Yosra Kerkeni,Fatma Thamri,Riadh Jouini
Management of Labial Adhesion in a Low-Income Country
Management of Labial Adhesion in a Low-Income Country

Labial adhesion, also called synechia vulvae or labial agglutination, is an acquired, benign condition known by many physicians. It is defined by the fusion of the labia minora or majora, and it is mostly located near the clitoris. The precise cause of labial adhesions is currently unknown. However, it is considered that estrogen deficiency may play a role. Almost 2% of girls in the first years of life may be affected, with a peak incidence in the second year of life. Complications of this condition are minor. The association of urinary tract infections particularly demands therapy. According to the research, the majority of patients receive conservative treatment without any intervention. However, the scenario may alter in low-income countries due to the current financial landscape, which requires a different approach to management. A 3-year-old girl consulted for vaginal itching evolving for a week. Interrogation revealed a history of 2 episodes of untreated vulvovaginitis. Physical examination showed adhesion of the labia minora (Figure 1A). Parents were informed of the diagnosis and were given the choice between topical therapy with estrogen, which is effective but gives late results and can cause labial pigmentation and thelarche, and manual separation of the labia affording immediate results but can be painful and potentially traumatic for the child. Parents chose the second alternative due to financial and transportation issues. After applying a local anesthetic, surgery was successfully performed by separating the labia without complications (Figure 1B). No adjuvant topical therapy was prescribed. Parents were involved in the subsequent management by explaining the triggering causes of such benign condition which include inadequate hygiene, dermatitis, and vulvovaginitis occurring in the hormonal dormancy period. The parents were given advice regarding how to practice adequate personal hygiene, and the control examination, after 4 weeks, revealed no signs of a recurrence of the condition. The patient was seen only once at the outpatient clinic, and there was no recurrence. The parents were then given an open appointment to consult in case of recurrence. One of the most prevalent pediatric gynecologic issues is labial adhesion. Despite being a benign condition, it could nevertheless cause significant parental anxiety. Contrary to what is mentioned in the literature, management strategy in developing countries is different. The majority of the literature is from the USA or European countries. The ideal method of treatment is either observation or the use of an estrogen cream with regular follow-up at the outpatient clinic. Topical betamethasone application has also been reported as a successful alternative for conservative treatment. Faced with the financial difficulties of the majority of our consultants, most prefer a solution with immediate results and opt for manual separation. Regardless of the method of treatment, recurrences may occur. According to some studies, the rate of recurrence following topical or surgical treatment ranges from 11% to 14%. To avoid recurrence, it is necessary to maintain local hygiene. The overall outcome is excellent.