Office pediatric urologic procedures from a parental perspective

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.

Clinic meatotomy under topical anesthesia

OBJECTIVES

Almost 20 years after Cartwright et al. (1996) demonstrated the feasibility and effectiveness of clinic meatotomy (CM) under topical lidocaine and prilocaine (EMLA) anesthesia, 50% of meatotomies are still performed under general anesthesia (GA) (Godley et al., 2015). The cost of a meatotomy under GA is approximately 10 times the cost of CM in the present practice. This study presented the outcomes for CM under topical anesthesia, in consecutive patients who presented with meatal stenosis secondary to circumcision.

MATERIALS AND METHODS

This was a retrospective descriptive study of data, which were collected prospectively for quality improvement purposes from July 2013 to September 2015, of 55 consecutive boys who underwent CM for meatal stenosis (occlusion of urethral meatus by a crust; deflected stream). Meatotomy was performed after applying EMLA and covering it with a Tegaderm^® dressing, and then waiting 20-60 min. The recorded outcomes were pain and success rate. Pain was defined at the beginning of data collection as any sound, grimace or movement during the procedure. Success rate was recorded during follow-up in the clinic or over the phone, when the family was asked if symptoms were the same, improved or completely resolved.

RESULTS

Forty-three boys (78%) had no pain and 12 (22%) had pain as defined above (Figure), but no CM had to be stopped due to pain. At a median follow-up of 1.6 months (IQR 1.3-2.7 months) 41 (75%) patients had resolution of their symptoms and a normal urinary stream, nine (16%) had improved symptoms, and three (5%) had unchanged symptoms.

CONCLUSIONS

More patients reported pain than those in the Cartwright study; this was perhaps because a full hour was not waited after EMLA application with most of the present patients. The present success rate was also lower than that reported by Cartwright, and for that there is no explanation. However, all CM could be completed and >90% of patients saw resolution or improvement of their symptoms. At a cost ten times lower than a meatotomy performed under GA, and with no evidence of inferiority evident in the literature, it is believed that CM should be the standard of care when meatal stenosis is treated by a meatotomy.

CDC's Male Circumcision Recommendations Represent a Key Public Health Measure

Frisch and Earp, opponents of male circumcision, have criticized draft recommendations from the CDC that advocate counseling men and parents of newborn boys in the United States about the benefits and risks of male circumcision. We provide a rebuttal to Frisch and Earp's criticisms and contend that the recommendations are entirely appropriate and merit consideration for policy development.

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.

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.

Surgical management of meatal stenosis with meatoplasty

Meatal stenosis is a common urologic complication after circumcision. Children present to their primary care physicians with complaints of deviated urinary stream, difficult-to-aim, painful urination, and urinary frequency. Clinical exam reveals a pinpoint meatus and if the child is asked to urinate, he will usually have an upward, thin, occasionally forceful urinary stream with incomplete bladder emptying. The mainstay of management is meatoplasty (reconstruction of the distal urethra /meatus). This educational video will demonstrate how this is performed.

Topical estrogen therapy in labial adhesions in children: therapeutic or prophylactic?

AIM

To evaluate the efficacy of topical estrogen therapy as a therapeutic or a prophylactic agent in labial adhesions in children.

PATIENTS AND METHODS

Patients who were diagnosed with labial adhesions were evaluated in three different groups according to a modified algorithm. A conservative treatment (CT) group consists of asymptomatic patients who did not receive any treatment previously. They received only topical estrogen twice a day for 14 days. A manual separation (MS) group includes patients who were symptomatic and unresponsive to medical therapy. Only manual separation was performed. Symptomatic patients who had not received any treatment were enrolled as manual separation with prophylaxis (MSP) group. Manual separation with postoperative prophylactic topical estrogen was the choice of treatment in the last group. Manual separations were performed in an outpatient facility with local anesthesia. All patients were followed up after 3 and 9 months.

RESULTS

In total, 49 patients were enrolled in the study. Mean age of patients was 14.05 +/- 4.19 (n =18), 14.64 +/- 4.60 (n =14) and 12.82 +/- 4.34 (n = 17) months for conservative treatment, manual separation, and manual separation with prophylaxis groups respectively. Success rates of the CT group was 66.6% (n = 12) in the third month and 55.5% (n = 2) in the ninth month. Recurrence was experienced in two (11%) patients. The MS group had a success rates of 85.7% (n = 12) in both 3(rd) and 9(th) months and recurrence was 14.2% (n = 2). All of the patients treated (100%, n = 17) by manual separation with prophylaxis recovered when followed up at three and nine months. No patient needed surgical intervention. The conservative group had significantly lower success rates when compared to other groups (P = 0.002). No statistical difference was detected between MS and MSP groups (P = 0.196).

