AbstractAcute renal failure is characterized by rapidly disruption in kidney function and postrenal causes typically result from obstruction of urinary flow. Multiple etiologies were described for acute renal failure, but labial fusion in postmenopausal female is a quite rarely encountered pathology among postrenal causes. Only a few cases have been presented in postmenopausal women presenting with urinary retention. We present a case with acute renal failure due to complete labial fusion in a postmenopausal woman and its treatment

Başaranoğlu, Serdar

Deregözü, Ayşegül

Doğan, Faruk

International Journal of Surgery Case Reports

Elsevier - Publisher Connector 

Acute renal failure due to complete labial fusion: A case report 

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oCASE  REPORT  –  OPEN  ACCESS
International Journal of Surgery Case Reports 29 (2016) 162–164
Contents lists available at ScienceDirect
International  Journal  of  Surgery  Case  Reports
j ourna l h om epage: www.caserepor ts .com
cute  renal  failure  due  to  complete  labial  fusion:  A  case  report
erdar  Bas¸ aranog˘lub,∗, Faruk  Dog˘ana, Ays¸ egül  Deregözüc
Bilge Hospital, Department of Obstetrics and Gynecology, 34240, Istanbul- TURKEY
Via Hospital, Department of Urology, 34350, Istanbul- TURKEY
Bahc¸ elievler State Hospital, Department of Obstetrics and Gynecology, 34344, Istanbul- TURKEY
 r  t  i  c  l e  i  n  f  o
rticle history:
eceived 26 April 2016
eceived in revised form 12 August 2016
ccepted 13 August 2016
vailable online 13 September 2016
a  b  s  t  r  a  c  t
Acute  renal  failure  is  characterized  by rapidly  disruption  in  kidney  function  and  postrenal  causes  typically
result  from  obstruction  of urinary  ﬂow.  Multiple  etiologies  were  described  for acute  renal  failure,  but
labial  fusion  in  postmenopausal  female  is  a quite  rarely  encountered  pathology  among  postrenal  causes.
Only  a few  cases  have  been  presented  in postmenopausal  women  presenting  with  urinary  retention.  We
present  a case  with  acute  renal  failure  due  to  complete  labial  fusion  in  a  postmenopausal  woman  and  itseywords:
omplete labial fusion
rinary retention
oiding dysfunction
cut renal failure
treatment.
© 2016  Published  by Elsevier  Ltd on  behalf  of  IJS Publishing  Group  Ltd.  This  is  an  open  access  article
under  the CC  BY-NC-ND  license  (http://creativecommons.org/licenses/by-nc-nd/4.0/).strogen
. Introduction
Acute renal failure is one of the most common urological prob-
ems. It is characterized by a quick loss of renal function, which
evelops over hours to days. Problems causing obstruction in the
rinary system are considered under the topic of post-renal failure.
ifferent precipitating factors that cause obstruction throughout
he ureteral trace, urine bladder tumors, and urethral obstructions
onsequently leads to post-renal failure [1].
There are multiple well-known etiologies for acute renal failure,
ut labial fusion in postmenopausal female is a quite rarely encoun-
ered pathology among obstructive uropathies and only a few cases
ave been reported on the association of ARF and labial fusion in the
ostmenopausal female. Labial fusion is described as the complete
r partial adherence of labia minora. It is most commonly seen in
repubertal girls (especially in the ﬁrst 2 years of life) and rarely
lder women [2,3]. The etiological factor is an association with low
strogen levels, chronic inﬂammation/irritation of the vulval skin,
ichen sclerosus and absence of sexual activity [4]. Most of the time,
linical presentation of labial fusion is urinary complaints as urinary
ncontinence, urinary frequency, voiding dysfunction and recurrent
rinary tract infections [3,5].
We  presented a rare case with acute renal failure due to
otal labial fusion and successful surgical management of a post-
enopausal woman with total labial adhesions.
∗ Corresponding author at: S¸ emsipas¸ a Mahallesi 56. Sokak No: 2 Küc¸ ükköy
G.O.Pas¸ a/ISTANBUL.
E-mail address: drsbasaran@gmail.com.tr (S. Bas¸ aranog˘lu).
ttp://dx.doi.org/10.1016/j.ijscr.2016.08.016
210-2612/© 2016 Published by Elsevier Ltd on behalf of IJS Publishing Group Ltd. This i
rg/licenses/by-nc-nd/4.0/).2. Case report
A 92-year-old woman  was referred to urogynecologic evalua-
tion for urinary retention for the last 3 days. She described difﬁculty
voiding, urgency, urinary incontinence, urinary tract infection,
vaginal pressure, vulvar itching or irritation for the last 4 years. She
reported that her urinary symptoms had been progressively wors-
ened over last three months. She gave no history of lichen sclerosus
et atrophics. She had been evaluated by gynecology and obstetrics
department and treated with topical estrogens therapy for 4 weeks
without any improvement or side effects.
On urogynecological examination, the external genitalia
revealed an atrophic vulva and fused labia minora at the midline.
The fused labia completely covered the vaginal introitus, clitoris,
and the external urethral meatus (Fig. 1). Laboratory results were as
follows: BUN:68 mg/dL, Cr:5,6 mg/dL, Na:139 mEq/L, K:5.1 mEq/L,
CRP:10.7 mg/Dl. The patient was  hospitalized for further analysis
and treatment. On her ultrasonographic examination; localization,
parenchyma echogenicity were normal; there was not solid or cys-
tic lesion but moderate pelvocaliectasis in both kidneys. A postvoid
bladder scan revealed an elevated residual of 525 Ml.  Abdominal
and pelvic tomography showed normal gynecologic anatomy and
there was no extrarenal pathology. With the suspicion of urethral
