Madhavi J*, Vibha More**, Satia MN***.
(* First Year Resident, ** Assistant Professor, *** Professor. Department of Obstetrics and Gynecology, Seth G S Medical College and KEM Hospital, Mumbai, India).
Complete labial agglutination is a rare clinical entity in adults. The most common complications of this presentation are infections of the urinary tract and retention of urine. We present the case of a post-menopausal woman with labial fusion who presented with complaints of dysuria and urinary retention. It was managed operatively with division of the labial fusion following which the patient was able to pass urine without difficulty.
Labial agglutination is a condition in which labia minora are fused with each other. It is most commonly seen in pediatric age. This condition is also known as labial synechiae, labial fusion or labial adherence. This condition in adult is rare and is predominantly seen in postmenopausal women. In most of the cases, the patient is asymptomatic or may present with post void dripping, urinary tract infections, vaginitis, hematuria and increased urinary frequency. Contributory factors for labial agglutination in reproductive age group and postmenopausal women are vaginal inflammation, vaginal laceration during childbirth, local trauma, lack of sexual activity, recurrent urinary tract infection and hypoestrogenism.
A 48 year old woman, para1, living 1, postmenopausal since 2 years presented to the outpatient department with a complaint of difficulty in passing urine with pain in abdomen since 2 months. She also gave history of burning micturition and foul smelling discharge per vaginum since 2 months. She had taken opinion from a private consultant and was given some local ointment without clinical examination. She was a known case of hypothyroidism since past 6 years on tablet Thyronorm 100 μg once daily. On examination, she was moderately built and well nourished. Her vital parameters were normal. Cardiovascular and respiratory system examination showed no abnormality. Her abdomen was soft with no guarding, tenderness and rigidity. Local examination revealed fused bilateral labia minora. Urethral opening was not visualized. Vaginal opening was also not seen. On per rectal examination, a small nodule felt. Uterine size could not be made out. There was no evidence of any collection. Her fasting and postprandial plasma sugar levels were 130 and postprandial of 140 mg/dl. An endocrinologist advised tablet Metformin 500 mg tid and continuation of Thyronorm 100 μg once daily on weekdays and 200 μg once daily on weekends. Ultrasonography showed a normal sized uterus and no evidence of any collection. Patient posted for examination under anesthesia and release of labial after all preanaesthetic work up and fitness. Under total intravenous anesthesia local examination revealed both labia minora fused to each other in midline. Urethral opening was not visualized. A small dimple was seen in midline through which an attempt was made to pass a pediatric Foley's catheter. However the effort failed. Catheter passed through another dimple above the first one entered the vagina. Then a stab incision was made between the two dimple and gentle traction was applied on both labia and the fused area was dissected with blunt dissection successfully. Urethral opening was visualized and urethral catheterization was done. Vaginal opening was visualized. Sims' speculum was inserted. A normal cervix was visualized. Bimanual examination revealed an anteverted, atrophic uterus. Postoperatively vaginal tampons were inserted for ten days to prevent reagglutinations and she was also started on estradiol cream and local antibiotic ointment. The patient tolerated the procedure well and was discharged on day 3 of procedure. She had regular follow up and continued local application of estradiol cream for six weeks.
Figure 1: Black arrow shows fused labia.
Figure 2: Black arrow shows raw area seen in bilateral labial after release of fusion.
Figure 3: Healed labia after estradiol therapy.
Labial agglutination is a state of partial or complete adhesion of the labia minora. It generally occurs in children or post-menopausal women, but is extremely rare in reproductive ages.In adults including postmenopausal women, labial fusion is more associated with recurrent urinary tract infections, vulvovaginitis, genital trauma, hypoestrogenism and lack of sexual activity.Labial agglutination in our patient is mostly due to the effect of vulvar hypoestrogenisation. Most predominant accompanying symptoms of labial fusion in postmenopausal women are vulvar soreness, pruritis and urinary symptoms such as dysuria, urinary incontinence, retention and voiding difficulties. Our patient presented with voiding difficulty. Due to labial fusion, the urethral opening is smaller and cannot stretch. It can be as small as a pinhead when labial adhesions are severe. Symptoms may be absent or the adhesions may lead to dribbling of urine on standing up after passing urine and dyspareunia. Other symptoms are itching and soreness, depending on the cause of the adhesions. Characteristics of labial agglutination are flat appearance of the genitalia, small or absent labia minora. Anterior fusion is often associated with disappearance or fusion of clitoral hood. Posterior vulval fusion may be due to scarring of perineum. The complications secondary to complete labial agglutination described in literature are chronic inflammation of the genital and urinary tract, recurrent urinary tract infection, urinary outflow obstruction, apareunia, acute renal failure, urocolpos, pyosalpinx and peritonitis. Most cases are managed surgically, and require division of the labial fusion along the anatomical plane, as was done in this case This can done under general or local anesthesia. In case of atrophic labial fusion, postoperative application of topical estrogen is recommended along with topical antibiotics to improve the healing process.[4,5]
Tsujita Y, Asakuma J, Kanbara T, Yoshii T, Azuma R, Sumitomo M, Asano T. A Case of Labial Adhesion in a Reproductive Woman. Hinyokika Kiyo 2010; 56 (8): 463-465.
Lambert B. Complete Adult Vulvar Fusion: A Case Report. Journal of Obstetrics and Gynaecology Canada 2004;26(5):501-502.
Mayoglou L, Dulabon L, Martin-Alguacil N, Pfaff D, Schober J. Success of treatment modalities for labial fusion: a retrospective evaluation of topical and surgical treatments. Journal of Pediatric and Adolescent Gynecology 2009;22(4):247–250.
Julia J, Yacoub M, Levy G. Labial fusion causing urinary incontinence in a postmenopausal female: a case report. Int Urogynecol J Pelvic Floor Dysfunct 2003; 14: 360-361.
Muppala H, Meskhi A. Voiding dysfuction due to long standing labial fusion in elderly woman: a case report. Int Urogynecol J Pelvic Floor Dysfunct 2009;20:251-252.
Madhavi J, Vibha More, Satia MN. Labial Agglutination In A Postmenopausal Female. JPGO Volume 2 Issue 6 Available from: http://www.jpgo.org/2015/06/labial-agglutination-in-postmenopausal.html