Gupta AS

Labial adhesions or agglutination or fusion is an acquired condition that results from the adhesions of the inner mucosal surface of the labia minora. This can be complete or partial. When it is complete the vaginal opening cannot be seen at all.A small opening anterior or in front of the sealed labia minora permits the flow of urine and this sealed labia form a pocket which acts as a container to hold the urine.Labial adhesions may be primary or secondary. Primary are present from birth and secondary usually occur after menopause. The labial fusion occurs in two age groups. The girl child or the adult woman.
Causes of labial adhesions
Estrogen deficient states: This is the commonest cause of fused labia. It affects young girls usually aged 6 months to 6 years, women during lactation, after menopause, following use of SERMs, aromatose inhibitors, GnRH agonists or anatagonists or women having hyperprolactinemia. Usually at birth maternal circulating estrogen's are present in the neonatal circulation preventing labial adhesions. Any irritant that can cause chronic inflammation to the labia like use of diapers, stools, urine, foreign bodies, undetected chronic sexual abuse can lead to adhesion formation between the inner surface of the labia minora resulting in their fusion. The condition may be detected if the girl complaints of dribbling of the urine that leaks out of the pocket formed by the sealed labia or it may remain undiagnosed. Most of the times it spontaneously resolves at puberty with the surge of endogenous estrogen's. In menopausal women lack of estrogen results in atrophic vulvovaginitis increasing the adhesiveness of the thinned out labia and the vagina. The adult woman may present with apareunia, dyspareunia, infertility, difficulty in introducing a vaginal tampon or dribbling of urine or menstrual blood.
Other causes can be inflammation due to infections like herpes genitalis, autoimmune disorders like Behcet syndrome, pemphigoid conditions of the mucous membranes, erosive lichen planus causing vulvovaginal gingival syndrome , or serious drug reactions like Steven-Johnson syndrome or toxic epidermal necrolysis affecting the vulva as a part of the systemic disorder. Inflammation and trauma following parturition or after vulvectomy for vulval cancer or after female circumcision can also predispose to labial adhesions.
Treatment can be medical or surgical. Always a trial of medical treatment should be given especially in girls and women in hypoestrogenic states. Estrogen creams applied to the in the mid line over the fused junction which can be identified as a white red or brown line daily for 4-6 weeks usually opens up the fused labia. However, an emollient cream should be continuously applied daily to prevent reformation of the adhesions. Patients with autoimmune disorders will need treatment of the cause along with local estrogen and emollient creams. In patients where the labia are densely stuck and estrogen, emollient or steroid creams fail will need to undergo surgical adhesiolysis.

We bring you two interesting articles on labial adhesion in this issue and we hope that readers gain useful scientific insight from these and the remaining interesting case reports. We have omitted the section on multiple choice questions for management reasons. While we will continue to use it in our institute locally, making it available to everyone reading our journal was not manageable.