AFJOG

CASE REPORT a combination of cautery (no sutures) and blunt dissection and reported resolution of symptoms and no recurrence at six months follow up. Other surgical management options as reviewed by them include use of Hegar diltators, curved forceps and use of skin flaps to prevent recurrence, all with promising long term outcomes. 3 Urinary Pseudo-incontinence in postmenopausal women According to Mikos et al. postmenopausal labial fusion is manifestation of a severe form of menopausal genitourinary syndrome. 8 They reported on a case series of women with an average age of 72, who presented with mainly continuous urinary incontinence and complete labial fusion. All women required surgical intervention which was uneventful with immediate resolution of incontinence and no recurrence of labial agglutination after two years follow up. In a case report of a postmenopausal woman with voiding difficulty and incontinence, Palla reports that she required surgical division of labial adhesions. Surgical management resulted in immediate resolution of her symptoms as confirmed by multichannel urodynamic testing post- operatively. 9 Julia reported on a 72 year old woman with complete labial fusion whose sole presenting complaint was urinary incontinence which resolved after surgical therapy. This was a case of failed conservative treatment with oestrogen cream. 10 Lu et al. reported on an 83 year old woman with labial agglutination, intermittently treated with topical oestrogen over a 3 year period. Surgery instantly resolved her symptoms and an incidental intraepithelial neoplasia was noted. There was no recurrence after 3 months and they emphasised that surgical intervention should be the first consideration for labial agglutination with urinary symptoms in postmenopausal women. Surgery also allows essential evaluation of other high risk conditions (malignancy) in this age group. 11 Lichen Sclerosus and Lichen Planus In a study of thirty-five patients with symptomatic labial adhesions due to Lichen Sclerosus (LS) or Lichen Planus (LP), the mean age was 57 years with a mean symptom duration of 9 years. Of the patients, 27 had LS and 8 had LP. Of the 35 patients, 21 had posterior fusion, 11 had anterior fusion, and 3 had both anterior and posterior fusions. 11 MacPherson reports that Lichen sclerosus (LS) and lichen planus (LP) are both immunologically mediated conditions and has a preference for the genitalia. While LP mainly affects mucous membranes such as the mouth and vagina, these are rarely affected by LS. 12 According to Howard et al , vulval lichen planus-lichen sclerosus overlap is an emerging observation. They report on a case of a 63 year old women with a 20-year history of ulcerative vulvo-vaginitis initially diagnosed with cicatricial pemphigoid. A later clinic-pathological diagnosis of LP was changed to LS following further biopsies of lesions in the labia, perineum and peri-anal area. They highlighted the challenge of extensive vulvo-vaginal ulceration. 13 The inflammatory mucocutaneous LS affecting the anogenital areas, affects mostly postmenopausal women and is largely underdiagnosed. Recognised associations include hormonal status, persistent trauma and autoimmune diseases, however infections do not seem to be clear risk factors. LS pathogenesis involves factors such as a Genetic predisposition and an immune-mediated Th1-specific IFNγ-induced phenotype is implicated in its pathogenesis. The clinical presentation, which can be confirmed with skin biopsy, is chronic whitish atrophic patches along with itching and soreness in the vulvar, perianal and penile regions. Genital scarring, and sexual, urinary dysfunction, and squamous cell carcinoma can result from the lesions. 14 While LS can be asymptomatic, it is usually a pruriginous condition. The treatment of lichen sclerosus aims at controlling the symptoms, stopping further scarring and distortion and reducing the risk of cancer. Follow-up must be kept indefinitely. 15 First-line treatment for LS is a super-potent topical corticosteroid ointment which has a high response rate, such as clobetasol propionate 0.05% ointment twice daily. Second-line therapies include topical calcineurin inhibitors ( pimecrolimus or tacrolimus) and systemic agents. There is limited evidence for systemic treatments for both conditions. The risk of vulval squamous cell carcinoma (SCC) is increased in both LP and LS, and it is not known how treatment affects this risk. 12 According to Perez-Lopez, surgery which include restoring vulvar anatomy and treating clitoral phimosis, introital stenosis, and vulvar granuloma fissuratum lead to improved sexual dysfunction and satisfactory outcome is used mainly for the treatment of complications associated with lichen sclerosus. 15,16 According to Krapf, other treatment modalities include platelet rich plasma, high energy modalities (photodynamic therapy, high intensity focused ultrasound, fractional laser therapy), as well as lysis of vulvar lesions and perineoplasty. 16 CONCLUSION Labial adhesion, a fusion of the labia minora or majora, is often an incidental finding. The exact cause is unclear but it is believed to occur in a low oestrogen state and diminished sexual activity espescially in postmenopausal women. Aggravating factors include chronic inflammation such as lichen planus or sclerosis, as well as poor hygiene, eczema, seborrheic dermatitis, eczema, local trauma or recurrent urinary tract infections. Complete labial fusion in postmenopausal women can lead to urinary pseudo- incontinence. Treatment consists of oestrogen with or without steroids and surgery in cases of failed conservative treatment or complete labial fusion with urinary symptoms. Figure 1: Labial Fusion African Journal of Obstetrics and Gynaecology | Volume 1 | Issue 1 | 2023 | 32