Labial fusion is defined as either partial or complete adherence of the labia minora (1), and also called vulvar fusion, adhesions of the labia minor or conglutination of the labia minora and sinechia of the vulva. The complete and severe labial fusion is a rare pathology with a small number of cases reported in the literature in adults. We present a case report of a postmenopausal woman who presented with voiding difficulty and incontinence and was treated by surgical division of the adhesions and immediate resolution of the urinary incontinence confirmed by multichannel urodynamic test postoperatively

Cervelli, V

De Angelis, B

Lucarini, L

Palla, G

Palla, L

Spallone, D

English

CERVELLI, VALERIO

Abstract. – Labial fusion is defined as ei-ther partial or complete adherence of the labiaminora (1), and also called vulvar fusion, adhe-sions of the labia minor or conglutination of thelabia minora and sinechia of the vulva. The com-plete and severe labial fusion is a rare pathologywith a small number of cases reported in the lit-erature in adults.We present a case report of a postmenopausalwoman who presented with voiding difficultyand incontinence and was treated by surgical di-vision of the adhesions and immediate resolu-tion of the urinary incontinence confirmed bymultichannel urodynamic test postoperatively.Key Words:Labial fusion, Urinary incontinence, Menopause.Case ReportA 71-year-old woman with 3 vaginal deliver-ies was referred with a 1-year history of symp-toms of voiding difficulty and urinary inconti-nence. Her past history included a vaginal hys-terectomy and repair of cystourethrocele bymeans of Kelly-Kennedy technique in the 1995.On examination of the vulva revealed that boththe labia minora were extensively fused. Thelabial adhesions covering the vaginal introitus,urethral meatus and clitoris. The rest of the vulvaappeared atrophic (Figure 1); a pinhole openingat the midline.The woman was unable to have voiding stimu-lus. Urine was unable to escape freely throughthe small introital opening and there was retro-grade filling of the vagina, which resulted in con-tinual leakage of urine postmicturition.European Review for Medical and Pharmacological Sciences 2010; 14: 491-493A case of labial fusion and urinarypseudo-incontinence in an elderly woman.A surgical treatment and a reviewL. PALLA, B. DE ANGELIS, L. LUCARINI, D. SPALLONE, G. PALLA*, V. CERVELLIPlastic Surgery Department, University of Tor Vergata, Rome (Italy); *Operative Unit of CentralHospital of Viterbo (Italy)Corresponding Author: Ludovico Palla, MD; e-mail: ludovicopalla@hotmail.com 491Urography, performed before the surgicaltime, revealed normal kidneys, ureteres, bladderand urethra morphology and reflux of urine inthe vagina (Figure 2).Preoperatively the woman was treated byoestriol 0.0125% cream daily for two weeks.Under a general anesthesia the labia wereseparated by sharp dissection along the line oflabial adhesion to restore normal anatomy (Fig-ure 3).A vesical 14 F catheter and vaginal pack wereinserted in attempt to keep the raw area of thelabia separated. The vaginal pack and vesicalcatheter was removed at 2nd day postoperatively.Oestrogen cream (oestriol 0.0125%) was topi-cally applied daily postoperatively to ward off arelapse.Removed the vesical catheter the woman wasable to bladder voiding and to have urinary conti-nence. Multichannel urodynamic test postopera-tively was performed. The multichannel urody-namic test have shown: the bladder give a Con-tractions not inhibited (C.N.I.) 23 cm of H2O;voiding normal pressures; moderate residue (25ml); closing normal pressure; normal functionallenght; expelled volume: 314 ml; max flux: 18,5ml/s; middle flux: 8,5 ml/s; voiding time: 39 s;flux time: 37 s; attainment time of max flux: 7 s;normal sphinteric function.DiscussionLabial fusion is typically described in chil-dren, especially in development countries, withhighest incidence in the first 2 years of life2,3.Labial fusion is a benign genital disorders ingirls: it may be either congenital or acquired,Figure 1. Preoperatory view.Figure 2. The RX urography shown urine reflux in thevagina.Figure 3. Intraoperative views.L. Palla, B. De Angelis, L. Lucarini, D. Spallone, G. Palla, V. Cervellipresentation is 2.5 years, with more than 90% oc-curring under the age of 6 years6. Parental panicabout this “absent vagina” contrasts with its sim-ple, rapid, radical treatment3. Is rarely reported inadolescents and women of reproductive age andappears to be associated with a combination oflocal inflammation and the estrogens deficiencyseen in the premenarchal age group4-7. One theo-ry for labial fusion is low prepuberal estrogenslevels. In fact, spontaneous separation of labialadhesions occurs at puberty with the productionof endogenous estrogens1. Estrogen’s action inregard to collagen may influence recurrent adhe-sions and adhesions that form after manual dis-ruption or surgical separation. Estrogens mayhave a role in vaginal healing in genital surgery.Topical estrogens remain the mainstay of ther-apy8. Estrogens treatment – twice daily – is along procedure (3 or 4 months)3,8.Lower urinary tract obstruction in women isan uncommon condition resulting from multipleeither organic or functional disorders. Partial andincomplete or complete vulvar fusion