Mrs. Jones brought her three-month-old daughter Ann to see me for a second opinion. When I saw her name on the schedule and noted that she was coming in for a consultation, I thought that there might be a serious medical problem to address. Upon entering the room and introducing myself, I saw a beautiful little baby girl, swaddled in mother’s arms.
Mrs. Jones gave me a brief and uncomplicated medical history on the baby. I asked what her concerns were about Ann before I examined her. Nervously mom said, “Let me just show you”, as she fumbled to undo the diaper. Her hands were trembling and she was clearly distraught. This made me a little uneasy, as I didn’t quite know what I was going to find. Could something nefarious have happened to this little girl? Could there have been some sexual abuse? As mom removed the diaper and gently spread the legs, she said, “See, her vagina is stuck together. I am so worried that this is something bad. Her doctor, who is NOT a pediatrician, told me it was a vaginal web, and that it was nothing to worry about.”
I did a complete examination on little Ann, and carefully inspected the genital area. Ann was not only a beautiful baby girl, but her examination was completely normal. I agreed with the primary doctor; she did have “vaginal webs”, better known as labial adhesions. And they were not at all serious. An explanation was in order.
The vagina has two sets of labia (from the Latin for lips): the outer labia majora, and the inner labia minora. In the female before puberty, especially in the infant female, the cells that line the labia minora are thin because of the lack of exposure to estrogen. This makes them very sensitive to any inflammation. One of the more common causes of inflammation that is implicated in causing webs is that the urine in pre-adolescent females is ammonia-like or “basic”. This basic urine pools and bathes the labial area, setting up a chronic inflammatory process. This may be subtle and cause no outward signs or symptoms...or, it may cause a diffuse redness and irritation for which the baby is taken to the doctor. After a while, the cells that line the labia minora are sloughed away, leaving a thinned out surface that is denuded in areas. A fibrinous, or mucus-like, discharge is produced as a result, and since the two labia are constantly in contact with one another, they become fused together. It literally looks as if they were glued together by a thin membrane.
This truly is a common phenomenon in female infants and rarely does it cause problems. The peak incidence is reported to be between birth and two years of age, and again between six and seven years. It can occur, however, up until the individual reaches puberty. Most girls with labial adhesions have no symptoms at all and, therefore, require no treatment of the adhesions. 30% - 50% of girls may have urinary symptoms such as difficulty or burning when they urinate. They may report having trouble emptying their bladder, or may actually have a urinary tract infection. These DO require treatment.
The treatment of vaginal webs is quite simple. A 0.1% estrogen cream is applied to the adhesions twice a day for two-to-four weeks, and then once a day for another two-to-four weeks. This should completely resolve the matter and open the vaginal vault. 90% resolution is reported by eight weeks with this treatment. After successful treatment, a bland petroleum based ointment, such as A and D or plain petroleum jelly, can be applied to the area to prevent re-adhesions. This may be necessary for weeks or months. If, however, the patient has no symptoms or urinary issues as a result of the adhesions, watchful waiting and observation is a perfectly acceptable approach.
As the female reaches puberty, two things occur that allow for the spontaneous resolution of the adhesions. First, they start to produce estrogens on their own, and this changes the make-up of the cells that line the labia minora. Secondly, the urine becomes more acidic, and this is less irritating to the cells of the labia.
In rare cases, the labial adhesions are thick and unresponsive to the standard treatment. These patients may have recurrent urinary tract infections as a result, or may have problems with urinary obstruction. In these cases, the adhesions may need to be removed surgically. In 19 years of practice, I have had two patients where this was necessary.