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trauma. More recent studies suggest that there may be etiologic factors other than
estrogen insufficiency. Most labial adhesions are asymptomatic and are noted by
a parent at home or a physician during the child’s routine physical examination.
The classic physical examination finding is a flat plane of tissue marked by a
central vertical line of adhesion that obstructs the view of the introitus. Even
when adhesions appear to have closed the vulva completely, a pinpoint opening
usually remains that permits urination.
Some patients with labial adhesions present with symptoms such as dysuria,
frequency, or refusal to void that may be a result of either the mechanical
obstruction or concurrent urinary tract infection. Whether associated urinary tract
infections are a cause or an effect of adhesions is unclear. For girls with urinary
tract infections, urine cultures should be performed and appropriate medical
follow-up provided. Because vaginal infection is not associated with adhesions,
vaginal cultures are not indicated except in patients who have concurrent vaginal
discharge.
Treatment is not indicated for asymptomatic girls with labial adhesions because
the condition spontaneously resolves early in puberty as a result of increasing
endogenous estrogen. For those that require therapy or if parents prefer, labial
adhesions can be treated successfully with application of a small amount of
estrogen cream (Premarin 0.01% or Estrace 0.01%) onto the adhesions once or
twice a day for 2 to 6 weeks. Resolution has been reported to be 50% to 89%.
Potential side effects include skin hyperpigmentation and breast budding; more
serious complications, such as vaginal bleeding or precocious puberty, are
theoretical concerns. Topical betamethasone (0.05%) is an alternative
management strategy with up to 68% success. Labial adhesions should not be
manually separated in the ED. The procedure is painful and usually results in
recurrence when the irritated, newly separated labia readhere. Even with medical
treatment recurrence rates vary from 7% to 55%, so care after separation is
important. Proper hygiene is recommended, as well as daily application of a bland
emollient such as petroleum jelly.

URETHRAL PROLAPSE
CLINICAL PEARLS AND PITFALLS