Labial fusion and asymptomatic bacteriuria

Pubertal Labial Fusion: A Case Study

Labial fusion, though rare, can present during puberty, or even adolescence leading to challenges in diagnosis and management. This case report offers a detailed examination of the clinical manifestation, diagnostic process, and therapeutic approach in an adolescent girl with labial fusion. This report emphasizes the importance of early intervention to improve patient outcomes for this complex medical condition.

Urinary Tract Infection in Children

BACKGROUND

Urinary Tract Infection (UTI) is a common infection in children. Prompt diagnosis and appropriate treatment are very important to reduce the morbidity associated with this condition.

OBJECTIVE

To provide an update on the evaluation, diagnosis, and treatment of urinary tract infection in children.

METHODS

A PubMed search was completed in clinical queries using the key terms "urinary tract infection", "pyelonephritis" OR "cystitis". The search strategy included meta-analyses, randomized controlled trials, clinical trials, observational studies, and reviews. The search was restricted to English literature and the pediatric age group. Patents were searched using the key terms "urinary tract infection" "pyelonephritis" OR "cystitis" from www.google.com/patents, http://espacenet.com, and www.freepatentsonline.com.

RESULTS

Escherichia coli accounts for 80 to 90% of UTI in children. The symptoms and signs are nonspecific throughout infancy. Unexplained fever is the most common symptom of UTI during the first two years of life. After the second year of life, symptoms and signs of pyelonephritis include fever, chills, rigor, flank pain, and costovertebral angle tenderness. Lower tract symptoms and signs include suprapubic pain, dysuria, urinary frequency, urgency, cloudy urine, malodorous urine, and suprapubic tenderness. A urinalysis and urine culture should be performed when UTI is suspected. In the work-up of children with UTI, physicians must judiciously utilize imaging studies to minimize exposure of children to radiation. While waiting for the culture results, prompt antibiotic therapy is indicated for symptomatic UTI based on clinical findings and positive urinalysis to eradicate the infection and improve clinical outcome. The choice of antibiotics should take into consideration local data on antibiotic resistance patterns. Recent patents related to the management of UTI are discussed.

CONCLUSION

Currently, a second or third generation cephalosporin and amoxicillin-clavulanate are drugs of choice in the treatment of acute uncomplicated UTI. Parenteral antibiotic therapy is recommended for infants ≤ 2 months and any child who is toxic-looking, hemodynamically unstable, immunocompromised, unable to tolerate oral medication, or not responding to oral medication. A combination of intravenous ampicillin and intravenous/intramuscular gentamycin or a third-generation cephalosporin can be used in those situations. Routine antimicrobial prophylaxis is rarely justified, but continuous antimicrobial prophylaxis should be considered for children with frequent febrile UTI.

Labial adhesion - diagnostics and treatment

BACKGROUND

Labial adhesion is relatively common, but the condition is little known among doctors and parents. The article assesses treatment in the specialist health service.

MATERIAL AND METHOD

The treatment and course are assessed in 105 girls in the age group 0 – 15 years who were referred to St. Olavs Hospital in the period 2004 – 14.

RESULTS

The majority of the girls (n = 63) were treated topically with oestrogen cream. In 26 of 51 girls (51 %) for whom the final result is known, the adhesion opened after one treatment. When 1 – 4 oestrogen treatments were administered, the introitus had opened completely in two out of three (65 %). Fewer than half of those who received supplementary surgical treatment achieved permanent opening.

INTERPRETATION

Treatment for labial adhesion had a limited effect in this study. As the literature suggests that the condition results in few symptoms and resolves spontaneously in virtually all girls in puberty, no compelling medical reason exists for opening the adhesion in asymptomatic girls. It is important that doctors are aware of the condition in order to prevent misdiagnosis and to provide parents with adequate information. For parents it is important to know that spontaneous resolution may result in soreness and dysuria. Knowledge of the condition can most likely prevent unnecessary worry.

