Labial Adhesions and Topical Estrogen

While we often consider the Emergency Department as being present only for “major” problems, we all know that our services go well beyond the critically ill and majorly injured. Often those “minor” issues can occupy a lot of our shift and even throw curveballs at us, testing our mental flexibility! As I have gotten “older,” I have realized that being proficient with the relatively “simple” issues can make your shift more efficient and enjoyable. Let us take a second to consider one such minor issue – Labial Adhesions in Preadolescents:

Labial Adhesions: Basics

  • Labial adhesions are due to fusion of the mucosa of the labia minora.
    • Possible mechanism = irritation of regional tissues
    • Related to low estrogen state
  • Relatively common with prevalence of 0.6-5%.
    • Occurs most often in the first 5 years of life.
    • Can occur in preadolescents.
  • Labial adhesions presentations:
    • Asymptomatic:
      • Most often are asymptomatic
      • Found during physical examine or when attempt at catheterization is made.
    • Symptomatic:
      • The adhesion may cause secondary issues and lead to symptoms.
      • Post-void dripping (perceived incontinence)
      • Urinary frequency
      • Recurrent urinary tract infections
      • Hematuria
      • Vaginitis
      • Genital pain with ambulation
  • Labial adhesions Ddx considerations:
    • Poor hygiene
    • Infection
      • Candidiasis
      • Infestations
    • Chemical irritations
    • Sexual assault

Labial Adhesions: Management

  • Physical Examination is important (duh)
    • Patients with “UTI symptoms” also deserve a full exam,… not just an order for a urinalysis.
    • Frog-leg positioning is best for inspecting the region.
      • Adhesion typically extends from posterior to anterior region.
      • The adhesion may cover the urethral meatus.
    • GENTLE traction to separate the labial majora can help reveal the labial adhesions.
      • This should NOT be painful (perhaps not comfortable…)!
      • Do not attempt to manually separate the adhesions.
        • This may be a part of the therapy, but not initially.
        • If performed, typically done by pediatric Gynecology under anesthesia.
  • There is no “gold standard” therapy that is agreed upon. [Bacon, 2015]
    • For ASYMPTOMATIC adhesions, which are the most common, no specific therapy is required:
      • Reassurance – most will resolve spontaneously over the next year
      • Good hygiene:
        • Avoid further irritation (ex, tight fitting underwear, remaining in wet clothing for prolonged times)
        • Avoid wiping back-to-front
        • Avoid bubble-baths and irritating soaps
      • Outpatient follow-up
    • In SYMPTOMATIC patients, simple therapies can be started by us in ED:
      • Topical Estrogen Cream has been found to be useful and are the most often used 1st line therapy. [Dowlut-McElroy, 2019]
        • Small amount of 0.01% estrogen ointment applied directly to area twice a day.
        • Used for 2-4 weeks.
        • Minimal side-effects: they are systemically absorbed – can lead to breast budding and even vaginal bleeding!
      • Steroid Ointment (Betamethasone) can also be effective.
    • It is not uncommon for the labial adhesion to RECUR.
      • Recurrence does often require manual separation by pediatric gynecologist.
      • Ensure the patient has this possibility included in your anticipatory guidance.

Moral of the Morsel

  • “Simple” is still important. Both for the patient and for us… be efficient with the relatively easy so you can “save” time and energy for the complex!
  • Dysuria does not equate to UTI. A simple exam can help you sort through your DDx.
  • Estrogen is Powerful! From helping with simple problems to grand one (like politics), estrogen can be a very useful therapy.

References

Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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