Labial Adhesions: A Guide for Parents

Labial adhesions occur when the labia (inner lips) stick together. This type of adhesion happens most commonly in girls who are between 3 months to 6 years of age, and can persist until puberty.

How is the diagnosis of labial adhesions made?

The diagnosis is made by looking at the vulvar area and observing that the vaginal opening is either partially or fully covered by the labia with a white line indicating the adhesion. If your child is having symptoms such as pain, particularly when she is in a straddle position (for example, while sitting on a riding toy), or having trouble passing urine, you may have discovered that her labia appears to be stuck together. If your child has not had any symptoms, her health care provider may have noted the adhesions during a routine well-child check.

What causes labial adhesions?

It is not clear why some young girls develop labial adhesions and others do not. It is thought that low levels of estrogen (which is normal in young girls) and/or vulvar irritation caused from harsh soaps, wet diapers, infection or trauma such as a straddle injury, might cause the labia to stick together. Labial adhesions are most commonly seen around the age of 2 years, but can also be seen in older and younger children.

Newborn baby girls don’t have labial adhesions because of high levels of estrogen passed on from the mother during pregnancy. Similarly, high levels of estrogen from puberty make it very unlikely for girls who are menstruating to develop adhesions.

What are the symptoms of labial adhesions?

Some children with labial adhesions will have no symptoms, while others may have pain in the genital area, difficulty urinating, or frequent urinary tract (bladder) infections.

What is the treatment for labial adhesions?

Whether or not treatment is recommended depends on how severe the adhesions are.

Small or mild adhesions do not cover the vaginal opening and may separate by themselves when the child reaches puberty or earlier. Your child’s health care provider will continue to watch how the labia appear over time, and may recommend treatment if the adhesions get worse or cause symptoms.

Slightly larger or moderate adhesions that cover the lower part of the vagina may be treated with a mild emollient such as Vaseline® or A & D ointment®, along with gentle separation twice a day over several weeks.

Significant adhesions that cover the vaginal opening, and often the urinary opening as well, can be effectively treated with an estrogen-containing cream or steroid cream. These adhesions may prevent drainage of normal vaginal secretions, as well as impair the flow of urine. Sometimes this will cause urine to collect in the lower vagina, behind the adhesion, and can lead to irritation or dribbling of urine after your child stops urinating. If she develops a fever, it will not be possible to collect a clean urine specimen to see if she has a urinary tract infection. The most effective treatment for significant adhesions is an estrogen-containing cream applied twice daily for a period of time or until the adhesions resolve. This treatment requires a prescription from a health care provider.

How is estrogen cream applied to the labia?

1. When possible have your child soak in a warm tub bath before you apply the (estrogen) cream. The water will remove any secretions and soften the labia.
2. Help your child gently dry her vulva with a soft towel.
3. Place your child in frog-leg position, as shown by your health care provider.
4. Stand next to your child, facing her feet.
5. When your child’s vulva is completely dry, squeeze a *small (pea-size) amount of (estrogen) cream on your pinkie or on the index finger of your dominant hand. (For example, if you are right handed, put the cream on your right pinkie or your right index finger and vice versa if you are left handed). Use your other hand to gently separate the outer labia (lips). Look for the white line, where the labia are stuck together. It will run up and down from the top of the adhesion towards the perineum (the area above the anal opening).
6. After the estrogen is applied, wait for about five minutes before putting on underwear or a diaper to ensure that the cream has maximally absorbed into the skin.
7. While keeping the outer lips separated with one hand, gently apply the cream to the adhesion line. Avoid touching the anal opening.
8. Once the adhesions start to separate, try to avoid putting the estrogen cream inside the vaginal opening.

*More is NOT better, and making sure that the estrogen cream is applied directly to the adhesion is important.  Apply the estrogen cream sparingly. Too much estrogen cream can cause rare side effects such as darkening of the vulvar skin, breast buds, and in some cases vaginal bleeding. However, all of these symptoms are reversible and will resolve after the treatment is discontinued.

How will I know if the (estrogen) cream is working?

Over time small openings will appear in the white or gray line as the adhesion gradually disappears.

Is estrogen (hormonal) cream safe to use?

Yes. Estrogen-containing creams are safe to use for the treatment of labial adhesions. Only a very small amount of estrogen cream will be used, for a limited amount of time. Very little of the estrogen will be absorbed into the child’s bloodstream. A few girls who are treated with estrogen cream may develop temporary small breast buds or darkening of the labia. Both of these conditions are not dangerous and will go away once treatment is stopped. You should make an appointment with your child’s health care provider as soon as the (labial) separation is complete so you can stop the estrogen treatment and change to Vaseline® or A & D ointment®. If you are worried about absorbing any estrogen, you can use disposable rubber or latex-free gloves (which you can buy in most pharmacies) while applying the estrogen cream.

Will the estrogen cream work and if so, how long does it take to open the labia?

It is very unusual for this treatment to fail. Half of all adhesions will separate in 2-3 weeks. Sometimes treatment may need to be continued for 1-2 months. If you have used this treatment before without success, your child’s health care provider may ask you to rub the estrogen cream or ointment into the adhesion line with an up and down motion 5-10 times (each time you apply the medicine). The gentle pressure helps to separate the adhesions.

What if the treatment doesn’t work?

Reasons why treatment fails may include applying the cream all over the vulva, instead of focusing just on the adhesion area, or not using the cream until the adhesion is gone. It is possible, but rare, that very thick adhesions won’t respond to treatment, even if the correct amount of cream is used in the right area. If your daughter’s adhesions do not improve with the estrogen cream, you should discuss other treatment options with her health care provider. Some girls may have success with a short course of steroid ointment. Surgery to open the adhesions is rarely done and would only be considered if a child was unable to pass any urine.  One reason why surgery is rarely done is that unfortunately, adhesions often do recur after surgical separation.

Are there other non-estrogen creams that work?

Estrogen cream is the standard treatment for labial adhesions. Betamethasone 0.05% can also be used.  Betamethasone 0.05% is a topical steroid cream that can be prescribed instead of estrogen, in addition to estrogen, or the estrogen cream doesn’t work. Since it is a steroid, it should not be used for more than 3 months.

Will my daughter need treatment once the adhesions are open?

Labial adhesions can recur or come back, even after they open up. Once the labia are separated, Vaseline® or A & D ointment® is used as an emollient for 6-12 months to keep the labia open and prevent or lessen irritation of the vulva area.

Ways to help keep your child’s labia open:

1. Have her take a daily tub bath
2. After her bath, pat dry her vulva area (or teach her to do so) with a soft towel
3. Apply a thin amount of Vaseline® or A & D ointment® to her dry labia

Harsh soaps, bubble bath products, scrubbing the vulva, and tight clothing should be avoided.

Try to be patient with the course of treatment which can last up to several weeks, and may require additional follow-up visits with your daughter’s health care provider (HCP). If the labial adhesions come back, do not restart the estrogen cream again unless you have discussed this with her health care provider.