AFJOG

CASE REPORT INTRODUCTION Labial adhesions, also known as synechia vulvae or labial agglutination is a condition characterised by the fusion of the labia minora or majora, and most commonly located near the clitoral area. 1 It can be complete or partial fusion, flimsy or dense, and it may be congenital or acquired. Acquired cases occur mainly in prepubertal girls and postmenopausal women due to oestrogen deficiency. 2 Advanced stages of labial fusion or labial adhesion, although rare, may be diagnosed in postmenopausal and sexually inactive women. In the elderly the incidence is not well elucidated , but the condition accounts for around 0.6% to 1.4% in children. 3 4 Patients may be asymptomatic or present with urinary or vulval symptoms. 2 When it manifests clinically, the common symptoms are post-void dripping, haematuria, dysuria, and local inflammation in the labial area. We present a case of a postmenopausal lady who presented to our Urogynaecology clinic with a history of dribbling of urine (intermittent incontinence) which progressed to urinary retention. CASE STUDY Mrs NC is a 65 year old para- 2 lady. She presented to our Urogynaecological clinic with a 6 month history of voiding dysfunction. She complained of progressively worsening of spontaneous urine dribbling, incontinence and suprapubic discomfort, but no dysuria, nor haematuria. She is a known hypertensive patient with no other co-morbidities. Her surgical history is unremarkable and she has been sexually inactive for more than ten years. She does not smoke nor use alcohol. On examination she was clinically well with a normal systemic examination. Her initial genito-urinary examination revealed excoriation of the vulva, which appeared flattened but with a bulging mass in the vagina. There was dense fusion (agglutination) of more than 90% the labia majora with only a small opening near the clitoris through which urine was draining (fig.1). A clinical assessment of labial adhesion was made. Her diabetic screen and urine culture was negative. Mrs NC was counselled and offered conservative management with topical oestrogen cream and reviewed after six weeks. The response to the oestrogen cream was poor and an examination under anaesthesia with surgical division of labia was planned. However the patient returned with almost complete fusion of the labia and inability to pass more than some drops of urine before the surgery date. She was subsequently taken to theatre and the adhesions separated with sharp (blade) and blunt (forceps) surgical technique. A biopsy was also taken to exclude malignancy, lichen sclerosus and lichen planus. She is currently discharged to continue with topical oestrogen cream and will be reviewed for histology results, recurrence and long term management and follow-up. DISCUSSION According to Norris, the precise etiology of labial fusion remains unknown, but low estrogen states are postulated as a cause. This is evidenced by the rareness of the condition in the reproductive age group where women have sufficient levels of estrogen. 5 The genital area is particularly susceptible to irritation and inflammation in the postmenopausal stage and the risk of adhesion increases in the setting of diabetes mellitus, lichen sclerosis or decreased sexual activity. 1 Risk factors such as low oestrogen levels of menopause, chronic vulvar inflammation, and sexual inactivity in the pathogenesis of labial fusion were reinforced in a study by Kaplan et al. 6 Erickson identified other possible causes such as malignancy, lichen sclerosis, radiotherapy, and topical medications, 7 while Singh reported chronic inflammation due to poor hygiene, eczema, lichen planus or sclerosis, seborrheic dermatitis, eczema, local trauma and recurrent urinary tract infections as possible aggravating factors. 2 Differential diagnoses across age groups include hymenal skin tags, imperforate hymen, introital cysts, Mayer- Rokitansky-Kuster-Hauser syndrome, ureterocoele, urethral prolapse, vaginal atresia and vaginal rhabdomyosarcoma. 1 There is usually no need for special laboratory investigations nor imaging in the diagnosis of labial adhesion as it is a clinical diagnosis and in asymptomatic patients it may be an incidental finding. A physical examination of the genitourinary system in is imperative in females who present with difficulty voiding, urinary retention or urinary tract infections, prompting early treatment. Gonzalez describes labial adhesion as being commonly located near the clitoral area and consisting of thin fibrotic tissue which could cause either partial or complete fusions that occlude the vaginal orifice, and associated post-void dripping, haematuria, dysuria, and local inflammation in the labial area, which resolve quickly when adhesions resolve. 1 Conservative management of labial adhesion is a reasonable approach in cases of early or partial labial fusion. This includes the application of topical oestrogen creams, with or without topical steroids. The aim is to block ongoing agglutination of especially labia minora and a restoration of the anatomy. While guidelines are lacking previous reviews recommended two months of conservative treatment before surgical management is considered. 2,8 . The use of betamethasone and clobetasol have been prescribed where Lichen Sclerosis is involved and betamethasone was shown to be superior to topical oestrogen in terms of resolution and side effect profile. 2 Where there is no response to topical therapy or the presence of complete labial fusion, surgical separation under general anaesthesia will be required. 3,8 Funda et al. described a technique for surgical management of a postmenopausal womenwith complete labial fusion using QC Blignaut 1 , Z Abdool 2 1 Department of Obstetrics and Gynaecology, Fellow in Urogynaecology, Steve Biko Academic Hospital, Pretoria, South Africa 2 Department of Obstetrics and Gynaecology, Urogynaecology unit, Steve Biko Academic Hospital, Pretoria, South Africa CORRESPONDENCE: Dr QC Blignaut| Email: qblignaut@gmail.com Labial Fusion with Urinary Symptoms: A Case Report African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 31