Significance of topical estrogens to labial fusion and vaginal introital integrity

Treatment of Prepubertal Labial Adhesions with Topical Estriol + Testosterone: A Case Report

BACKGROUND

Labial adhesions, a frequent gynecological condition in prepubertal girls, occur when the labia minora adhere along the midline. The prevailing hypothesis about their etiology suggests that labial adhesion may occur when the delicate and non-estrogenized labia minora undergo an inflammatory response, triggered by exposure to an irritant environment. Therefore, conservative treatment involves the application of topical estrogen or betamethasone cream. The role of androgens has not been considered yet in the pathophysiology or therapy of this condition. However, some studies have shown that androgen receptors are prevalent in the labia minora and vulvar vestibule.

CASE SUMMARY

We present the case of a 29-month-old girl with symptomatic labial adhesions. She was first ineffectively treated with topical estriol, and then she was treated with a galenic cream containing both estriol and testosterone with complete recovery and without side-effects.

CONCLUSIONS

Both androgens and estrogens play a significant role in maintaining the physiological trophic state of the vulva and vagina, even during childhood. Topical estriol+testosterone could be considered an alternative treatment for prepubertal labial adhesions refractory to standard topical therapy.

Pubertal Labial Fusion: A Case Study

Labial fusion, though rare, can present during puberty, or even adolescence leading to challenges in diagnosis and management. This case report offers a detailed examination of the clinical manifestation, diagnostic process, and therapeutic approach in an adolescent girl with labial fusion. This report emphasizes the importance of early intervention to improve patient outcomes for this complex medical condition.

Effect of topical estrogen cream compared with observation in prepubertal girls with labial adhesions

BACKGROUND

Topical estrogen treatment has been considered the first-line treatment of labial adhesions in prepubertal girls. However, the effect of topical estrogen cream is different according to studies, and no study compared estrogen cream to observation.

OBJECTIVE

This study aims to investigate the efficacy of topical estrogen cream treatment compared with observation in prepubertal girls with labial adhesions.

STUDY DESIGN

The medical records of prepubertal girls diagnosed with labial adhesions from April 2005 to June 2019 were retrospectively analyzed. Baseline characteristics such as age at diagnosis and initial symptoms were collected. The primary outcome was the resolution of labial adhesion. Secondary outcomes were recurrence and side effects.

RESULTS

A total of 114 patients were enrolled and divided into two groups, topical estrogen cream (n = 94), and observation (n = 20). Girls who were treated with estrogen cream had older age (24.6 ± 19.0 vs. 16.7 ± 15.3 months, p = 0.037) and higher resolution rate than the observation group (100.0% vs. 85.0%, respectively, p = 0.005). Girls younger than 23.3 months showed a significantly higher resolution rate to topical estrogen treatment (100% vs. 86.7%, p = 0.043). Side effects and recurrences occurred exclusively in children treated with topical estrogen therapy without significant differences compared to the observation group.

CONCLUSION

Topical estrogen therapy showed a higher resolution rate than observation for the treatment of prepubertal girls with labial adhesions, especially in younger girls.

Retrospective evaluation of labial fusion in girls

Aim: The aim of this study was to determine the factors affecting fusion in girls treated for labial fusion retrospectively over a three-year period. Material and Method: The research has a cross-sectional design. The research sample consists of girls with ICD10 code Q52.5 who were brought to the hospital with labial fusion symptoms in a three-year period (January 2018-December 2020). The data were obtained from the hospital information system. Variables that were effective in labial fusion recurrence were determined by Chi-Square analysis, and the marginal effects of effective variables on recurrence were analyzed by Poison Regression analysis. Results: 52.9% of 308 cases were younger than one year old (mean age 4.36±1.10 months). Symptom presentation is 10.4% in children younger than one year of age, and 84.83% in older. The most commonly presented symptoms are pain, burning, soiling of underwear, and bad odor during urination. Labial fusion recurrence is 14.1% in children younger than one year of age, and 62.8% in older. Manual opening was applied in all cases, and weekly follow-ups were performed with topical treatment. The Poison Regression analysis revealed that a history of allergy (1.31 times; z:3.61, p:0.000), winter (0.86 times; z:3.22, p:0.001), and diaper dermatitis (1.22 times; z:5.19, p:0.000) increased the number of labial fusion recurrence. Conclusion: The findings of our study are similar to the literature in terms of factors causing labial fusion and treatment type. The recurrence rate was found to be higher in our study. It should be kept in mind that labial fusion is asymptomatic, especially in girls in the first year of life. Considering the possibility of recurrence of labial fusion, mothers and physicians examining the child should be aware of this issue.

