Labial Adhesions

Labial adhesions are fusion of the labia minora in the midline, caused by low oestrogen levels and local inflammation in prepubertal girls, and they are usually asymptomatic.

• They occur in about 1 to 2 percent of girls, peaking at age 3 months to 6 years, commonly at 2 to 3 years.
• They are caused by labial irritation (nappy rash, vulvovaginitis) and low oestrogen.
• The fused tissue forms a thin, translucent midline raphe, usually with a small pinhole opening.
• Most resolve spontaneously with puberty, when oestrogen rises. Many resolve earlier.
• Trauma and abuse can cause scarring and adhesions; consider safeguarding if features suggest it.

Most are asymptomatic and found on routine examination.

• Fused labia with a thin, translucent midline line (raphe). Vaginal opening is obscured, but urethral opening may be hidden.
• Altered urine stream (downward or sprayed), post-micturition dribbling, dysuria, and recurrent urinary infection.
• Vulvovaginitis or perineal irritation.
• Rarely complete fusion with urinary retention.
• Differential diagnosis: imperforate hymen, vaginal agenesis, ambiguous genitalia (congenital adrenal hyperplasia), lichen sclerosus, scarring from trauma or abuse, and congenital fusion.
• Complications: urinary retention (rare), recurrent urinary tract infection, vulvovaginitis, and recurrence after treatment.

Diagnosis is by inspection.

• Gentle examination by separating the buttocks and labia; the midline raphe is characteristic.
• Check for the urethral meatus and any distension of the introitus or hydrocolpos.
• Urinalysis and culture if urinary symptoms.
• Ambiguous genitalia needs endocrine evaluation.

Most need no treatment.

• Supportive: reassure parents. Gentle hygiene, avoid irritants, and treat associated vulvovaginitis or nappy rash.
• Pharmacological: if symptomatic (urine retention, infection, dribbling), topical oestrogen cream (oestradiol 0.01 percent cream or conjugated oestrogen cream 0.625 mg/g) applied thinly to the raphe twice daily for 2 to 4 weeks, with gentle lateral traction, then a barrier emollient (petroleum jelly or zinc oxide) nightly for 4 to 6 weeks to prevent recurrence. Short courses minimise breast budding and vaginal bleeding.
• Topical betamethasone 0.05 percent cream twice daily for 4 to 6 weeks is an alternative.
• Procedures: manual separation is not advised because of pain, trauma and recurrence. Surgical separation under anaesthesia only for complete obstruction or failure of medical treatment, followed by emollient to prevent re-adhesion.
• Special groups: suspected abuse requires safeguarding assessment.
• Red flags: urinary retention, painful bleeding, recurrent urinary infection, signs of trauma and failure of medical treatment.
• Follow-up: review in 4 to 6 weeks. Recurrence is common; reapply emollient and review as needed. Spontaneous resolution by puberty.