1. 9 month old female presents with mother for WCC Mom complains of recent lice infestation, treated with Nix On physical exam of genitalia, labial adhesion observed which almost completely occludes the vagina Small pinpoint opening noted beneath the clitoris Mom denies any change in number of wet diapers, unexplained fevers, noticing any urine pooling beneath the adhesion or vaginal discomfort Lydia Travnik, DO, MPH Clinical Pearls 2016

2. Labial Adhesions

3. Etiology – unclear 1.Vulvar irritation 2.Lack of estrogen  decreased estrogen after 3 months of age Epidemiology 1.Includes 2% of girls within first few years of life 2.Peak incidence 13-23 months of life Clinical presentation (per Mayoglou, Dulabon, Schober et al) 1.Urinary frequency – 7.3% 2.UTI – 19.9% 3.Vaginitis – 8.6% 4.Post-void dripping – 12.6% 5.Most are asymptomatic and found incidentally on exam

4. Treatment options 1.Observation 2.Estrogen cream (Premarin)* – Grade 2B -Literature shows up to 90% success rate -Application 1-2x daily x several weeks 3.Betamethasone topical 4.Manual separation 5.Surgical separation – referral to Pediatric Urologist Labial Adhesions *Side effects of topical estrogen - minimal breast development and vaginal bleeding which remit after treatment is finished The most common reason for medical failure is placement of the cream in the wrong location or placement of too small an amount of cream.

5. Retrospective Chart Review by Mayoglou et al (2009) N=151 Time to resolution: Premarin (2.0-2.5 wks) vs. betamethasone (1.0-1.5 wks) Complete resolution after treatment  recurrence Premarin 71%  35% Betamethasone 79%  16% Surgery 100%  26% Literature Review Retrospective Chart Review by Schober et al (2006) N=109 Topical estrogen therapy was successful in 79 percent of patients after a mean duration of four months. 41% (44/107) had recurrence of labial fusion one to five times (range 2 to 72 months) Surgery was required in 21% (22/107)

6. Female GYN exams are important at every age - a complete genital exam is essential if presenting with urinary complaint Labial adhesions can develop at any time, especially in females under age 3 Consider estrogen but also consider betamethasone for treatment Make sure parents know this isn’t normally a “quick fix” after use of topical therapy Summary

7. Child health update: estrogen cream for labial adhesion in girls. Goldman RD. Can Fam Physician. 2013 Jan;59(1):37-8. Labial adhesions and outcomes of office management. Granada C1, Sokkary N2, Sangi-Haghpeykar H3, Dietrich JE2. J Pediatr Adolesc Gynecol. 2015 Apr;28(2):109-13. doi: 10.1016/j.jpag.2014.06.004. Epub 2014 Jun 25. Significance of topical estrogens to labial fusion and vaginal introital integrity. Schober J, Dulabon L, Martin-Alguacil N, Kow LM, Pfaff D. J Pediatr Adolesc Gynecol. 2006 Oct;19(5):337-9. Success of treatment modalities for labial fusion: a retrospective evaluation of topical and surgical treatments. Mayoglou L; Dulabon L; Martin-Alguacil N; Pfaff D; Schober J. J Pediatr Adolesc Gynecol. 2009; 22(4):247-50. References