Betamethasone cream for the treatment of pre-pubertal labial adhesions

Treatment of Prepubertal Labial Adhesions with Topical Estriol + Testosterone: A Case Report

BACKGROUND

Labial adhesions, a frequent gynecological condition in prepubertal girls, occur when the labia minora adhere along the midline. The prevailing hypothesis about their etiology suggests that labial adhesion may occur when the delicate and non-estrogenized labia minora undergo an inflammatory response, triggered by exposure to an irritant environment. Therefore, conservative treatment involves the application of topical estrogen or betamethasone cream. The role of androgens has not been considered yet in the pathophysiology or therapy of this condition. However, some studies have shown that androgen receptors are prevalent in the labia minora and vulvar vestibule.

CASE SUMMARY

We present the case of a 29-month-old girl with symptomatic labial adhesions. She was first ineffectively treated with topical estriol, and then she was treated with a galenic cream containing both estriol and testosterone with complete recovery and without side-effects.

CONCLUSIONS

Both androgens and estrogens play a significant role in maintaining the physiological trophic state of the vulva and vagina, even during childhood. Topical estriol+testosterone could be considered an alternative treatment for prepubertal labial adhesions refractory to standard topical therapy.

Labial Fusion Recurrence in a Prepubertal Girl: A Case Report and Review of Literature

Labial fusion is the fusion of labia minora or majora and results in partial or complete fusion of the vaginal orifice. The condition is commonly seen in prepubertal girls and post-menopausal women, but it can sometimes be seen in reproductive age group women also.

We present here a case of a three-year-old girl who presented with recurrence of labial fusion and dysuria. The patient had a similar labial fusion three months before, which was treated with manual separation followed by estrogen cream application. The recurrence of labial fusion was managed conservatively. This case report highlights the possibility of recurrence of labial fusion in prepubertal girls till they attain puberty, as well as its conservative management.

Retrospective evaluation of labial fusion in girls

Aim: The aim of this study was to determine the factors affecting fusion in girls treated for labial fusion retrospectively over a three-year period. Material and Method: The research has a cross-sectional design. The research sample consists of girls with ICD10 code Q52.5 who were brought to the hospital with labial fusion symptoms in a three-year period (January 2018-December 2020). The data were obtained from the hospital information system. Variables that were effective in labial fusion recurrence were determined by Chi-Square analysis, and the marginal effects of effective variables on recurrence were analyzed by Poison Regression analysis. Results: 52.9% of 308 cases were younger than one year old (mean age 4.36±1.10 months). Symptom presentation is 10.4% in children younger than one year of age, and 84.83% in older. The most commonly presented symptoms are pain, burning, soiling of underwear, and bad odor during urination. Labial fusion recurrence is 14.1% in children younger than one year of age, and 62.8% in older. Manual opening was applied in all cases, and weekly follow-ups were performed with topical treatment. The Poison Regression analysis revealed that a history of allergy (1.31 times; z:3.61, p:0.000), winter (0.86 times; z:3.22, p:0.001), and diaper dermatitis (1.22 times; z:5.19, p:0.000) increased the number of labial fusion recurrence. Conclusion: The findings of our study are similar to the literature in terms of factors causing labial fusion and treatment type. The recurrence rate was found to be higher in our study. It should be kept in mind that labial fusion is asymptomatic, especially in girls in the first year of life. Considering the possibility of recurrence of labial fusion, mothers and physicians examining the child should be aware of this issue.

Management of labial adhesion in a developing country—an observational study

Background

Labial adhesion is the fusion of the labia minora or majora. The literature reports conservative management. However, the situation may be different in our setup, where management differs due to prevailing circumstances. The present study was conducted to evaluate labial adhesion presentation, management, and outcome in our center.

Methods

It was a retrospective observational study from January 2015 to January 2020. The patients were evaluated for age at presentation, presenting symptoms, type of adhesions, treatment, recurrence, and follow-up. The treatment included the manual release of labial adhesion and Mupirocin ointment application for 15 days. They were advised to attend the outpatient department after 1 month for evaluation and later on in case of any problem.

Results

The total number of patients was 150, of which 104 (69.33%) were from rural backgrounds. The complaint was of the absent vaginal opening in all patients. Seventeen (11.33%) were advised ultrasonography of the abdomen elsewhere to look for the presence of internal genital organs. The local examination revealed poor hygiene in 65 (43.33%) patients. The patient with thick adhesions has minor erythema after the release of adhesions. Ten (6.66%) patients had a recurrence managed by repeat release with no recurrence.

Conclusion

Despite being a benign entity, labial adhesion may be a cause of severe concern. Manual separation and antibiotic ointment may be a viable first option in its management with minimal recurrence. Maintenance of local hygiene may be needed to prevent a recurrence. The overall outcome is excellent.

