Saturday, February 20, 2010

Vaginal Health:Problems with hypo-oestrogenism

A 56-year-old postmenopausal woman presented with a history of incontinence and weak micturition. The incontinence was continuous with intermittent normal voiding. The urine culture was sterile. General physical examination was within normal limits. Pelvic examination demonstrated extreme labial fusion with only a pinhole opening. Conservative management in the form of local estrogen cream application was instituted without improvement. The woman underwent labial separation under spinal anesthesia. There were also vaginal synechiae and urethral stenosis which were lysed and dilated with Hegar’s dilators. Postoperatively the patient was instructed to apply estrogen cream locally. She presented in the interim period twice with loose fibrinous adhesions for which gentle separation and Hegars dilatation under local anesthesia sufficed. She has till now not needed major procedure for treatment.
Adhesions of the labia are rare in the adult population.It presents with vulvodynia,pruritus ,dyspareunia etc.Labial fusion presentation with pseudoincontinence is still rarer. The etiology of labial adhesions probably relates to vaginal inflammation or irritation. Once the superficial epithelium of the labia is denuded subsequent healing leads to fibrous adhesions between the labia. Etiological factors for labial fusion in adult women are senile vaginitis, hypoestrogenism, lack of sexual activity, local trauma, vaginal laceration following childbirth, female genital cutting(practice prevalent in some communities) and recurrent urinary tract infections( and /or STDs). In the present case, pseudoincontinence was caused by collection of urine in the space behind the fused labia.
Treatment is most often conservative in the form of estrogen cream for hypoestrogenism and atrophic mucosa. Labial separation should be employed when this treatment fails; but as the labia are often tender the separation may need to be done under anesthesia. In addition, the presence of vaginal synechiae or urethral stenosis can make regional or general anesthesia essential. Postoperatively estrogen or steroid cream should help to prevent recurrence of the problem.
Labial fusion is a rare condition in adults, most often caused by hypoestrogenism. While conservative topical estrogen therapy is sufficient in most cases, labial fusion may persist and require surgical intervention.In our case; even after the surgical separation and local oestrogen therapy fusion recurred albeit the adhesion was filmsy and did not need anaesthesia.
In some refractory cases advancement flap surgery will be needed to cover the raw area.