Surgical reconstruction in female genital mutilation

Female genital mutilation (FGM) is an unusual condition for our country. However, an increase in FGM in future days can be predicted with the increasing numbers of exchange students coming from African countries, migration of refugees and socioeconomic relations with the African countries. We want to share our experience of two FGM victims admitted to our clinic with the request of reconstructive vulvar surgery before their marriage. Both women had WHO Type III FGM. Physical examination findings and surgical reconstruction techniques were presented.

Comparison of Conservative and Surgical Therapy Concepts for Synechia of the Labia in Pre-Pubertal Girls

Introduction: The aim of this study was to evaluate the primary and secondary therapeutic successes of different therapy schemes for the treatment of synechia of the labia in pre-pubertal girls. Materials and Methods: The treatment courses of 47 pre-pubertal girls who were treated between February 2007 and February 2013 in the special outpatient clinic for paediatric gynaecology of a department for gynaecology at a German university hospital and for whom information on the course of the disease was available for at least the six months following end of the treatment. 23 of these children were treated with a topical estriol therapy (treatment group A). For 24 of the girls a manual separation of the adhering labia minora was undertaken (treatment group B). Statistical evaluation was performed using the χ² test, Fischer's exact test and the Mann-Whitney U test. Results: For 18 of the 23 (80 %) girls in treatment group A topical estriol therapy alone led to a resolution of the synechia. Five of these 23 children (20 %) required a secondary manual separation. All girls for whom treatment was not successful were under 5 years of age. For all 24 girls (100 %) of treatment group B the primary manual separation was performed with success. The recurrence rates after ≥ 6 months in cases with identical after-care did not differ between the two treatment groups (treatment group A: 34 %, treatment group B: 33 %, χ² test: p = 0.853). 16 of the 17 recurrences occurred ≥ 3 months after the end of the therapy. Conclusion: Our results show that for children < 5 years of age a 4-week topical therapy with estriol is a promising therapy option for synechia of the labia that is less of a burden for the family situation. Especially for girls ≥ 5 years of age, primary therapy fails in up to 20 % of the cases. Primary manual separation represents a more effective therapeutic option. Irrespective of the treatment applied, a recurrence after ≥ 3 must be expected in one-third of the treated girls.

Labial adhesion and urinary tract problems: The importance of genital examination

BACKGROUND

Urinary tract infection (UTI) is a common bacterial illness in children. Delay in the treatment of UTI may lead to acute renal parenchymal damage and subsequent renal scarring. It is well established that several risk factors increase the tendency for UTI - one being labial adhesion (LA).

OBJECTIVE

The purpose of this study was to emphasize the importance of genital examination in girls with nephrourologic symptoms, particularly UTIs, in order to detect LA.

MATERIAL AND METHODS

Data were collected from the files of 46 girls with LA, including: the girl's age, thickness of LA, any recurrence and treatment options of LA, and the reason for admission to hospital. The LAs were grouped in terms of thickness as thin, moderate and dense, and also partial or complete.

RESULTS

The average age of the girls at the first visit was 51.9 ± 37.57 months (min-max: 3.5-157 months). Twenty-seven (58.7%) of the girls had history of recurrent UTI. There was a marked association between the presence of UTI and the type of adhesions. The percentages of UTIs in girls with complete and partial LA were 84.0% and 28.6%, respectively (P < 0.05). The percentages of UTIs in girls with thick and thin LA were 100% and 44.1%, respectively (P < 0.05). None of the girls' primary care physicians or pediatricians recognized LA at the time of a periodic health examination.

DISCUSSION

In the present study, girls with complete and thick LA had a greater tendency towards having UTIs than those with partial and thin LA, respectively. After treatment of LA, the UTIs did not recur in any girls. None of the girls in this study had undergone a previous genital examination. Therefore, this study suggests that physicians do not often perform genital examinations. Limitations of this study were the small sample size and the short follow-up period. In addition, although all of the girls were examined by the same physician, the thickness of the membrane is subjective and solely depends on the physician's experience.

CONCLUSIONS

This study showed that although genital examination is a routine part of a physical examination, it is not always performed. Therefore, it is recommend that genital examination should be performed in girls with nephrourologic complaints, particularly for UTI. By timeously determining the presence of LA, many unnecessary and invasive investigations could be avoided in these children.

