Punam M Satpute, Sneha D Shirodkar, Vijaya R Badhwar
*Lecturer; **Professor; ***Professor and Head, Department of Obstetrics and Gynaecology, LTMG Hospital, LTMM College, Sion, Mumbai 400 022.
When sexual activity is at an ebb, soreness of vulva or urinary complaints (anuria or dysuria) are the only symptoms of LF. The shape of the labial folds are lost into a flat, smooth, thin surface with a tiny aperture draining urine. Urethra and vagina are hidden behind it. Diagnosis can be confused for an imperforate hymen, congenital adrenogenital syndrome and mullerian anomalies. Local oestrogens can spontaneously resolve adhesions, but fusion needs surgical resection. Re-fusion rates are high, so pre and postop. topical oestrogens prevent re-fusion.
INTRODUCTIONFusion of the Labia minora is a rare event. Adhesions between the 2 labial folds are known in infants, rare in adults, though it is not a congenital but an acquired lesion. Low oestrogen status, nonspecific vulvitis and repeat urinary infections are causal factors. We encountered this rare lesion in an adult patient, who merited surgical correction and had a re-fusion. Local oestrogens, we found can prevent re-fusion allaying patientís anxiety and emotional trauma.
CASE REPORT40 years patient with 2 living issues (14 and 12 years), posthysterectomised since 7 years (genital prolapse), c/o severe dysuria since 6 months. O/E - the labia minora were fused in the midline with a pinpoint aperture draining urine (Fig. 1). UTI was treated. MCU suggestive of outlet obstruction. Dilatation of the aperture identified the urethra separate and urine collecting behind the labial fusion (LF). A rectocoele was seen. Surgical labial resection to separate the fusion was done and the edges sutured separately with absorbable catgut sutures. Posterior colpoperineorrhaphy was done. A mould kept in the vagina and the introitus (1 week), kept the 2 edges away. 18th and 60th day follow up visits were asymptomatic and uneventful.
Fig 1 : Labial fusion with a pinpoint aperture (shown by a probe) draining the urine
Re-fusion of the labia causing occasional anuria and severe dysuria brought the patient back in the 7th post op. month. This time she was a widow since 3 months. O/E same findings as before, only pinpoint aperture was surrounded by a denuded epithelium. UTI and active local infection were ruled out and an IVP was normal. This time, local topical oestrogen cream (twice daily for 2 weeks) followed by surgical resection (Fig. 2) of fusion line and eversion of labial margins with a delayed absorbable suture material was done. Local topical oestrogens were used for 6 wk instead of a mechanical mould. Inspite of no sexual activity the labia remained separate till date.
Fig 2 : Resection of the fused libia Fig 3 : Eversion of the labial edges with delayed absorbable suture material
DISCUSSIONLabial adhesions are common in infants,  but labial fusion is seen in elderly (low oestrogen) age group, never in the reproductive ages. Urinary infections are both, the cause and the sequelae.  Imperforate hymen has no pinpoint aperture; clitoral hypertrophy is seen in congenital adrenogenital syndrome and in mullerian agenesis,  vagina is absent but labial folds are normal. LF is known to associate with renal anomalies,  in our case there were none. In contrast to adhesions which resolve with topical oestrogens alone,  LF merits surgical resection. Simple surgical resection however can cause re-fusion. Factors preventing re-fusion are,
1. Topical oestrogen Cream : self administered preoperative for 2 wk and postoperative 6 wk do not cause discomfort of mechanical moulds and are effective in sexually-abstinent patients.2. Eversion of labial edges (instead of simple sutures) and use of nonabsorbable suture material.
3. Mechanical moulds and sexual activity.
We thank our Dean to permit the publication of our Hospital data.
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