A novel surgical treatment for labial adhesion - The combination of Z- and Y-V-plasty: A case report

Labial adhesion is characterised by complete or partial fusion of the labia minora. It occurs rarely in postmenopausal women. Although various methods have been proposed, there is no established treatment for postmenopausal patients with labial adhesions due to its low prevalence in this age group. Severe cases require surgical intervention, and the postoperative recurrence rate is relatively high at 14-20%. In this study, a novel therapeutic method was designed to treat labial adhesions: a combination of Z- and Y-V-plasty. An 82-year-old woman was diagnosed with severe long labial adhesion during an episode of urinary tract infection. The labia could not be separated manually; hence, Z-plasty was performed on the ventral side and Y-V-plasty on the anal side under general anaesthesia. No recurrence was noted eight months postoperatively. This method is relatively easy and produced the desired therapeutic effect with decreased risk of recurrence. This is a novel approach for postmenopausal patients with severe labial adhesion.

Manual separation of labial synechiae: A cost-effective method in prepubertal girls

BACKGROUND

Labial synechiae is a fairly common gynaecological problem that occurs as a result of inflammation leading to fusion between the labia minora. Being in a developing country with limited resources and poor compliance of patients to prolonged treatments, we are faced with immense challenges in the management of these girls.

AIMS

We wanted to evaluate the efficacy and the cost-effectiveness of manual separation and topical antibiotics with perineal hygiene in the management of pre-pubertal girls with labial synechiae.

MATERIALS AND METHODS

Design.

Prospective, non-randomised interventional study. Participant: Pre-pubertal girls presenting with the diagnosis of labial synechiae in the period from September 2015 to January 2018. Interventions: Manual separation followed by topical antibiotic ointment application for 1 week with local hygiene. Outcomes measure: Complete release of the synechiae and no recurrence up to 6 months.

RESULTS

Out of the total 55 patients, only 48 patients were included, their age ranged from 3 months to 7 years (mean 2.8 years). Almost half of our patients were asymptomatic, and other half had symptoms (urinary tract infection, dripping of urine and itching). Majority of our patients belong to low middle class status. We had 100% complete release of synechiae and no recurrence on 6 months follow-up.

CONCLUSION

Manual separation followed by topical antibiotics is a cost-effective method of the treatment of labial synechiae with immediate response and low recurrence rate.

Vulvovaginal involvement in Stevens-Johnson syndrome and toxic epidermal necrolysis: management and techniques used to reduce gynecologic sequelae

BACKGROUND

Vulvovaginal involvement in Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) is common, likely underdiagnosed, and can result in severe sequelae if not managed acutely. There are few studies on acute management of vulvovaginal SJS/TEN. Current recommendations are predominantly based on expert opinion. We aimed to determine the frequency of vulvovaginal involvement in SJS/TEN at a single institution, identify treatment modalities, and assess outcomes at a tertiary care burn center.

METHODS

This is a retrospective review of vulvovaginal SJS/TEN cases between 2009 and 2019. Demographic and clinical data including exam findings, treatment regimens, and outpatient follow-up were collected from the electronic medical record.

RESULTS

Vulvovaginal involvement was observed in 12.7% (19/149) of cases of female patients with SJS/TEN. The mean age was 38.7 years (SD 23.6), and 21% (4/19) of patients were pediatric (age 9-18). Vulvar involvement was seen in 47.3% (9/19), and vulvar plus vaginal involvement was reported in 42.1% (8/19). Treatment regimens were variable until 2017, at which time institutional guidelines were implemented including application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression. Gynecology follow-up occurred in 15.7% (3/19) of cases. One complication of superficial vaginal agglutination was noted and was successfully treated in the office with blunt dissection.