CONCLUSIONS

Labial adhesion is a common gynecologic problem in childhood. Asymptomatic patients also require treatment in which topical estrogen therapy is adequate. Topical estrogens have limited satisfactory results with considerable adverse events. Manual separation should be performed for symptomatic patients. Topical estrogens prevent recurrences when used as prophylaxis after manual separation in labial adhesions.

Estrogen treatment success in recurrent and persistent labial agglutination

STUDY OBJECTIVE

To estimate the success rate of conservative medical management and indications for surgery in cases of recurrent and/or persistent labial agglutination.

DESIGN

A retrospective chart review was performed of girls treated for labial agglutination between 1996 and 2004. Records were reviewed for age, length of time of symptoms, previous treatments, results of topical estrogen therapy, and indications for surgery.

SETTING

The study was performed in a tertiary care teaching university hospital.

PARTICIPANTS

Charts of 67 girls with labial agglutination who were treated at the pediatric and adolescent gynecology clinic between 1996 and 2004 were reviewed. The average age was 4.1 years (range 0.6-14 years).

INTERVENTIONS

None.

MAIN OUTCOME MEASURES

Improvement of persistent or recurrent agglutination labial agglutination with estrogen.

RESULTS

Out of the 67 charts reviewed, 48 had recurrent or persistent disease. Within those 48 girls, initial treatments included: topical estrogen in 40 (83%), oral and topical estrogen in 1 (2%), topical estrogen in addition to manual separation in 5 (10%), and treated with manual separation alone in 2 (4%). Five girls were immediately treated surgically due to urinary problems or parents declining further topical treatment. Forty-three were treated with topical estrogen therapy with the following results: 15 opened either partially or completely, 9 required surgery, and 19 did not follow up. In the subset of girls with prior manual separation, 2 had resolution of adhesions with estrogen, 3 required surgery, and 2 had no follow-up.

CONCLUSION

This study suggests that re-treatment of persistent or recurrent labial agglutination with topical estrogen therapy following detailed application instruction leads to avoidance of surgical intervention in at least 35% of cases. Even in cases which previously required manual separation, an attempt at conservative medical management may be considered.

Betamethasone cream for the treatment of pre-pubertal labial adhesions

PURPOSE

We evaluated the efficacy of 0.05% betamethasone cream for the treatment of pre-pubertal labial adhesions.

METHODS

We retrospectively reviewed the records of 19 children with labial adhesions who were treated with betamethasone cream from 6/2001 to 3/2003. Children were treated with 1 to 3 courses of twice-daily 0.05% betamethasone cream for 4 to 6 weeks. Successful lysis of adhesions was assessed by clinical exam or parental phone contact and outcomes were defined as: (1) success--complete separation of labia, (2) partial success--greater than 75% separation, (3) progression to surgical lysis, and (4) lost to follow-up.

RESULTS

Nineteen patients with an average age of 58 months (range 12 to 132 months) were treated. Four of the 19 patients had never been treated previously and 1 had been treated previously with surgical lysis of adhesions only. Fourteen of the 19 patients had been previously treated with conjugated estrogen (Premarin) cream. Two of these fourteen patients had also undergone surgical lysis of adhesions. Severity of adhesions ranged from 33% to 99% labial closure. Betamethasone cream was successful in treating 13/19 (68%) pre-pubertal labial adhesions. Eleven (85%) of these 13 patients had complete resolution of labial adhesions with 1 course of treatment, 1 (7.5%) had resolution with 2 courses of treatment and 1 (7.5%) had resolution with 3 courses of treatment. One patient had a partial success with 3 courses of betamethasone cream. Two (11%) patients underwent surgical lysis of adhesion after 1 and 2 courses of betamethasone cream respectively. Three (16%) patients were lost to follow-up. Average follow-up was 7 months (range 1-24 months). No adverse outcomes or untoward effects were noted in any of the patients treated.

CONCLUSIONS

Betamethasone 0.05% cream appears to be a safe and effective treatment of pre-pubertal labial adhesions as primary therapy or in patients that have failed previous therapies and it may avoid the undesirable side effects of breast budding and hyperpigmentation that can be associated with Estrogen creams.

