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

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.

Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions

BACKGROUND

Topical estrogen treatment has been considered the first-line treatment of labial adhesions in prepubertal girls. However, the effect of topical estrogen cream is different according to studies, and no study compared estrogen cream to observation.

OBJECTIVE

This study aims to investigate the efficacy of topical estrogen cream treatment compared with observation in prepubertal girls with labial adhesions.

STUDY DESIGN

The medical records of prepubertal girls diagnosed with labial adhesions from April 2005 to June 2019 were retrospectively analyzed. Baseline characteristics such as age at diagnosis and initial symptoms were collected. The primary outcome was the resolution of labial adhesion. Secondary outcomes were recurrence and side effects.

RESULTS

A total of 114 patients were enrolled and divided into two groups, topical estrogen cream (n = 94), and observation (n = 20). Girls who were treated with estrogen cream had older age (24.6 ± 19.0 vs. 16.7 ± 15.3 months, p = 0.037) and higher resolution rate than the observation group (100.0% vs. 85.0%, respectively, p = 0.005). Girls younger than 23.3 months showed a significantly higher resolution rate to topical estrogen treatment (100% vs. 86.7%, p = 0.043). Side effects and recurrences occurred exclusively in children treated with topical estrogen therapy without significant differences compared to the observation group.

CONCLUSION

Topical estrogen therapy showed a higher resolution rate than observation for the treatment of prepubertal girls with labial adhesions, especially in younger girls.

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.

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.

Vulvovaginal involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis: management and techniques used to reduce gynecologic sequelae

BACKGROUND

Vulvovaginal involvement in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is common, likely underdiagnosed, and can result in severe sequelae if not managed acutely. There are few studies on acute management of vulvovaginal SJS/TEN. Current recommendations are predominantly based on expert opinion. We aimed to determine the frequency of vulvovaginal involvement in SJS/TEN at a single institution, identify treatment modalities, and assess outcomes at a tertiary care burn center.

METHODS

This is a retrospective review of vulvovaginal SJS/TEN cases between 2009 and 2019. Demographic and clinical data including exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record.

RESULTS

Vulvovaginal involvement was observed in 12.7% (19/149) of cases of female patients with SJS/TEN. The mean age was 38.7 years (SD 23.6), and 21% (4/19) of patients were pediatric (age 9-18). Vulvar involvement was seen in 47.3% (9/19), and vulvar plus vaginal involvement was reported in 42.1% (8/19). Treatment regimens were variable until 2017, at which time institutional guidelines were implemented including application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression. Gynecology follow-up occurred in 15.7% (3/19) of cases. One complication of superficial vaginal agglutination was noted and was successfully treated in the office with blunt dissection.

CONCLUSION

The most common treatment modalities employed at our institution included application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression. While follow-up was limited for our patient population, we propose an algorithm to prevent long-term sequalae of vulvovaginal SJS/TEN. Gynecologic surveillance is recommended to reduce urogynecologic sequelae.

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.

Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial

STUDY OBJECTIVE

Although various treatment options have been proposed for the treatment of labial adhesions, there are currently no clearly outlined limits on the duration of topical therapy, amount of lateral traction to apply, and methods to decrease the recurrence. This clinical trial was undertaken to assess the need for estrogen for treatment of prepubertal labial adhesions.

DESIGN

Randomized, double-blinded, controlled trial.

SETTING

Pediatric and Adolescent Gynecology Clinic at a children's hospital in a metropolitan area.

PARTICIPANTS

Prepubertal girls ages 3 months to 12 years with labial adhesions.

INTERVENTIONS

Lateral traction with topical estrogen or topical emollient.

MAIN OUTCOME MEASURES

The primary outcome was resolution of labial adhesions. The secondary outcome was the change in severity of labial adhesions over time between the 2 groups.

RESULTS

Forty-three girls were enrolled and 38 (88%) completed the study. The difference in complete resolution between the topical emollient group (19%) and the topical estrogen group (36%) was not statistically significant (P = .21). There was a statistically significant decrease in severity of labial adhesions over time, with the magnitude of improvement favoring the topical estrogen group.

CONCLUSION

Although labial adhesion severity decreased when treated with lateral traction and topical emollient or topical estrogen, the magnitude of the effect was significantly greater for topical estrogen.

Spontaneous resolution of labial adhesions in pre-pubertal girls

AIMS

This study sought to observe the rate and timing of spontaneous resolution of labial adhesions that had been diagnosed in pre-pubertal girls. The secondary aim was to evaluate the conservative approach to management of labial adhesions that has been advocated by the Gynaecology Department, by assessing the rates of concurrent uro-gynaecological symptoms in this population, as well as parent satisfaction with their child's management.