CONCLUSION

The most common treatment modalities employed at our institution included application of ultrapotent topical steroid, vaginal estrogen, and menstrual suppression. While follow-up was limited for our patient population, we propose an algorithm to prevent long-term sequalae of vulvovaginal SJS/TEN. Gynecologic surveillance is recommended to reduce urogynecologic sequelae.

Diagnosis and Management of Hymenal Variants: ACOG Committee Opinion, Number 780

At puberty, a patient with an imperforate hymen typically presents with a vaginal bulge of thin hymenal tissue with a dark or bluish hue caused by the hematocolpos behind it. Other findings that may be present include an abdominal mass, urinary retention, dysuria, constipation, and dyschezia. On evaluation, the goal is to differentiate an imperforate hymen from other obstructing anatomic etiologies, such as labial adhesions, urogenital sinus, transverse vaginal septum, or distal vaginal atresia. Surgical intervention is necessary only in symptomatic prepubertal patients. After confirmation of the diagnosis, surgical intervention usually is deferred until pubertal estrogenization has occurred because the imperforate hymen may open spontaneously at puberty. It is important to complete an abdominal and a perineal examination. If the physical examination reveals a bulging hymen and ultrasonography reveals hematocolpos, further imaging is not required. However, if the diagnosis is not certain or there is a concern for a distal vaginal atresia, cervical atresia, an obstructed uterine horn, or transverse or longitudinal vaginal septum, magnetic resonance imaging is recommended. The ideal time for surgical intervention on hymenal tissue is before the onset of pain and after onset of pubertal development, when the vaginal tissue is estrogenized. Surgical management of clinically significant hymenal variations involves excision of the hymenal tissue and rarely is associated with long-term sequelae. If there is concern that the patient has a distal vaginal atresia or a transverse vaginal septum, the patient should be referred to a center with expertise in the management of these conditions.

Reconstruction for labial adhesion in postmenopausal woman using vulvoperineal flap

We report the case of an 86-year-old postmenopausal woman with severe labial adhesion. The adhesion overlying the vestibule was manually separated and the skin defect was covered with bilateral vulvoperineal flaps. Reconstruction using the vulvoperineal flap enabled to prevent recurrence by covering with normal skin tissue.

Treatment of Prepubertal Labial Adhesions: A Randomized Controlled Trial

STUDY OBJECTIVE

Although various treatment options have been proposed for the treatment of labial adhesions, there are currently no clearly outlined limits on the duration of topical therapy, amount of lateral traction to apply, and methods to decrease the recurrence. This clinical trial was undertaken to assess the need for estrogen for treatment of prepubertal labial adhesions.

DESIGN

Randomized, double-blinded, controlled trial.

SETTING

Pediatric and Adolescent Gynecology Clinic at a children's hospital in a metropolitan area.

PARTICIPANTS

Prepubertal girls ages 3 months to 12 years with labial adhesions.

INTERVENTIONS

Lateral traction with topical estrogen or topical emollient.

MAIN OUTCOME MEASURES

The primary outcome was resolution of labial adhesions. The secondary outcome was the change in severity of labial adhesions over time between the 2 groups.

RESULTS

Forty-three girls were enrolled and 38 (88%) completed the study. The difference in complete resolution between the topical emollient group (19%) and the topical estrogen group (36%) was not statistically significant (P = .21). There was a statistically significant decrease in severity of labial adhesions over time, with the magnitude of improvement favoring the topical estrogen group.

CONCLUSION

Although labial adhesion severity decreased when treated with lateral traction and topical emollient or topical estrogen, the magnitude of the effect was significantly greater for topical estrogen.

Treatment with oestrogen or manual separation for labial adhesions - initial outcome and long-term follow-up

Background

Topical oestrogen and manual separation are the main treatments for labial adhesions. The aim was to evaluate treatment of labial adhesions and compare the outcome of topical oestrogen treatment with that of manual separation.

