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LABIAL ADHESIONS PRESENTING AS PSEUDO-MENOURIA

Pratima H Anjaria, Pravin N Mhatre,Vandana R Walvekar
*Associate Professor, Nowrosjee Wadia Maternity Hospital. **Asst. Hon. Professor; ***Hon. Professor, Seth G S Medical College and Dean, NWHM.

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A young girl presented with scanty periods, a lump in abdomen and passage of menstrual blood through the urethral meatus. Pelvic examination revealed a right-sided ovarian tumour and a flat vulva with visualisation of only the urethra and upper one-fourth of labia majora. Were these two pathologies interrelated or discrete? Was the vulvar finding a congenital abnormality or an acquired defect? After investigations and examination under anaesthesia, the diagnosis of "Labial adhesions and coincidental mucinous cystadenoma of ovary" was made.

INTRODUCTION

Labial adhesions or synechiae vulva are defined as complete or partial fusion of the lower labia majora or labia minora in the midline. [1] Labial adhesions commonly occur in prepubertal girls, the incidence being 1.8%.5 The exact cause is unknown but it appears to be associated with hypooestrogenism and/or vulvar irritation or trauma. Both these factors cause denudation of the superficial squamous epithelium of the labia with fibrous tissue formation and sealing of the labia in the midline along apposed areas of trauma. [5] Vulvitis or vulvovaginitis in young girls associated with poor perineal hygiene, pin worms and dermatitis could also result in labial adhesions. Such adhesions could also result following vulvar trauma related to masturbation, sexual abuse or fall.

Most girls are asymptomatic and may be brought to the clinician by an anxious mother while some would complain of distorted urinary stream or post-void dribbling of urine or symptoms suggestive of urinary infection. In severe cases of complete labial adhesions, the girl would present with urinary outflow obstruction and an overdistended bladder.

Mild cases of labial adhesions need to be only reassured as the adhesions separate on their own with the pubertal increase in oestrogens. The others are treated with application of oestrogen cream once or twice daily till the adhesions are lysed followed by vaseline gel. Recurrence rate is 10-15%1 and hence the patients should be followed up till puberty.

CASE REPORT

Miss S., an 18 year old unmarried girl presented with complaints of scanty periods, burning micturition and passage of menstrual blood through the urethral meatus since 1 year. She had also noticed a lump in abdomen for the past 2 months. Her menarche was at 16 years of age and menstrual cycles were regular but scanty. There was no history of medications, vulvar trauma, masturbation or seuxal abuse. She had no period of amenorrhoea or cyclical abdominal pain.

Fig 1

Her secondary sexual characteristics were well-developed though breast development corresponded to Tanner Stage II. On per abdomen examination, a 24 weeks size, non-ballotable mass arising from the pelvis was palpated. Vulvar inspection revealed a flat vulva with labia majora delineated only in the upper one fourth part and flat, homogeneous tissue posteriorly. The labia minora, fourchette and hymen were not visualised. The urethra, clitoris, perineum and anus was normal. Per rectal examination revealed a normal size uterus with a well-defined cystic mass in the right fornix separate from the uterus. The cervix was felt distinctly and there was no swelling suggestiveof a haematocolpos.

Pelvic USG confirmed a normal uterus and left ovary with a right ovarian mucinous cystadenoma. The ovarian mass was multilocular with thin septae and intact capsule with no evidence of papillary growths or solid areas. There was no ascites and liver, spleen and kidneys were normal. CA 125 was 3.6 units/ml. Intravenous Urogram (IVU) revealed bilateral mild hydronephrosis but normal distal ureters and normal urinary bladder with no fistulous connections. Micturating Cystourethrogram (MCU) was also normal.

Fig 2 : Examination under naesthesia showing 'flat vulva'.