METHODS

A retrospective chart review was performed of all patients diagnosed with labial adhesions in the Department of Paediatric and Adolescent Gynaecology between 2000 and 2017. Patients and their parents (depending on the age of the patient at the time of this study) were then invited to participate in follow-up surveys and questionnaires and clinical examination.

RESULTS

Of 148 girls identified, the median age of the follow-up participants (n = 45) was 6.1 years (2.6-27.2 years), compared with that of the entire cohort of 7.4 years (1-27 years). After a median follow-up period of 2.6 years (0.4-20.7 years), 40% (18/45) of girls reported and/or had findings that supported resolution of labial adhesions without treatment. Two parents (4%) sought treatment elsewhere after their appointment. A history of UTI was reported in 30% (14/45) of patients, and 16% (7/45) had a known history of vulvovaginitis.

CONCLUSIONS

Our findings support the natural history of spontaneous resolution of labial adhesions. Concurrent uro-gynaecological conditions that developed were successfully treated according to standard treatments. A conservative approach to the management of labial adhesions is associated with very low rates of parental concern and intervention.

Treatment with oestrogen or manual separation for labial adhesions - initial outcome and long-term follow-up

Background

Topical oestrogen and manual separation are the main treatments for labial adhesions. The aim was to evaluate treatment of labial adhesions and compare the outcome of topical oestrogen treatment with that of manual separation.

Method

All girls aged 0–12 years admitted to a tertiary centre for paediatric surgery for labial adhesions were included. The study design was dual: The first part was a retrospective chart review of the treatment success according to the medical charts. The second part was a cross-sectional parent-reported long-term outcome study (> 6 months after last treatment finished).

Results

In total 71 patients were included and the median follow-up time for the chart study was 84 (6–162) months after treatment with oestrogen or manual separation. Oestrogen was the first treatment for 66 patients who had an initial successful rate of 62% but this was followed by recurrences in 44%. Five patients had manual treatment as their first treatment and they had a 100% initial success rate followed by recurrences in 20%. Therefore, for the first treatment course there was a final success rate of 35% for oestrogen and 80% for manual separation (p = 0.006). Corresponding final success rates including all consecutive treatments over the study period were 46/130 (35%) for oestrogen and 21/30 (70%) for manual separation (p = 0.001). The success rate for oestrogen did not differ if treatment was given in a course length of 0–4 weeks (39% success) or > 4 weeks (32% success) (p = 0.369).

In the parent-reported long-term outcome study the response rate was 51% (36/71).

Parents reported that recurrences of adhesions after last prescribed/performed treatment were frequent: in total 25% of patients still had adhesions corresponding to 8/29 (29%) of those whose last treatment was oestrogen and 1/9 (11%) of those whose last treatment was manual separation.

Conclusion

Due to the results recurrences are common after both oestrogen and manual separations. However, the overall final outcome after manual separation seems to be more successful when compared to that of topical oestrogen treatment.

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.

Clinical Recommendation: Labial Adhesions

Labial adhesions, also known as labial agglutination, are a common finding in prepubertal adolescents. They are defined as fusion of the labia minora in the midline or are termed vulvar adhesions when they occur below the labia minora (inner labia). Patients are often asymptomatic but might present with genitourinary complaints. The decision for treatment is based on symptoms. The mainstay of treatment in asymptomatic patients is conservative, with careful attention to vulvar hygiene and reassurance to parents. In symptomatic patients, topical treatment with estrogen and/or steroid cream is often curative. Less often, corrective surgery is necessary. Recurrence is common until a patient goes through puberty. These recommendations are intended for pediatric and gynecologic health care providers who care for pediatric and adolescent girls to facilitate diagnosis and treatment.

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.

Surgical correction of labial fusion with vaginoplasty in a cat

A spayed female domestic shorthair cat was first examined at the age of 16 months because of persistent licking of the perineal area. The cat had a grossly enlarged and oedematous vulva with pronounced superficial pyoderma of the perivulvar area, which responded favourably to systemic antibiotics, analgesics and local corticosteroids. A month after the initial examination, the cat was re-presented owing to pollakiuria, stranguria and dyschesia. The oedema of the vulva had disappeared and the vulvar labia were fused together; there was only a fistulous tract with a diameter of 1 mm present in the area of the vulva, and the cat strained to urinate through that opening. A contrast study revealed normal transit through the lower urinary tract, but labial adhesions resulted in the development of dilation cranially, where the vaginal vestibule was supposed to be. Vaginoplasty was subsequently performed, the cat recovered normally and, 10 months after the procedure, the lumen of the vaginostoma is preserved and the cat is urinating without difficulty.