obstruction and post-renal acute renal failure development due to
labial fusion, 16 gauge catheter was  inserted percutaneously into
the bladder under ultrasonography guidance to achieve a suprapu-
bic urine diversion. Renal functions returned to normal levels (BUN
was decreased to 21 mg/dL from 68 mg/dL, serum Cr was decreased
to 0,9 mg/dL from 5.6 mg/dL) within 4 days. According to result of
urine culture antibiotherapy were commenced for a week.
s an open access article under the CC BY-NC-ND license (http://creativecommons.
CASE  REPORT  –  OPEN  ACCESS
S. Bas¸ aranog˘lu et al. / International Journal of Surgery Case Reports 29 (2016) 162–164 163
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Fig. 2. Labia separated by sharp dissection after surgery.ig. 1. Complete labial fusion before surgery and 16 gauge suprapubic urinary
atheter to achieve a urine diversion.
The patient was offered surgical treatment. Under general anes-
hesia, the patient was placed in the dorsal lithotomy position.
he adhesive labia was separated by sharp dissection using sur-
ical blade (Fig. 2). There were no anatomical abnormalities in the
aginal canal, cervix and urethral meatus. 3-0 Vicryl rapide stitches
ere continuously applied to the edges of skin and vaginal mucosa
o form contact with each other (Fig. 3). Punch biopsie of the vulvar
dhesions was acquired at the time of surgery. Pathology reports
howed lichen sclerosis. Patient was discharged with instructions
o perform twice daily topical estrogen and steroids (clobetasol
.05%) to the vaginal introitus for 4 weeks. The patient was  seen
or postoperative evaluation at 3 months follow-up after surgery.
he reported complete resolution of all urinary symptoms and no
ecurrence of labial fusion was noted (Fig. 4). The postvoid bladder
can revealed a normal residual volume.
. DiscussionUrologic pathologies causing acute postrenal failure typically
esult from obstruction of urinary ﬂow and the frequency varies
mong age groups. Prostatic hypertrophy and malignancies are the
Fig. 3. Immediate postoperative view; Skin and vaginal mucosa continuously closed
in l ayers (The mucocutaneous border).
CASE  REPORT  –  O
164 S. Bas¸ aranog˘lu et al. / International Journal of S
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cFig. 4. Final appearance after surgery.
ost common cause of obstruction in the advanced age groups and
esicoureteral reﬂux, bladder dysfunction (including neurogenic
ladder), and ureteropelvic junction obstructions in the childhood
ead to renal disease [1]. Although they are rare, urinary prolapses
1] and labial fusions [2,6] are usually encountered in older women.
ost of the published data of labial fusion in the postmenopausal
emale population are case reports, at the same time symptoms in
his literature are with related urinary complaints. Agglutination
nitially occurs only in the posterior aspect of the labia and ure-
hra is “partially” obstructed. In most advanced cases the urethral
nd vaginal oriﬁces are “completely” covered by fusion. When the
rine cannot freely exit the vagina, it can lead to urinary retention
nd recurrent urinary tract infections [3]. In addition, serious kid-
ey damage due to urinary obstruction has been reported [2]. Also,
ostmenopausal females with symptomatic labial fusion present
ith vulvar pruritis, dyspareunia, urinary incontinence, urinary
etention, difﬁculty in voiding, frequency and dysuria. The etiol-
gy of labial adhesions are uncertain. It has been associated with
ecurrent trauma, vulvovaginitis and inﬂammation caused by an
nfection, mechanical irritation, low endogenous estrogen, atopic
czema or lack of intercourse as causative factors [2,4]. An alter-
ative etiology for these adhesions may  include vulvar dystrophies
uch as lichen sclerosis [4]. In this case, biopsy ﬁndings showed
ichen sclerosus and it seems that the hypoestrogenic state, lichen
[
[
pen Access
his article is published Open Access at sciencedirect.com. It is distrib
ermits unrestricted non commercial use, distribution, and reproduct
redited.PEN  ACCESS
urgery Case Reports 29 (2016) 162–164
sclerosus and lack of intercourse were the main participant for
the labial fusion. The ﬁrst-line management of labial adhesions in
the postmenopausal patient is topical estrogen or steroids replace-
ment therapy, although it has not high success rate [5]. When the
topical oestrogens therapy failed, labial separation by means of
blunt/sharp dissection is required [7]. In our case, local estrogen
treatment was  not effective and we performed labial separation by
blunt dissection. Postoperative topical steroids and estrogen ther-
apy and daily manual separation of the labia can be used to prevent
recurrence of the adhesions [7].
In summary, we report a case of postmenopausal woman  who
presented with labial fusion-related urinary retantion and acute
renal failure and these adhesions was  treated with a combination
of surgery and topical steroids and estrogen therapy with complete
resolution of the urinary symptoms.
Authors contribution
Faruk Dog˘an and Serdar Bas¸ aranog˘lu (1)–(3)
(1) the conception and design of the study, or acquisition of data,
or analysis and interpretation of data.
(2) drafting the article or revising it critically for important intel-
lectual content.
(3) ﬁnal approval of the version to be submitted.
Conﬂict of interest
None.
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ion in any medium, provided the original authors and source are


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Acute renal failure due to complete labial fusion: A case report

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