Method

All girls aged 0–12 years admitted to a tertiary centre for paediatric surgery for labial adhesions were included. The study design was dual: The first part was a retrospective chart review of the treatment success according to the medical charts. The second part was a cross-sectional parent-reported long-term outcome study (> 6 months after last treatment finished).

Results

In total 71 patients were included and the median follow-up time for the chart study was 84 (6–162) months after treatment with oestrogen or manual separation. Oestrogen was the first treatment for 66 patients who had an initial successful rate of 62% but this was followed by recurrences in 44%. Five patients had manual treatment as their first treatment and they had a 100% initial success rate followed by recurrences in 20%. Therefore, for the first treatment course there was a final success rate of 35% for oestrogen and 80% for manual separation (p = 0.006). Corresponding final success rates including all consecutive treatments over the study period were 46/130 (35%) for oestrogen and 21/30 (70%) for manual separation (p = 0.001). The success rate for oestrogen did not differ if treatment was given in a course length of 0–4 weeks (39% success) or > 4 weeks (32% success) (p = 0.369).

In the parent-reported long-term outcome study the response rate was 51% (36/71).

Parents reported that recurrences of adhesions after last prescribed/performed treatment were frequent: in total 25% of patients still had adhesions corresponding to 8/29 (29%) of those whose last treatment was oestrogen and 1/9 (11%) of those whose last treatment was manual separation.

Conclusion

Due to the results recurrences are common after both oestrogen and manual separations. However, the overall final outcome after manual separation seems to be more successful when compared to that of topical oestrogen treatment.

Labial adhesion - diagnostics and treatment

BACKGROUND

Labial adhesion is relatively common, but the condition is little known among doctors and parents. The article assesses treatment in the specialist health service.

MATERIAL AND METHOD

The treatment and course are assessed in 105 girls in the age group 0 – 15 years who were referred to St. Olavs Hospital in the period 2004 – 14.

RESULTS

The majority of the girls (n = 63) were treated topically with oestrogen cream. In 26 of 51 girls (51 %) for whom the final result is known, the adhesion opened after one treatment. When 1 – 4 oestrogen treatments were administered, the introitus had opened completely in two out of three (65 %). Fewer than half of those who received supplementary surgical treatment achieved permanent opening.

INTERPRETATION

Treatment for labial adhesion had a limited effect in this study. As the literature suggests that the condition results in few symptoms and resolves spontaneously in virtually all girls in puberty, no compelling medical reason exists for opening the adhesion in asymptomatic girls. It is important that doctors are aware of the condition in order to prevent misdiagnosis and to provide parents with adequate information. For parents it is important to know that spontaneous resolution may result in soreness and dysuria. Knowledge of the condition can most likely prevent unnecessary worry.

Comparison of Conservative and Surgical Therapy Concepts for Synechia of the Labia in Pre-Pubertal Girls

Introduction: The aim of this study was to evaluate the primary and secondary therapeutic successes of different therapy schemes for the treatment of synechia of the labia in pre-pubertal girls. Materials and Methods: The treatment courses of 47 pre-pubertal girls who were treated between February 2007 and February 2013 in the special outpatient clinic for paediatric gynaecology of a department for gynaecology at a German university hospital and for whom information on the course of the disease was available for at least the six months following end of the treatment. 23 of these children were treated with a topical estriol therapy (treatment group A). For 24 of the girls a manual separation of the adhering labia minora was undertaken (treatment group B). Statistical evaluation was performed using the χ² test, Fischer's exact test and the Mann-Whitney U test. Results: For 18 of the 23 (80 %) girls in treatment group A topical estriol therapy alone led to a resolution of the synechia. Five of these 23 children (20 %) required a secondary manual separation. All girls for whom treatment was not successful were under 5 years of age. For all 24 girls (100 %) of treatment group B the primary manual separation was performed with success. The recurrence rates after ≥ 6 months in cases with identical after-care did not differ between the two treatment groups (treatment group A: 34 %, treatment group B: 33 %, χ² test: p = 0.853). 16 of the 17 recurrences occurred ≥ 3 months after the end of the therapy. Conclusion: Our results show that for children < 5 years of age a 4-week topical therapy with estriol is a promising therapy option for synechia of the labia that is less of a burden for the family situation. Especially for girls ≥ 5 years of age, primary therapy fails in up to 20 % of the cases. Primary manual separation represents a more effective therapeutic option. Irrespective of the treatment applied, a recurrence after ≥ 3 must be expected in one-third of the treated girls.