Manual separation of labial synechiae: A cost-effective method in prepubertal girls

BACKGROUND

Labial synechiae is a fairly common gynaecological problem that occurs as a result of inflammation leading to fusion between the labia minora. Being in a developing country with limited resources and poor compliance of patients to prolonged treatments, we are faced with immense challenges in the management of these girls.

AIMS

We wanted to evaluate the efficacy and the cost-effectiveness of manual separation and topical antibiotics with perineal hygiene in the management of pre-pubertal girls with labial synechiae.

MATERIALS AND METHODS

Design.

Prospective, non-randomised interventional study. Participant: Pre-pubertal girls presenting with the diagnosis of labial synechiae in the period from September 2015 to January 2018. Interventions: Manual separation followed by topical antibiotic ointment application for 1 week with local hygiene. Outcomes measure: Complete release of the synechiae and no recurrence up to 6 months.

RESULTS

Out of the total 55 patients, only 48 patients were included, their age ranged from 3 months to 7 years (mean 2.8 years). Almost half of our patients were asymptomatic, and other half had symptoms (urinary tract infection, dripping of urine and itching). Majority of our patients belong to low middle class status. We had 100% complete release of synechiae and no recurrence on 6 months follow-up.

CONCLUSION

Manual separation followed by topical antibiotics is a cost-effective method of the treatment of labial synechiae with immediate response and low recurrence rate.

Labial Adhesion: New Classification and Treatment Protocol

STUDY OBJECTIVE

To determine the subtypes of labial adhesion (LA) and arrange treatment options accordingly.

DESIGN AND SETTING

Patients who presented to our clinic with LA between July 2016 and February 2018 were divided into 4 groups. Location of the adhesion area, thickness of the adhesive tissue, and response to topical steroid (betamethasone valerate 0.1% ointment) therapy were identified as common features.

PARTICIPANTS

Seventy-five prepubertal girls.

INTERVENTIONS AND MAIN OUTCOME MEASURES

To determine the subtypes of the LA and evaluate the treatment response of patients in each subtype group.

RESULTS

LA was divided into 4 subtypes according to their common characteristics. For patients with type I, 2 weeks of topical steroid treatment resulted in complete recovery (100%). For those with type II, 12 (80%) patients had complete response to topical steroid treatment for an average of 3 weeks. Type III and IV patients were completely unresponsive to topical steroid treatment.

CONCLUSION

Classification of LA patients into subtypes and determination of treatment on the basis of this classification make a major contribution in planning the treatment of patients, not by trial-and-error, but using a predetermined strategy.

Demographic characteristics of labial adhesion in South Korea: a population-based study from 2010 to 2014

OBJECTIVE

To investigate the demographic features of labial adhesion (LA) in South Korea.

DESIGN

A population-based nationwide study.

SETTING

Census population of South Korea.

PARTICIPANTS

With the entire population of South Korea (n=47 990 761), patients under age 7 who were newly diagnosed with LA from January 2010 to December 2014 were included.

MAIN OUTCOME MEASURE

The average incidence and the peak age of LA occurrence were estimated.

RESULTS

A total of 4934 newly diagnosed LAs were analysed. The incidence of LA has constantly increased since 2008, the year that the Korean Developmental Screening Test for InfantsandChildren registry began. The average incidence of LA was 55.0 cases/100 000 person-years (95% CI 53.5 to 56.6). The highest incidence was 183.6 cases/100 000 person-years (95% CI 175.8 to 191.6) in the age group of13 to 24 months. The relative risk of acquiring LA in the age group of 13 to 24 months was 1.481 (95% CI 1.381 to 1.587) compared with the age group of 0 to 12 months.

CONCLUSIONS

The demographic characteristics of LA including the average incidence and the highest incidence age group in South Korea were revealed in this nationwide, population-based study including a total of 4934 newly developed LA cases. Further studies are needed to reveal the natural disease course and the significance of diagnosing asymptomatic LA cases.

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.

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 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.

Labial adhesions and outcomes of office management

STUDY OBJECTIVE

To evaluate clinical outcomes of labial adhesions (LA) and to examine the association between LA, lichen sclerosus (LS), eczema (ECZ), or asthma.

DESIGN

Retrospective study.

SETTING

Single pediatric and adolescent gynecology clinic, Houston, Texas.

PARTICIPANTS

50 girls diagnosed with LA from 2006-2011.

INTERVENTIONS AND MAIN OUTCOME MEASURES

Resolution, recurrence, single vs multiple treatments, need for surgery, and conditions such as LS, ECZ, and asthma were reviewed.

RESULTS

Mean age was 19.6 months (range 0-84 months), and 48% were Caucasian. Most patients were symptomatic (62%) and all 50 patients chose estrogen treatment. The majority (74%) required multiple treatments, as opposed to a single treatment (26%). Patients with multiple treatments were more likely to be severely agglutinated (P = .05) and to need manual separation after failed topical treatment (P = .08). The prevalence of asthma, LS, and ECZ was 9.8%, 7.8%, and 3.9% respectively. There was no association between LS, ECZ, or asthma, and number of treatments. Both asthma (N = 3; 8%), and LS (N = 2; 5%) were present among the severe agglutinated group; however, this difference was not statistically significant (P values .59 and .99). No association with ECZ was seen in either group.

