girls and women in hypoestrogenic states. Estrogen creams applied
to the in the mid line over the fused junction which can be identified as a
white red or brown line daily for 4-6 weeks usually opens up the fused labia.
However, an emollient cream should be continuously applied daily to prevent
reformation of the adhesions. Patients with autoimmune disorders will need
treatment of the cause along with local estrogen and emollient creams. In
patients where the labia are densely stuck and estrogen, emollient or steroid
creams fail will need to undergo surgical adhesiolysis.
We
bring you two interesting articles on labial adhesion in this issue and we hope
that readers gain useful scientific insight from these and the remaining
interesting case reports. We have omitted the section on multiple choice questions for management reasons. While we will continue to use it in our institute locally, making it available to everyone reading our journal was not manageable.