Labial adhesion and urinary tract problems: The importance of genital examination

BACKGROUND

Urinary tract infection (UTI) is a common bacterial illness in children. Delay in the treatment of UTI may lead to acute renal parenchymal damage and subsequent renal scarring. It is well established that several risk factors increase the tendency for UTI - one being labial adhesion (LA).

OBJECTIVE

The purpose of this study was to emphasize the importance of genital examination in girls with nephrourologic symptoms, particularly UTIs, in order to detect LA.

MATERIAL AND METHODS

Data were collected from the files of 46 girls with LA, including: the girl's age, thickness of LA, any recurrence and treatment options of LA, and the reason for admission to hospital. The LAs were grouped in terms of thickness as thin, moderate and dense, and also partial or complete.

RESULTS

The average age of the girls at the first visit was 51.9 ± 37.57 months (min-max: 3.5-157 months). Twenty-seven (58.7%) of the girls had history of recurrent UTI. There was a marked association between the presence of UTI and the type of adhesions. The percentages of UTIs in girls with complete and partial LA were 84.0% and 28.6%, respectively (P < 0.05). The percentages of UTIs in girls with thick and thin LA were 100% and 44.1%, respectively (P < 0.05). None of the girls' primary care physicians or pediatricians recognized LA at the time of a periodic health examination.

DISCUSSION

In the present study, girls with complete and thick LA had a greater tendency towards having UTIs than those with partial and thin LA, respectively. After treatment of LA, the UTIs did not recur in any girls. None of the girls in this study had undergone a previous genital examination. Therefore, this study suggests that physicians do not often perform genital examinations. Limitations of this study were the small sample size and the short follow-up period. In addition, although all of the girls were examined by the same physician, the thickness of the membrane is subjective and solely depends on the physician's experience.

CONCLUSIONS

This study showed that although genital examination is a routine part of a physical examination, it is not always performed. Therefore, it is recommend that genital examination should be performed in girls with nephrourologic complaints, particularly for UTI. By timeously determining the presence of LA, many unnecessary and invasive investigations could be avoided in these children.

Labial adhesion and bacteriuria

OBJECTIVE

The purpose of this study is to evaluate the clinical presentation, laboratory findings, and response to treatment in girls with labial adhesion younger than 23 months.

MATERIAL AND METHODS

A retrospective chart review of all girls younger than 23 months with the diagnosis of labial adhesion was referred to Dr Sheikh children's clinic in Mashhad in northeast Iran between 1998 and 2013.

RESULTS

Sixty-three patients were diagnosed with labial adhesion during the review period. Most patients were diagnosed by physicians during the physical examination or during the evaluation for their voiding problems. The most prevalent symptom among patients was dysuria and restlessness while voiding. Twenty-one (33.3%) patients had a history of urinary tract infection. 17 (26.9%) patients had sterile pyuria and 69.8% showed presence of bacteria in their urine samples.

CONCLUSION

Physicians may frequently encounter pre-pubertal girls whose urinalysis may show sterile pyuria or presence of bacteria with colony counts <105 in the absence of urinary tract infection symptoms. In these cases, labial adhesion should always be suspected and genital examination should be performed.

Nonsurgical separation of complete labial fusion using a Hegar dilator in postmenopausal women

INTRODUCTION AND HYPOTHESIS

Labial fusion is a rare condition in postmenopausal women. The cause is unknown but is associated with low estrogen levels and chronic vulval inflammation. The aim of this video is to demonstrate the nonsurgical separation of labia using blunt dissection with a Hegar dilator in postmenopausal women with complete labia fusion.

METHODS

Two postmenopausal women with urinary incontinence and voiding difficulty secondary to complete fusion of labia minora failed estrogen treatment and underwent labial separation using serial Hegar dilators to restore normal introital anatomy. Medical treatment with estrogen and digital massage was administered after surgery to avoid recurrence.