usually oc-curs in significant repercussion on urination dy-namics9.The etiology for the adhesions is unclear, al-though vulvovaginitis and mechanical irritationhave been implicated as causative factors6,12.Chronic inflammation is thought to produce de-nudation of the thin surface epithelium, which inclose approximation allows the labia to adhere toeach other and result in obstruction of introitus13.The hypo estrogenic state may predispose the ep-ithelium to trauma and inflammation. The repro-ductive age, whit a normal sexual steroids produc-tion, may be protective against this condition14,15.A new surgical technique to treat refractorylabial fusion in the elderly was presented insometimes due to poor hygiene. Congenital labi-al fusion may be associated with anatomical ab-normalities in the newborn including ambiguousgenitalia and congenital absence of the vagina oroccur as a result of true hermaphroditism,pseudohermaphroditism, congenital adrenal hy-perplasia or intrauterine exposure to exogenousandrogens4. Acquired labial fusion can occur alsofor trauma to the upper squamous layer of thelabial epithelium with formation of scar tissuebetween the 2 opposed labia as healing occurs5.Acquired labial fusion can occur in childhoodin prepubescent girls and the commonest age of4921989. This surgical technique is so described indetail: (1) Labial separation; (2) The subsequentraw area is covered by a rotational skin flap fromthe thigh. The flap is deroted of epithelium prox-imally and tunneled subcutaneously. The distalportion emerged to cover the raw clitoral areaand this successfully prevented contraction andscarring. This new technique is suitable in elder-ly patients with cases of labial adhesion that arerefractory to all other treatment modalities16.We have reviewed the literature on labial fu-sion and when identified in the postmenopausalwoman, these adhesions may be treated with acombination of surgery, topical hormones (estro-gens and/or steroids) and manual separation ofthe labia during the reparative period with resolu-tion of coexisting urinary symptoms and dys-function. Management of the incontinence andagglutination and response to treatment were re-viewed. Medication usage was examined.In this case report the surgical treatment have re-solved the urinary symptoms and dysfunction as toprove by multichannel urodynamic test (Figure 4).The quick resolution of the urinary inconti-nence after the surgical lysis of the labial fusionshould to define this condition a urinary pseudo-incontinence and non-a urinary incontinence soas habitually is defined in the reviewed literature.References1) BEN-AMI T, BOICHIS H, HERTZ M. Fused labia. Clini-cal and radiological findings. Pediatr Radiol 1978;7: 33-35.2) FISCHER GO. Vulval disease in pre-pubertal girls.Australas J Dermatol. 2001; 42: 225-234; quiz,235-236.3) GAUDENS DA, MOH-ELLO N, FIOGBE M, BANDRE E,OSSOH BM, YAOKREH JB, TEMBELY S, GOULY JC,ODÉHOURI T, OUATTARA O, DA-SILVA-ANOMA S, KOBE-NAN RD. Labial fusion in the paediatric surgerydepartment of Yopougon University hospital(Côte d’Ivoire): 108 cases. Sante 2008; 18: 35-38.4) ONG NC, DWYER PL. Labial fusion causing voidingdifficulty and urinary incontinence. Aust N Z J Ob-stet Gynaecol 1999; 39: 391-393.5) CAPRARO VJ, GREENBERG H. Adhesions of the labiaminora. A study of 50 patients. Obstet Gynecol1972; 39: 65-69.6) KLEIN VR, WILLMAN SP, CARR BR. Familial posteriorlabial fusion. Obstet Gynecol 1989; 73(3 Pt 2):500-503.7) CHUONG CJ, HODGKINSON CP. Labial adhesions pre-senting as urinary incontinence in post-menopausal women. Obstet Gynecol 1984; 64(3Suppl): 81S-84S.8) FINLAY HV. Adhesions of the labia minora in child-hood. Proc R Soc Med 1965; 58(11 Part 1): 929-931.9) QUEIPO ZARAGOZÁ JA, LÓPEZ BAEZA F, BUDÍA ALBA A,FUSTER ESCRIVÁ A, LLORET MARTÍ MT, JIMÉNEZ CRUZ JF.Infravesical obstructive uropathy secondary to ex-treme vulval atrophy. Actas Urol Esp 1999; 23:792-796.10) HUFFMAN JW. Principles of adolescent gynecology.Obstet Gynecol Annu 1975; 4: 287-308.11) CHRISTENSEN EH, OSTER J. Adhesions of labia mino-ra (synechia vulvae) in childhood. A review andreport of fourteen cases. Acta Paediatr Scand1971; 60: 709-715.12) SCHOBER J, DULABON L, MARTIN-ALGUACIL N, KOW LM,PFAFF D. Significance of topical estrogens to labialfusion and vaginal introital integrity. J Pediatr Ado-lesc Gynecol 2006; 19: 337-339.13) PULVINO JQ, FLYNN MK, BUCHSBAUM GM. Urinary in-continence secondary to severe labial agglutina-tion. Int Urogynecol J Pelvic Floor Dysfunct 2008;19: 253-256.14) GOLDSTEIN AI, RAJCHER WJ. Conglutination of thelabia minora in the presence of normal endoge-nous estrogen levels: an exception to the rule. AmJ Obstet Gynecol 1972; 113: 845-846.15) KUO DM, CHUANG CK, HSIEH CC, LIOU JD, CHENKC, HSIEH TT. Labial fusion in a thirty-year-oldwoman. Acta Obstet Gynecol Scand 1998; 77:697-698.493A case of labial fusion and urinary pseudo-incontinence in an elderly womanFigure 4. Post-operative after 6 months.

A case of labial fusion and urinary pseudo-incontinence in an elderly woman. A surgical treatment and a review

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A case of labial fusion and urinary pseudo-incontinence in an elderly woman. A surgical treatment and a review

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