Treatment of Labial Fusion: Is Watchful Waiting an Option?

Consultations & Comments
Reader Reaction and Timely Answers From Experts

I have a comment regarding one of the cases presented in the Photo Essay “A Collage of Genital Lesions in Children, Part 6” (CONSULTANT FOR PEDIATRICIANS, April 2011, pages 118-120). I see labial fusion in infants quite often in my general pediatric practice. I prefer watchful waiting for the treatment, because estrogen cream application can cause breast development, which parents do not like to see in their young daughters. None of the patients treated this way in my practice have had urinary tract infections or outflow tract obstruction thus far.

Terry L. Dise, MD
Associate Professor of Pediatrics
Tulane University Health Sciences Center

We thank Dr Dise for her interest in our Photo Essay. Labial fusion occurs most commonly in preschool girls between 3 months and 4 years of age.1 The peak incidence occurs between 13 and 23 months, during which 3.3% of girls are affected.1 Because of the possibility of vulvovaginitis, asymptomatic bacteriuria, or urinary tract infection that may complicate labial fusion,2,3 we recommend that topical estrogen cream be applied twice a day sparingly until the labial adhesion has lysed. With this regimen, the problem usually resolves in 1 to 3 months. The presenting symptoms of urinary tract infection vary significantly with age. In general, the younger the child, the less localizing are the symptoms. As such, urinary tract infection can be easily missed in a preschool aged child unless specifically looked for. Occasionally, the labial fusion is complete enough to cause urinary outflow obstruction, with resultant bladder distension and hydronephrosis.4

Adverse effects of estrogen cream (mainly breast enlargement and pigmentation of the labia and areolae) are mild.5 These effects are reversible when treatment is discontinued.4,5 Precise topical application of only a small amount of estrogen cream minimizes the possibility of adverse effects.

To prevent readhesion of the labia minora, we tell parents to apply petroleum jelly daily for at least 1 month after separation has been achieved. Parents are also advised to avoid forceful separation of the labia minora, which can lead to bleeding, inflammation, discomfort, enhanced adhesion, disfiguration, and emotional sequelae.

Alexander K. C. Leung, MD
Clinical Professor of Pediatrics
University of Calgary
Pediatric Consultant
Alberta Children’s Hospital

C. Pion Kao, MD
Clinical Assistant Professor of Pediatrics
University of Calgary
Pediatric Consultant
Alberta Children’s Hospital