RESULTS

Nonsurgical separation of labia is appropriate in postmenopausal women with complete labia minora fusion when medical treatment fails.

Labial adhesion with acute urinary retention secondary to vaginitis

Labial adhesion occurs most often in infants and girls and is usually associated with low estrogen levels. Labial adhesion in the reproductive age group is extremely rare due to abundance of estrogen. Herein we present a case of almost complete labial adhesion with acute urinary retention in a 21-year-old virgin woman secondary to a probable untreated severe vaginitis.

Do hygienic factors affect labial fusion recurrence? A search for possible related etiologic factors

BACKGROUND/PURPOSE

The purpose of our study was to define the factors related to recurrence of labial fusion.

METHODS

The data of 110 patients diagnosed with labial fusion were gathered. The data collected and queried included age and body weight of the patient, season of presentation/occurrence, frequency of diaper change, frequency of diaper dermatitis, products used for hygiene, duration of breast milk feeding, infections, presence of allergy, thickness of the adhesion, mother's use of oral contraceptive drugs before pregnancy, mother's use of alcohol/drugs/cigarettes or presence of disease during pregnancy, the number of recurrences, treatment method, presence of labial fusion among maternal sisters or any relatives, and blood estrogen levels.

RESULTS

Eighty-one patients (73.6%) with labial fusion were admitted for the first time, whereas 29 patients (26.4%) had been treated previously at least once. The adhesion was denser in patients with recurrence. There was no correlation between recurrence of labial fusion and age-based body weight percentile, frequency of diaper change, frequency of diaper dermatitis, hygiene products used, presence of infection, presence of allergy, mother's use of oral contraceptive drugs before pregnancy, or presence of any pathology in other family members.

CONCLUSIONS

The products used for hygiene, frequency of diaper dermatitis, duration of breast milk feeding, presence of infection, and prenatal factors showed no correlation with the recurrence of labial fusion.

Precocious puberty and empty sella syndrome in a girl cured of acute lymphoblastic leukemia

We describe a case of precocious puberty in a girl treated with chemoradiotherapy according to the Italian Association of Pediatric Hematology and Oncology ALL 9503 protocol for acute lymphoblastic leukemia (ALL) from the age of 15 months until the age of 3 years and 4 months. The patient was treated with chemotherapy and cranial irradiation (18 Gy in 12 fractions). At 7 years of age, during topical estrogenic treatment for congenital adhesions of the labia minora, she showed bilateral breast development that evolved into precocious puberty. A magnetic resonance imaging of the brain showed an "empty sella" (ES); the etiology of the ES, and the consequent precocious puberty, being presumably iatrogenic. Children treated with cranial radiotherapy should be carefully checked for signs of precocious puberty and the exogenous administration of estrogens should be avoided, as far as possible, because these could act as a trigger factor in a population at higher risk of precocious puberty.

Manual separation followed by local cleanliness for pediatric labial adhesion

AIM

Although labial adhesion is usually a benign disorder in childhood, it may occasionally be misdiagnosed as a severe disorder, causing parental anxiety. The present study was undertaken to analyze the clinical features, treatments employed and their effectiveness in pediatric patients with labial adhesion, with special emphasis on manual separation.

METHODS

We reviewed the medical charts of pediatric patients with labial adhesion who were treated in our Pediatric Gynecology Division of the university hospital over 3.5 years.

RESULTS

Eight pediatric patients received manual separation followed by local gentamicin ointment and washing. In all eight, manual separation remedied the condition at one visit without recurrence.

CONCLUSION

Manual separation followed by local cleanliness not only remedied pediatric labial adhesion but also prevented its recurrence. Thus, it is an effective treatment for pediatric labial adhesion.

Detection of RXFP1 receptors in skin biopsies from children with congenital adrenal hyperplasia: a preliminary report

OBJECTIVE

Relaxin may potentiate the effect of topical estrogen treatment to eradicate post-incisional scarring in congenital adrenal hyperplasia (CAH) patients undergoing genitoplasty. The aim of this study was to determine whether CAH skin is capable of responding to relaxin.

