Author Information
Sinha S*, Tiwari N**,
Samant PY***, Chauhan AR***.
(* Second year resident,
** Assistant Professor, *** Additional Professor, Department of Obstetrics and
Gynaecology, Seth G S Medical College and KEM Hospital, Mumbai, India.)
Abstract
Genital
herpes is a common sexually transmitted disease but labial adhesions following this infection are a rare but recognized local complication. Chronic
labial adhesion in the reproductive age group is extremely rare. It occurs most
often in infants, prepubertal girls, postpartum and postmenopausal women. It is
usually associated with low estrogen levels. We present a case of almost
complete labial adhesion with dysuria, altered stream of urine, and perineal
discomfort in a 35-year-old female secondary to herpes genitalis.
Introduction:
The incidence of genital herpes nearly doubled over 20 years (11.4% to
20.5%) from 1977 to 2000 as observed in a review from North India1. The infection is
transmitted through contact with lesions on mucosal surfaces, and from genital
and oral secretions. The incubation period ranges from 2 to 21 days2.
Vesicles on or around the genital area, rectum or mouth which may later
ulcerate are typical lesions. Ulcers take two to four weeks to heal.
Complications like secondary bacterial infection of lesions, blindness due to
corneal infection, meningitis, and labial adhesions have been known to occur.
Case
Report:
A 35- year old married
parous woman presented in emergency with complaints of vulvar and lower
abdominal pain, dysuria and fever for two days. She had regular menstrual
cycles. She was afebrile. Minimal tenderness was present in hypogastrium. No
lesion or lymphadenopathy was present on local vulvar examination. On speculum
examination, copious vaginal discharge and hypertrophied congested cervix were
seen. The discharge was collected for bacterial culture and antibiotic
sensitivity. Patient did not allow bimanual examination as she was in severe
pain. She was advised personal hygiene, testing for HIV and VDRL, urine routine
microscopy with culture sensitivity, and pelvic ultrasonography. She was
prescribed oral clindamycin and metronidazole and was asked to follow up in a
week.
After 5 days she
presented again to the emergency room in view of vaginal discharge, pain, and
fever not responding to antibiotics. On examination she was afebrile and
vitally stable. Multiple vesicles and papules in various stages of eruption
were now noted on vulva. Her routine pathological, biochemical investigations,
pelvic ultrasonography and urine analysis were unremarkable. Culture and
sensitivity tests of vaginal discharge and urine did not yield any bacterial
growth. Diagnosis of herpes genitalis was made. Oral acyclovir (1000 mg per day
in divided doses) and antibacterial ointment for local application were
prescribed. Patient’s partner did not report symptoms suggestive of herpes.
She followed in the
outpatient department 10 days after the second visit with complaint of altered
stream of urine. At this time, healed herpetic lesions on both labia majora and
agglutination of labia minora were noted on local examination.
For her voiding
difficulty, manual separation of the labial adhesions with local lignocaine
jelly application was done gradually in 4 daily sittings after counseling the
couple. Patient was advised to continue antibacterial ointment with additional
use of liberal application of lignocaine jelly after urination, washing,
bathing. Adhesions were completely separated over the course of these 4 days.
Patient was asked to maintain genital hygiene and continue ointment application
for 2 weeks before resuming sexual activity. Partner was referred to
dermatology department for further advice. Follow up examination of the patient
after two weeks showed normal appearance of genitalia. She could void urine
normally and was otherwise asymptomatic.
Figure 1: Labial
agglutination.
Figure 2: Partially
separated labia on day 2 of manual separation.
Figure 3: Completely
separated labia.
Discussion
Labial adhesions are membranous structures resulting due to fusion of
the adjacent mucosal surfaces of the labia minora or majora. Infants and adolescent
girls are more prone to labial adhesions due to hypoestrogenemia3.
Adhesions form when apposing surfaces of labia become raw due to worm
infestation, nappy rash, poor hygiene or sexual abuse.
Atrophic vaginitis can cause labial adhesions in post menopausal women4.
Topical application of oestrogen cream is the treatment of choice. Surgical
intervention is required only in long standing cases. The entity is rare in
reproductive age but can occur as a result of
inflammatory skin conditions like lichen sclerosus, herpes genitalis, Stevens
Johnson syndrome, surgery or childbirth trauma. Seehusen and Earwood found that estrogen therapy was
ineffective and surgery was required to resolve postpartum adhesions5.
In case of herpes genitalis, formation of fibrinious exudates can lead to
adhesions between the labia minora6. If left untreated, this can
lead to midline fusion with coital and voiding difficulty. In our patient, in a
short period of 14 days after prodromal symptoms almost complete agglutination
of labia minora occurred; probably due
to apposition between raw surfaces and unwashed exudates at the time of healing
with resultant distortion of urinary stream.
Spontaneous resolution of prepubertal labial adhesions is reported in
nearly 80% cases within 1 year7. Topical steroid application has
been successfully tried of post herpetic labial adhesions in an adult woman8.
Mayoglou et al in retrospective review of prepubertal cases with labial
adhesions observed that topical steroid therapy resolved adhesions
faster and had less recurrence and side effects as compared to topical estrogen
therapy9. Obstruction to
urinary flow or refactory adhesions after local therapy requires surgical
intevention9. Our patient required intervention due to her urinary
symptoms. Surgery and CO2 laser vaporisation are recommended for
restoring voiding and sexual function impaired by adhesion10.
Amniotic membrane graft on raw surfaces has been used to prevent reformation of
adhesions after surgery.11
Conclusion
Incorrect
diagnosis, poor hygiene and lack of topical treatment may predispose to
development of labial adhesions in women with herpetic vulvitis. Topical
therapy and saline baths in addition to antiviral medication are integral part
of treatment for primary genital herpes, with manual or sugical separation
reserved for obstructive symptoms.
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