The patient was posted for surgery at which time an examination under anaesthesia and cystoscopy was first done. Cystoscopy was normal. The cystoscope was now inserted in the suburethral portion where the upper one-fourth of the non-fused labia majora were seen. Vaginal rugae were visualised here, confirming vaginal patency and the diagnosis of fused posterior three-fourths of labia majora. The labia majora were separated by blunt and sharp dissection as they were densely adherent posteriorly while anteriorly the adhesions were quite flimsy and fine. The raw separated edges of the labia majora were covered with vaseline gauze. The patient’s position was now changed to supine and the abdomen opened by a Pfannenstiel incision. The right ovarian mucinous cystadenoma was excised by oophorectomy. The uterus and the other ovary was normal. Histopathology confirmed the findings of a benign mucinous cystadenoma of ovary.

Fig 3: labia minora now visualised and vestibule seen after lysis of labial adhesions

The patient was counselled to apply oestrogen cream to the separated labia once a day for 4 weeks followed by vaseline gel thereafter. At one month and 3 months follow-up, the labia majora were separate without recurrence of adhesions.

DISCUSSION

The noteworthy features in this case on history and examination were 1) history of passing menstrual blood through the urethra since 1 year 2) pelvic mass separate from the uterus. 3) vulvar inspection revealed a normal urethra with only upper one-fourth of labia majora seen. A flat vulva was seen obscuring the labia minora, hymen and fourchette.

Based on the above and the relevant negative history, we made a list of differential diagnosis.

1. Mullerian agenesis with cervico-vesical fistula - In mullerian agenesis, the vulva is normal but there is absence of vagina. In this case, there was a flat vulva and PR examination could palpate a cervix and uterus. USG on full bladder confirmed the presence of vagina and uterus and on cystoscopy, no fistulous connection was found. Also, when the cystoscope was inserted in the suburethral space between the labia majora, vaginal rugae were seen confirming vaginal patency. The patient when menstruating was passing blood through the suburethral area where the labia majora were unfused and not through the urethra (pseudomenouria).

2. Imperforate hymen - The flat vulva did not bulge on Valsalva’s manoeuvre, did not appear bluish and there was no evidence of haematocolpos or haematometra, both clinically and on USG.

3. Haematometra in non-communicating rudimentary horn of unicornuate uterus - Pelvic USG ruled out the pelvic mass as a haematometra and confirmed the presence of an ovarian tumour.

4. Congenital adrenogenital syndrome - There was no evidence of clitoromegaly ruling out adrenogenital syndrome. Labial adhesions are an acquired and not a congenital lesion.3,4

5. Labial adhesions. - Thus, by detailed history and examination and followed by relevant investigations including cystoscopy and examination under anaesthesia, the diagnosis of labial adhesions was established.

CONCLUSION

Labial adhesions are generally seen in prepubertal girls in association with their hypooestrogenic state. They may occur in some post-pubertal girls in relation to vulvitis and vulvar trauma. They are clinically important as they are a cause of a lot of anxiety, stress and emotional trauma to the girl and her parents. Labial adhesions are an important differential diagnosis for mullerian agenesis, imperforate hymen, adrenogenital syndrome and malformations of external genitalia. [2] They are easily treated but tend to recur, hence the need for follow-up for early management of recurrence.

REFERENCES

1. Laufer MR, Goldstein DP. Paediatric and Adolescent Gynaecology in Kistener’s Gynaecology - Principles and Practice, 6th edition. Mosby-USA. 1995; 589.

2. Jain S. Labial adhesions in The Adolescent Girl, FOGSI Publication. Ed-Dr. Krishna UR, Dr. Parulekar SV, Dr. Salvi VS. 1991; 191.

3. Jeffcoate’s Principles of Gynaecology, ‘Adhesive Vulvitis’, 5th edition. Butterworth and Co. Ltd., UK Revised by Tindall VR. 1987; 257.

4. Dewhurst’s textbook of Obst and Gyn. for post-graduates, 4th edition. Blackwell Scientific Publications, Oxford Ed-Whitfield CR. 1986; 720 : 44-45.

5. Leung A, Robson W, Wong B. Labial Fusion. Paediatrics and Child Health 1996; 1 (3) : 216-18.

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