PATIENTS AND METHODS

Skin biopsies were obtained from four female CAH patients (aged 2-9 years; Prader 4-5, salt-wasting, 21-hydroxylase deficiency, Caucasian) during routine genitoplasty surgery and screened for relaxin receptors. All received corticosteroid and mineralocorticoid replacement therapy. Specimens were sectioned, mounted and screened for the presence of the putative H2 relaxin receptor using conventional two-antibody immunohistochemistry. Tissue controls were processed concurrently.

RESULTS

Tissue controls evidenced appropriate staining. Biopsies from CAH patients stained positively for RXFP1 expression while some variation between specimens was evident. Staining occurred adjacent to the basement membrane of the epithelium, localized to germinative basal keratinocytes.

CONCLUSION

Based on a limited patient sample, germinative keratinocytes in CAH patients appear competent to respond to relaxin perhaps topically applied. Given that relaxin downregulates collagen accretion and upregulates collagenases, its use may potentiate the effects of estradiol and abrogate post-incisional wound scarring. More research is needed to confirm or refute this thesis.

Lower genital tract lesions requiring surgical intervention in girls: perspective from a developing country

AIM

To determine the spectrum, outcome of treatment and the challenges of managing surgical lesions of lower genital tract in girls in a low-resource setting.

METHOD

Retrospective study of 87 girls aged 13-years and younger, with lower genital tract lesions managed between February 2002 and January 2007 at the University of Nigeria Teaching Hospital, Enugu, southeastern Nigeria. Clinical charts were reviewed to determine the types, management, outcome of treatment and management difficulties.

RESULTS

The median age at presentation was 1 year (range 2 days-13 years). Congenital lesions comprised 67.8% and acquired lesions 32.2%. The lesions included: masculinized external genitalia (24), vestibular fistula from anorectal malformation (23), post-circumcision labial fusion (12), post-circumcision vulval cyst (6), low vaginal malformations (6), labial adhesion (5), cloacal malformation (3), bifid clitoris (3) urethral prolapse (3), and acquired rectovaginal fistula (2). Seventy-eight (89.7%) had operative treatment. Procedure related complications occurred in 19 cases (24.4%) and consisted of surgical wound infection (13 cases), labial adhesion (4 cases) and urinary retention (2 cases). There was no mortality. Overall, 14 (16.1%) abandoned treatment at one stage or another. Challenges encountered in management were inadequate diagnostic facilities, poor multidisciplinary collaboration and poor patient follow up.

CONCLUSION

There is a wide spectrum of lower genital lesion among girls in our setting. Treatment of these lesions may be challenging, but the outcome in most cases is good. High incidence of post-circumcision complications and poor treatment compliance may require more efforts at public enlightenment.

Infected urocolpos and generalized peritonitis secondary to labia minora adhesions

INTRODUCTION

Labia minora adhesions (LMA) are a common finding in young girls. Usually, this condition is asymptomatic and spontaneously disappears during adolescence. We report on a case revealed by infected urocolpos and peritonitis and whose treatment finally required surgical reduction labioplasty.

CASE REPORT

A 9-year-old girl presented with a 2-day history of abdominal pain and fever. Urinary continence had never been obtained, with diurnal leaks. Physical examination showed signs of peritoneal irritation and a subtotal vulvar obstruction due to LMA. At surgery, after LMA lysis, a large amount of cloudy urine-like fluid emptied under pressure from the vagina. Laparoscopy showed generalized peritonitis without any intraabdominal cause. The same Escherichia coli was identified in the infected urocolpos and the abdominal fluid. Postoperative course was uneventful. Because of recurrent LMA, the patient underwent several courses of local estrogen therapy. Labia minora hypertrophy with LMA developed 2 years after peritonitis, requiring surgical reduction labioplasty. We used a new technique with interposition of skin flaps. The girl is now well, without LMA or infection, 4 years after labioplasty.

CONCLUSION

Although rare, subtotal vulvar obstruction because of LMA may lead to infected hydrocolpos and peritonitis. Recurrent LMA may necessitate surgical labioplasty.