Labial Adhesions

What is it?

Infant, toddler, and preschool girls sometimes develop a temporary condition known as "labial adhesions." These are areas along the inner lips of the vagina ("labia minora") that become stuck together. They are fairly common in girls before puberty. There is little fluid in the vagina before girls start producing the hormone estrogen. Before puberty any minor friction of the delicate labia can be enough to cause them to stick together. Labial adhesions are especially common during and after toilet training. Children tend to wipe themselves too hard in an attempt to be thorough. Most often there is no obvious cause. Parents usually discover the adhesions during a bath or a diaper change.

Labial adhesions are never serious, but they often frighten parents, who may think that their daughter’s vagina is "closed up" or is abnormal. In rare cases the adhesions can cover over most of the vaginal opening. This is only a problem if they cover the opening where urine passes through, called the "urethra." If the urethra is partly or completely covered, urine will collect or pool inside the vagina. This causes discomfort, irritation, and itching, and can even lead to vaginitis or a bladder infection.

When parents first notice labial adhesions they tend to worry that their daughter has a serious deformity. They may be afraid she will not mature normally. Labial adhesions are actually benign, and often go away on their own. Girls who have them grow up to have perfectly normal vaginas and urinary tracts. The chief concern that doctors have is to reassure anxious parents, and to decide whether any treatment will be needed. Because of the risk of bladder infections, doctors do want to get the labia to separate. In unusual cases, girls may have repeated episodes of labial adhesions.

In cases in which the labial adhesions are thin and not very long, doctors often recommend no medical treatment at all. They will simply want to see the child again in a few weeks (sooner if there are problems). In many cases these small adhesions clear up on their own. Doctors do treat thick or long adhesions, or those that don’t go away on their own. They also treat any that might be causing bladder infections or irritation. Most doctors will prescribe a mild estrogen cream (Premarin® and others) to apply to the labia for about a week. The estrogen stimulates the vaginal lining to secrete fluid and mucous. This helps to lubricate and open the labia. This treatment helps in the majority of cases.

If estrogen cream does not help, the doctor may perform a "manual" separation of the labia. Your doctor may refer your child to a pediatric urologist or gynecologist if she needs this procedure. Many doctors now use a local anesthetic cream before they do this procedure. In more mild cases, or if the doctor feels that the discomfort of the anesthetic is worse than the procedure, s/he may not use it. The doctor will gently pull the labia apart to separate them. Most of the time this procedure works very easily, and the doctor will discharge you with estrogen cream to apply for a week to prevent the adhesions from coming back.

If the adhesions are especially thick or long, and if estrogen cream and gentle manual separation don’t work, then a minor surgical procedure may be necessary. This is very unusual, and most doctors do not use this technique unless the adhesions pose a serious problem.

The vast majority of cases of labial adhesions do not cause any problems. In a few cases, as we’ve mentioned, they can interfere with urine flow and cause infection or irritation. Here are some things to watch for:

• Cloudy, dark, or foul-smelling urine
• Fever
• Crying or complaining of pain with urination
• In toilet trained girls, leaking of urine after using the toilet (can appear like soiling the underwear)
• Redness of the vaginal area, or any vaginal discharge

Although it is an unusual cause of labial adhesions, sexual abuse is unfortunately so common among children that we have to mention it here. Most labial adhesions have completely innocent causes, such as those we’ve mentioned. In rare cases, trauma to the vagina can be the cause of adhesions. These adhesions are usually thicker and more irregular than "normal" labial adhesions. Most of the time doctors cannot tell for certain whether abuse has happened. Girls who have been abused may become fearful of adults or of a specific person. They may suddenly become very modest, or by contrast they may develop inappropriate sexual behaviors . They may become sad and withdrawn. In some cases children who have been abused will "regress" and start having "accidents" with urine or stool. If you have any concerns whatsoever about these things in your own child, please be sure to tell your doctor.

Other Conditions that Might Be Present

A condition called "imperforate hymen" can sometimes confuse parents and doctors. In this case the hymen, or thin membrane covering part of the vaginal opening, doesn’t have any hole in it at all. The hymen is deeper in the vagina than the labia minora, and so this does not interfere with urine flow. It can prevent normal menstrual flow later in life. If your daughter has this condition your doctor will advise you on what steps to take.

Urethral prolapse is a situation in which the urethra pushes out into the vagina (like turning a sock inside out). This can be uncomfortable for the child and can cause small amounts of bleeding. Sometimes parents think there is a mass or a tumor in the vagina. We treat urethral prolapse with estrogen cream as well. It is almost never a serious condition.