Labial adhesion and bacteriuria

OBJECTIVE

The purpose of this study is to evaluate the clinical presentation, laboratory findings, and response to treatment in girls with labial adhesion younger than 23 months.

MATERIAL AND METHODS

A retrospective chart review of all girls younger than 23 months with the diagnosis of labial adhesion was referred to Dr Sheikh children's clinic in Mashhad in northeast Iran between 1998 and 2013.

RESULTS

Sixty-three patients were diagnosed with labial adhesion during the review period. Most patients were diagnosed by physicians during the physical examination or during the evaluation for their voiding problems. The most prevalent symptom among patients was dysuria and restlessness while voiding. Twenty-one (33.3%) patients had a history of urinary tract infection. 17 (26.9%) patients had sterile pyuria and 69.8% showed presence of bacteria in their urine samples.

CONCLUSION

Physicians may frequently encounter pre-pubertal girls whose urinalysis may show sterile pyuria or presence of bacteria with colony counts <105 in the absence of urinary tract infection symptoms. In these cases, labial adhesion should always be suspected and genital examination should be performed.

Complement 4 phenotypes and genotypes in Brazilian patients with classical 21-hydroxylase deficiency

The aim of this work was to analyse C4 genotypes, C4 protein levels, phenotypes and genotypes in patients with the classical form of 21-hydroxylase deficiency. Fifty-four patients from 46 families (36 female, 18 male; mean age 10.8 years) with different clinical manifestations (31 salt-wasting; 23 simple-virilizing) were studied. Taq I Southern blotting was used to perform molecular analysis of the C4/CYP21 gene cluster and the genotypes were defined according to gene organization within RCCX modules. Serum C4 isotypes were assayed by enzyme-linked immunosorbent assay. The results revealed 12 different haplotypes of the C4/CYP21 gene cluster. Total functional activity of the classical pathway (CH50) was reduced in individuals carrying different genotypes because of low C4 concentrations (43% of all patients) to complete or partial C4 allotype deficiency. Thirteen of 54 patients presented recurrent infections affecting the respiratory and/or the urinary tracts, none of them with severe infections. Low C4A or C4B correlated well with RCCX mono-modular gene organization, but no association between C4 haplotypes and recurrent infections or autoimmunity was observed. Considering this redundant gene cluster, C4 seems to be a well-protected gene segment along the evolutionary process.

An approach to daytime wetting in children

Daytime wetting is a common problem with various causes that can usually be identified through a careful history, thorough physical examination, and urinalysis. Conservative approaches to therapy have a successful outcome in most children. Invasive diagnostic imaging studies and pharmacologic or surgical intervention are necessary only for carefully selected children.

Treatment of labial fusion with topical estrogen therapy

Twenty girls with labial fusion that covered at least 50% of the vaginal opening were treated with a topical estrogen cream. The cream was precisely applied to the fused area twice a day until the adhesions were totally lysed. After separation of the adhesions, a petroleum ointment (Vaseline) was applied twice a day to the labia minora for at least 1 month. The introital area was carefully rinsed twice each day before application of either the estrogen cream or the petroleum ointment. The mean age of the studied population was 13.2 months (range, 2 to 38 months). The mean duration of estrogen treatment was 2.4 months (range, 1 to 3.5 months). All patients were successfully treated. Five patients developed vulval pigmentation, which lasted for a mean of 1.5 months. One patient developed breast enlargement, which lasted for 1 month. The mean duration of follow-up was 3.1 months, and there was no recurrence of labial fusion during the period of follow-up. We conclude that treatment of labial fusion with topical estrogen therapy is safe and effective.

The incidence of labial fusion in children

A retrospective study of 9070 female infants born at the Foothills Provincial Hospital was conducted to determine the incidence of labial fusion at birth. A prospective study was also conducted on 1970 female patients assessed through a paediatric outpatient clinic to determine the incidence of labial fusion in this population. None of the newborn infants had labial fusion. Thirty-five children (1.8%) assessed at the paediatric outpatient clinic were found to have labial fusion with a peak incidence at 13-23 months of age (3.3%).