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Treatment not needed for most pediatric labial fusion.

HOUSTON -- Labial agglutination resolves spontaneously at puberty in up to 80% of girls and has a 40% recurrence rate after treatment, whether medical or surgical, making nontreatment the best option when patients are asymptomatic, according to Dr. Abbey B. Berenson, professor of obstetrics and gynecology at the University of Texas at Galveston.

"There is only one case report of this leading to urinary retention," she said at a conference on vulvovaginal diseases jointly sponsored by Baylor College of Medicine and the Methodist Hospital. "That's why I don't start treatment when they're asymptomatic. You could end up taking them to the OR just so they look normal, and you don't want to do that."

Extensive labial agglutination is present in 5% of prepubertal girls and up to 10% of girls aged 12 months or under, she said. Patients are usually referred with the chief complaint of "absent vagina" because there may be only a small opening visible below the clitoris. Although the majority of patients are asymptomatic, some may have urinary symptoms. "The vagina can form a sort of pocket in which urine gathers and then dribbles out. These are the ones you want to treat because you don't want to see kidney damage due to repeat urinary tract infections or urethritis," she said.

Dr. Berenson recommends topical estrogen cream as first-line treatment.

"I really think it's important to try and avoid surgery," she said in an interview. "It is such a big deal to take these children to the operating room, and so often the problem recurs anyway."

The success rates for estrogen medical therapy range from 50% to 100%, she said. "This works for thin adhesions but not thick or recurrent ones." Parents should be instructed to use a finger to apply the estrogen cream over the gray fusion line using some pressure. This should be done twice a day for 2-4 weeks but stopped if breast budding occurs.

The risk of recurrence can be lowered with good hygiene and reduced irritation, because the condition is believed to develop as a result of low estrogen levels and local irritation, which injures tissue and results in adherence of the labia minora.

Surgical treatment should be reserved for those who fail medical therapy, Dr. Berenson said.

At a meeting sponsored by the American Academy of Pediatrics that took place in Vail, Colo., Dr. Patricia Simmons also counseled physicians generally not to treat labial fusion in prepubescent girls.

Her recommendations echoed much of what Dr. Berenson said.

Dr. Simmons did emphasize that some health care providers used to simply try to pry the labia apart. But that is not a good idea.

"If you rip them apart, they are going to heal back together, and you will just have traumatized the child," she said.

As an alternative to estrogen cream, she said, a medium-potency steroid is "probably quite a reasonable treatment." But even though it is probably reasonable, the practitioner has to keep in mind that it has not been well studied.

One of the most recent reports documented use of 0.05% betamethasone cream treatment in 19 pediatric patients, 14 of whom had previously been treated with topical estrogen. The report noted that there were no adverse effects in any patients, and the success rate, defined as complete separation of the labia, was 68% (J. Pediatr. Adolesc. Gynecol. 2006;19:407-11).

Timothy E Kirn contributed to this report


Montreal Bureau
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Title Annotation:Clinical Rounds
Author:Johnson, Kate
Publication:Pediatric News
Geographic Code:1USA
Date:Apr 1, 2007
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