THE EFFICACY OF LMX VERSUS EMLA FOR PAIN RELIEF IN BOYS UNDERGOING OFFICE MEATOTOMY

PURPOSE

We determined if a difference in pain management occurred when topical anesthetics LMX (formerly ELA-Max, lidocaine 4%) and EMLA (lidocaine 2.5% and prilocaine 2.5%) were compared in boys undergoing office meatotomy for symptomatic meatal stenosis.

MATERIALS AND METHODS

A prospective randomized study was performed on 52 boys who underwent office meatotomy by a single pediatric urologist. Of the boys 26, 2 to 9 years old (mean age 4.4) underwent meatotomy 45 minutes after topical anesthetic application (LMX 13, EMLA 13) between February and December 2001, 26, ages 1 to 10 years old (4.6) underwent meatotomy 30 minutes after topical anesthetic application (LMX 13, EMLA 13) between April 2002 and January 2003. A single pediatric urological nurse performed pain assessment using the Wong-Baker Faces scale before applying the anesthetic ointment and immediately following the procedure. Each child had either LMX or EMLA applied and covered with an occlusive dressing for either 45 or 30 minutes before the procedure. Oral acetaminophen (10 mg/kg) was given at the time of anesthetic application. A meatotomy was then performed using a straight crushing hemostat for 1 to 2 minutes followed by incision. Mann-Whitney rank sum test was implemented to determine statistical significance.

RESULTS

Excellent procedure outcomes were experienced by all patients without recurrent meatal stenosis.

CONCLUSIONS

There was no significant difference between LMX and EMLA when applied 45 minutes before meatotomy. When applied 30 minutes before meatotomy LMX provided significantly superior pain management than EMLA.

The surgical treatment of labial adhesions in pre-pubertal girls

STUDY OBJECTIVE

A review of our experience with the surgical treatment of labial adhesions refractory to medical treatment.

DESIGN

Retrospective review.

SETTING

University tertiary care hospital same-day surgery center.

PARTICIPANTS

Nine prepubertal females, age 3-6 yrs, presenting with thick, symptomatic labial adhesions refractory to medical management.

INTERVENTION

All patients underwent surgical lysis of labial adhesions under general anesthesia. Adhesions were incised sharply and the cut edges were reapproximated with 7-0 chromic suture by a pediatric urologist (JGB).

MAIN OUTCOME MEASURES

Duration of recurrence-free follow-up.

RESULTS

No patient had recurrence in an average of 8.6 months of follow-up. Surgery was well tolerated in all cases.

CONCLUSION

This technique effectively treats and prevents the recurrence of moderate to severe labial adhesions that are unresponsive to medical therapy.

Prepubertal labial adhesions: evaluation of a referral population

OBJECTIVE

The purpose of this study was to assess patient demographics, clinical presentation, response to previous treatment, and current evaluation of prepubertal girls referred for gynecologic care of labial agglutination.

STUDY DESIGN

A retrospective chart review of all prepubertal female patients with labial agglutination referred from 1996 through 2001.

RESULTS

Twenty-three girls were diagnosed with labial agglutination during the review period. All of the diagnoses were made by a primary care provider. At the time of referral, most patients had received medical therapy, but had not obtained resolution of their labial agglutination with topical estrogen. Twenty-two of the 23 patients required manual separation of the labial adhesions. Findings most frequently revealed a pinpoint opening and thick (3-4 mm) adhesions with >90% of the vestibule adhered in 21 of 23 girls. Nine of 23 girls had recurrence of adhesions. Four girls required a repeat manual separation because of recurrent thick adhesions. One of 4 girls required a third manual separation. Five of the 9 recurrences were treated successfully with topical estrogen.

CONCLUSION

Gynecologists who treat patients with labial agglutination frequently may encounter children for whom medical treatment has failed. Patients whose condition does not respond to topical therapy may have thick adhesions and require manual separation.

Surgery to the external genitalia

Surgery to the external genitalia is one of the most challenging chapters of reconstructive urology, due to the need to correct complex problems such as hypospadias or epispadias (isolated or associated to exstrophies). Although this specialty has shown a continuous technical advancement there is no consensus as to the most efficient surgical procedure or to the best strategy to treat these pathologies. The papers reviewed here reflect these statements and reinforce the idea that surgeons' good sense, allied with their experience in the area, are the factors that define the choice of the ideal surgical option for each case.