Labial Adhesions Following Herpes Genitalis And Management Options: A Case Report

Author Information

Sinha S*, Tiwari N**, Samant PY***, Chauhan AR***.
(* Second year resident, ** Assistant Professor, *** Additional Professor, Department of Obstetrics and Gynaecology, Seth G S Medical College and KEM Hospital, Mumbai, India.)


Genital herpes is a common sexually transmitted disease but labial adhesions following this infection are a rare but recognized local complication. Chronic labial adhesion in the reproductive age group is extremely rare. It occurs most often in infants, prepubertal girls, postpartum and postmenopausal women. It is usually associated with low estrogen levels. We present a case of almost complete labial adhesion with dysuria, altered stream of urine, and perineal discomfort in a 35-year-old female secondary to herpes genitalis.

The incidence of genital herpes nearly doubled over 20 years (11.4% to 20.5%) from 1977 to 2000 as observed in a review from North India1. The infection is transmitted through contact with lesions on mucosal surfaces, and from genital and oral secretions. The incubation period ranges from 2 to 21 days2. Vesicles on or around the genital area, rectum or mouth which may later ulcerate are typical lesions. Ulcers take two to four weeks to heal. Complications like secondary bacterial infection of lesions, blindness due to corneal infection, meningitis, and labial adhesions have been known to occur.

Case Report:

A 35- year old married parous woman presented in emergency with complaints of vulvar and lower abdominal pain, dysuria and fever for two days. She had regular menstrual cycles. She was afebrile. Minimal tenderness was present in hypogastrium. No lesion or lymphadenopathy was present on local vulvar examination. On speculum examination, copious vaginal discharge and hypertrophied congested cervix were seen. The discharge was collected for bacterial culture and antibiotic sensitivity. Patient did not allow bimanual examination as she was in severe pain. She was advised personal hygiene, testing for HIV and VDRL, urine routine microscopy with culture sensitivity, and pelvic ultrasonography. She was prescribed oral clindamycin and metronidazole and was asked to follow up in a week.
After 5 days she presented again to the emergency room in view of vaginal discharge, pain, and fever not responding to antibiotics. On examination she was afebrile and vitally stable. Multiple vesicles and papules in various stages of eruption were now noted on vulva. Her routine pathological, biochemical investigations, pelvic ultrasonography and urine analysis were unremarkable. Culture and sensitivity tests of vaginal discharge and urine did not yield any bacterial growth. Diagnosis of herpes genitalis was made. Oral acyclovir (1000 mg per day in divided doses) and antibacterial ointment for local application were prescribed. Patient’s partner did not report symptoms suggestive of herpes.
She followed in the outpatient department 10 days after the second visit with complaint of altered stream of urine. At this time, healed herpetic lesions on both labia majora and agglutination of labia minora were noted on local examination.
For her voiding difficulty, manual separation of the labial adhesions with local lignocaine jelly application was done gradually in 4 daily sittings after counseling the couple. Patient was advised to continue antibacterial ointment with additional use of liberal application of lignocaine jelly after urination, washing, bathing. Adhesions were completely separated over the course of these 4 days. Patient was asked to maintain genital hygiene and continue ointment application for 2 weeks before resuming sexual activity. Partner was referred to dermatology department for further advice. Follow up examination of the patient after two weeks showed normal appearance of genitalia. She could void urine normally and was otherwise asymptomatic.

Figure 1: Labial agglutination.

Figure 2: Partially separated labia on day 2 of manual separation.

Figure 3: Completely separated labia.


Labial adhesions are membranous structures resulting due to fusion of the adjacent mucosal surfaces of the labia minora or majora. Infants and adolescent girls are more prone to labial adhesions due to hypoestrogenemia3. Adhesions form when apposing surfaces of labia become raw due to worm infestation, nappy rash, poor hygiene or sexual abuse. Atrophic vaginitis can cause labial adhesions in post menopausal women4. Topical application of oestrogen cream is the treatment of choice. Surgical intervention is required only in long standing cases. The entity is rare in reproductive age but can occur as a result of inflammatory skin conditions like lichen sclerosus, herpes genitalis, Stevens Johnson syndrome, surgery or childbirth trauma. Seehusen and Earwood found that estrogen therapy was ineffective and surgery was required to resolve postpartum adhesions5. In case of herpes genitalis, formation of fibrinious exudates can lead to adhesions between the labia minora6. If left untreated, this can lead to midline fusion with coital and voiding difficulty. In our patient, in a short period of 14 days after prodromal symptoms almost complete agglutination of  labia minora occurred; probably due to apposition between raw surfaces and unwashed exudates at the time of healing with resultant distortion of urinary stream.
Spontaneous resolution of prepubertal labial adhesions is reported in nearly 80% cases within 1 year7. Topical steroid application has been successfully tried of post herpetic labial adhesions in an adult woman8. Mayoglou et al in retrospective review of prepubertal cases with labial adhesions observed that topical steroid therapy resolved adhesions faster and had less recurrence and side effects as compared to topical estrogen therapy9. Obstruction to urinary flow or refactory adhesions after local therapy requires surgical intevention9. Our patient required intervention due to her urinary symptoms. Surgery and CO2 laser vaporisation are recommended for restoring voiding and sexual function impaired by adhesion10. Amniotic membrane graft on raw surfaces has been used to prevent reformation of adhesions after surgery.11


Incorrect diagnosis, poor hygiene and lack of topical treatment may predispose to development of labial adhesions in women with herpetic vulvitis. Topical therapy and saline baths in addition to antiviral medication are integral part of treatment for primary genital herpes, with manual or sugical separation reserved for obstructive symptoms.

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Sinha S, Tiwari N, Samant PY, Chauhan AR. Labial Adhesions Following Herpes Genitalis And Management Options: A Case Report. JPGO 2015. Volume 2 No. 8. Available from: