Reproductive Age Group Vaginal Synechia: A Rare Finding of Full Term Pregnancy with Fused Labia: A Case Report

Vaginal synechia also know vulval fusion or labial fusion or labial adhesion or labial agglutination is a condition in which lips of labia minora are fused and cover the opening of vagina with fleshy membrane. The term synechia of labia is used to describe a superficial adhesion or fusion of labia minora at there median edges [1]. Labial adhesion is most commonly seen in pediatric age group and post menopausal females [2]. Hypoestrogenemic state in female infants, leads to labial fusion in midline, usually posterior to anterior until only a small opening is left, through which urine is passed [1]. Typically seen between age of 3 months to 6ys. About 1-2% of females of this age group have varying degree of adhesion, often it is asymptomatic though occasionally it may give rise to difficultly in passage of urine. It often resolves spontaneously with onset of puberty [3]. 

Differential diagnosis includes imperforated hymen, transverse septate vagina, congenital absence of vagina etc., [3]. In post menopausal females it is also commonly seen, associated with chronic skin conditions like lichen sclerosis other causes include serial abuse, genital mutilation, trauma etc. Sometimes it is also seen in post vaginal delivery females. However labial fusion in reproductive age group and even during pregnancy without evidence of hypoestrogenemic state or chronic skin conditions is extremely rare [3,4].

We are reporting one such rare case report in this paper, 25 yrs. old primigravida, with 37 week 6 day pregnancy, resident of sachendi kanpur, was referred to our side from CHC, with complain of pain in abdomen since last 15-16 hrs.’ Her receiving vitals were stable, and she was in advanced labor, adequate hydration and hygiene, on per abdominal examination, term size uterus longitudinal lie, Cephalic presentation, moderate to strong contractions, head entered, 2/5 palpable, FHS 138/min; on local examination her labia minora were fused in midline, a small midline cranial opening 0.5×0.5 cm left behind, through which baby’s hairs were visible. She gave no history of vaginal trauma, urinary retention or symptoms related to voiding of urine, no any chronic skin disease, chronic urinary tract infection, sexual abuse or genital mutilation was present. 

She had history of some vaginal procedure done at age of 17yrs, when she had complain for primary amenorrhea. She gave history of cyclical pains with no menses till age of 17. But all her secondary sexual characters were well developed. Some vaginal procedure was done under regional anesthesia in private set up. But she could not present with any documentation- probably she was operated for imperforated hymen. After the procedure, she had regular menses of 4-5 days with 28-30 day cycle with average blood loss of 2-3 pads per day.

She got married at age of 23 yrs. And had uneventful married life of 2 yrs. Though history of infrequent intercourse was present. She had no complaints regarding difficulty in micturition or coitus. She conceived spontaneously. Had regular ANC visits at community health center sachendi, from where she was referred to our side for non progress of labor with closed cervical os ,as non dilating cervix , here she was received in active labour.

She was admitted, investigated and immediately shifted to OT, where her synechiolysis was done under regional anesthesia. It was found that agglutination minora was just making a shield like membrane at level of vaginal orifice. After infiltrating membrane with local anesthesia, a dilator was inserted from visible opening in postero- downward direction, longitudinal incision was given with 23 number blade, which exposed vaginal canal and cervix, and were absolutely normal, os fully dilated and fully effaced, head +1 station membranes were absent liquor clear, she delivered a single alive female of 2.4 kg, baby cried immediately; scar tissue was excised and remaining tissue was stitched with vicryl 2-0; an indwelling Foley’s catheter was placed for 5 days, regular episiotomy cleaning with betadine solution and application of estrogen ointment and Sitz bath was advised. 

The patient was discharged on day 5 of delivery and was advised to follow up.

Mostly patient of vaginal synechia are asymptomatic. The most common presentation if seen is urinary pooling in vagina on voiding, followed by leaking from vaginal area on standing, after voiding or shift of urinary stream direction [1]. Occasionally, vaginal synechia may be noted in children with urinary tract or vaginal infection, asymptomatic bacteria, low serum levels of estrogen, sequelae of laceration or hematoma formation, use of nappies too has incriminate as a cause. In reproductive age women, it usually is seen immediately postpartum period, following female circumcision, along with lichen sclerosis, genital herpes, diabetes, pemphigoid, vaginitis and severe monilial infection [5]. 

Spontaneous resolution has been observed at onset of puberty and has been correlated with the rise of estrogen levels. Topical application of estrogen has been recommended in symptomatic patients with success rates varying from 47-100%. 68% success with use of 0.05% betamethasone cream and 23% recurrence in maximum follow up period of 24 months. 

The prognosis of vaginal synechia is excelled. 

Differential diagnosis includes congenital anomalies, vaginal atresia, Garten’s duct cyst, ambiguous genital, and imperforated hymen in children or hematometrocolpos in severe cases. The choice of treatment depends on age group and the type. Manual separation in the form of steady, gentle pressure to stretch the labia apart with or without application of a local anesthetic has been recommended. Local application of emollient for a few days after the maneuver allows time for reepithelialization and prevents reformation of vaginal synechia. Surgical lysis under general anesthesia may be required for dense and fibrous adhesion. On recurrent cases, the use of amniotic membrane grafting is recommended. 

Topical estrogen is selected management indicated for superficial vaginal synechia. Topical estrogen could also be combined with steroid cream. Conjugated estrogen cream or estradiol vaginal cream (0.01%) applied to the adhesions 1-2 times daily for several weeks until the adhesion resolve. This topical treatment is applied not more than 6 weeks considering the side effects. This side effects are local irritation, vulvar pigmentation and breast enlargement. 

The recurrence rate of vaginal synechia is around 40%. Adhesion that recurs after surgery is usually denser and mostly respond with medical management [1].

Vaginal synechia is very uncommon in reproductive age group and even more rare with term pregnancy due to abundance of estrogen levels. Treatment usually is topical steroid and estrogen or if synechia is thick and fleshy, surgical synechiolysis with topical antibiotics and steroids are recommended to avoid recurrence.

1. Dinata KA, Setia DP, Putra IR (2022) Vaginal synechiae in reproductive woman: A case report. Andalas Obstetrics and Gynecology Journal.
2. Mitra S, Banerjee D, Chakrabarty D, Das S (2022) Labial Agglutination in Different Age Groups: A Case Series. J Clin  of  Diagn  Res 16: 1-4.
3. Putran J, Khaled MA, Almusawa S (2008) Labial fusion in the reproductive age group: A rare presentation. Gynecol Surg 5: 313-314.
4. Dayu ARB, Yap-Garcia IM (2022) Labial Agglutination in a Reproductive Age Woman. Obstet Gynecol Cases Rev 9: 231.
5. Wakode SR, Bhat VN (2021) Post-partum labial adhesion-a case report. Int J Reprod Contracept Obstet Gynecol 10: 2528-2530.