CONCLUSION

Severe agglutination tends to be associated with need of multiple treatments and manual separation. A concurrent diagnosis of LS, ECZ, or asthma was not associated with number of treatments but there appears to be a trend towards severity of LA in patients with asthma and LS.

How should we treat prepubertal labial adhesions? Retrospective comparison of topical treatments: estrogen only, betamethasone only, and combination estrogen and betamethasone

Labial adhesion is a common finding in prepubertal girls. Traditionally, topical estrogen cream application has been the choice of conservative treatment, however, topical betamethasone treatment has also recently been employed with some success. In this retrospective study, we analysed 131 children with labial adhesions. Eleven of 71 (15.4%) patients were treated successfully with topical estrogen cream only, and 5 of 32 (15.6%) patients were treated successfully with betamethasone cream only. We successfully treated 5 of 28 (28.5%) patients with a combination of estrogen and betamethasone creams. The mean time of treatment for each regimen of therapy was 4 weeks. There was no significance between the single-therapy estrogen and single-therapy betamethasone groups (P = 1.00), between single-therapy estrogen and the combination therapy (P = .16), and the single therapy betamethasone to combination therapy (P = .35) groups. There was also no significant difference between combination estrogen and betamethasone therapy and the combined data of the single therapies (relative risk 1.85; 95% confidence interval 0.89-3.89; P =.11). For the treatment of prepubertal labial adhesions, topical estrogen and betamethasone creams were found to have similar success rates, with limited satisfactory results. The combination therapy was mildly more efficacious than each of the single therapies but was not found to be statistically significant. Surgical separation is recommended if conservative treatment fails.

Success of treatment modalities for labial fusion: a retrospective evaluation of topical and surgical treatments

STUDY OBJECTIVE

Standard treatment for girls with labial fusion has included topical estrogen cream, manual separation, or surgery. Side effects may limit the use of topical estrogen. Betamethasone has recently shown efficacy at separating labial fusion. Local irritation and inflammation may be an initiator of labial fusion. No adverse effects of betamethasone treatment have been documented. Long-term side effects are unknown. This study compares therapies for conservative management of labial fusion for efficacy and focuses on the response rate, time to separation, recurrence, and side effects of treatment.

DESIGN

A retrospective chart review.

PARTICIPANTS

One hundred fifty-one prepubertal girls, mean age 3 years (range 0.25-8.75 years) diagnosed with labial fusion.

MAIN OUTCOME MEASURES

To investigate the incidence of related symptoms, length of topical estrogen or betamethasone treatment, side effects, rate of successful separation, rates of recurrence, percentage requiring surgery, and postoperative outcomes in patients with labial adhesion who underwent treatment.

RESULTS

Of 151 patients with labial adhesion, 11 (7.3%) presented with urinary frequency, 30 (19.9%) with urinary tract infections, 13 (8.6%) with vaginitis, and 19 (12.6%) with post-void dripping. When compared to patients treated with betamethasone (1.3 months), patients treated primarily with premarin took nearly twice as long (2.2 months) for resolution of their adhesions. Rates of recurrence were lower for patients receiving betamethasone therapy. Side effects for estrogen therapy included breast budding and vaginal bleeding, and for betamethasone, local irritation was reported. Some patients went on to surgery and experienced recurrence after surgery.

CONCLUSION

Initial comparison of topical estrogen and betamethasone treatment of labial fusion suggests that betamethasone may separate fusion quicker with less recurrence and fewer side effects than topical estrogen therapy.

Infected urocolpos and generalized peritonitis secondary to labia minora adhesions

INTRODUCTION

Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty.

CASE REPORT

A 9-year-old girl presented with a 2-day history of abdominal pain and fever. Urinary continence had never been obtained, with diurnal leaks. Physical examination showed signs of peritoneal irritation and a subtotal vulvar obstruction due to LMA. At surgery, after LMA lysis, a large amount of cloudy urine-like fluid emptied under pressure from the vagina. Laparoscopy showed generalized peritonitis without any intraabdominal cause. The same Escherichia coli was identified in the infected urocolpos and the abdominal fluid. Postoperative course was uneventful. Because of recurrent LMA, the patient underwent several courses of local estrogen therapy. Labia minora hypertrophy with LMA developed 2 years after peritonitis, requiring surgical reduction labioplasty. We used a new technique with interposition of skin flaps. The girl is now well, without LMA or infection, 4 years after labioplasty.

CONCLUSION

Although rare, subtotal vulvar obstruction because of LMA may lead to infected hydrocolpos and peritonitis. Recurrent LMA may necessitate surgical labioplasty.