What is your diagnosis? Labial adhesions – Classification and treatment

An 8-month-old Caucasian female infant with a history of two urinary tract infections presented with fever, poor oral intake, and increased irritability for 3 days prior to presentation. The mother reported a fever T max 103F and a strong odor of urine. Mother denied any cold, cough, diarrhea, vomiting, rash, and sick contacts at home. Her initial vitals were normal other than a temperature of 101F. The infant was alert, active and comfortable in her mother's lap. On examination of her external genitalia, there was fused labia minora at the midline forming a midline raphe, and pinhole urethral opening was also noted (Figure 1). Due to close approximation of labia minora and tiny urethral opening, we were unbale to catheterize the bladder. According to the mother, previous attempts to catheterize the bladder for urinary samples were never successful as well. We confirmed the labial adhesions as shown in (Figure 1) based on our clinical examination and a presumptive diagnosis of UTI was made based on a positive bag urine sample and her symptoms. Giridhar Guntreddi*; Jayasree Vasudevan Nair; Swayam P Nirujogi Sanford Medical Center, 1300 Anne St NW, Bemidji, MN 56601, USA. Abbreviations: LA: Labial Adhesions; UTI: Urinary Tract Infection; Premarin cream. Labial adhesions/vulvar synechiae (Figure 1) are defined as fusion of the Labia minora in the midline. It is one of the most common pediatric-gynecological problems [1] with an estimated prevalence of 0.6 to 5%, with a peak incidence between 13 to 23 months of age [2]. Chronic inflammation of the labia minora combined with the hypoestrogenic state of the female infant is considered as the possible explanation of the condition. The labia minora stick together in the midline, usually from posterior to forwards until only a small opening is left anteriorly through which urine is passed and present as labial adhesions. Other contributory factors are poor perineal hygiene, vulval irritation, chronic diaper use, and sexual abuse [3]. Vaginal infections with candida, group A streptococcus, Gonorrhea, Gardnerella vaginalis, chlamydia trachomatis, and trichomonas vaginalis are also considered as etiological factors in the environment of low estrogenic state.