|Year : 2001 | Volume
| Issue : 1 | Page : 98-99
Complete labial fusion in a post-menopausal woman - a possible explanation
Ganesh Gopalakrishnan, Anjali Bhatnagar, AMVC Raju
Department of Surgery, Faculty of Medicine, UNIMAS and Sarawak General Hospital, Kuching, Sarawak, Malaysia
Department of Pathology, Faculty of Medicine and Health Sciences, UNIMAS. 10, Bormill Estate, Jalan Tun Ahmed Zaidi Adruce, 93150, Kuching, Sarawak
Source of Support: None, Conflict of Interest: None
Keywords: Labial Fusion; Women.
|How to cite this article:|
Gopalakrishnan G, Bhatnagar A, Raju A. Complete labial fusion in a post-menopausal woman - a possible explanation. Indian J Urol 2001;18:98-9
| Case Report|| |
An 80-year-old woman was referred to the urology clinic for evaluation of recurrent episodes of urinary tract infection. She denied any lower urinary symptoms in the past. The intervals between episodes of urinary infection were free of voiding difficulty. She had not undergone any urological procedures. She was 30 years post-menopausal and had five full-term normal pregnancies.
Physical examination showed a thinly built but healthy, normotensive individual. Abdominal examination was unremarkable, in particular the bladder was not palpable. Examination of the genitalia showed compete labial fusion in the midline. The urethral orifice was not visible. At the superior extent of the fusion there was a small opening about 3 fr in size through which she voided [Figure - 1]. On applying pressure over the site of fusion urine was seen to exude easily from this opening. Additionally, there was quite prominent clitoromegaly. The length of the clitoris measured 3.5 cm and the stretched length was 4.0 cm [Figure - 2]. Pubic hair was present but sparse and appeared to be consistent with her post-menopausal state. There was mild facial hirsutism.
Investigations showed normal renal profile. Ultrasound of the bladder and the kidneys was unremarkable. Post void residual was significant. There was no adnexal pathology detected. In view of the significant clitoromegaly, hormonal assays were carried out. Serum testosterone was 1.Onmol/L (normal 0.5-2.6 mnol/L). Serum DHEA-S was 0.7 umol/L (normal 0.4-3.2 umol/L). The 24 hour urinary keto-steroids was 38.6 nmol/L (normal 17-59 nmol/L). Assays of 3-alpha diolG could not be carried out.
Surgical correction was relatively simple. The midline fusion was divided and this opened into a vagina which to our surprise was without significant atrophic changes and of good capacity. The urethra was mildly narrowed. The skin edges were sutured to the vaginal epithelium. She was advised local application of oestrogen cream into the vagina.
| Discussion|| |
Labial adhesions or fusion usually occurs in young girls and at any age prior to puberty. Fusion may be partial or complete. Fusion usually starts at the posterior fourchette and progresses towards the clitoris. Labial adhesions are usually the result of local inflammation and chronic irritation due to hypoestrogenised vulval tissue at this age.
Considering the relative frequency of post-menopausal urethritis and vaginitis, complete labial fusion as a result of this condition alone is poorly recorded. Dong-Ming Kuo has reported labial fusion in a 30-year-old woman. We could assume that labial fusion in our patient is due to the effect of vulvar hypoestrogenisation.
Having supposed that oestrogen deficiency could have caused this fusion defect, the presence of clitoromegaly would require another explanation. In fact, clitoromegaly along with labial fusion in post-menopausal women has not been recorded in literature.
We feel that this in the absence of significant post-menopausal vaginitis or ovarian pathology, labial fusion and clitoromegaly could suggest a possible common etiology for this clinical picture. During the post-menopausal years, the ovaries virtually secrete no oestrogen; androgens continue to be produced by both the ovaries and adrenals. One of the signs of androgen excess in females is the presence of hirsutism. Idiopathic hirsutism is commonly thought to be constitutional. It has been shown that women with idiopathic hirsutism have abnormally high androgen metabolism in peripheral tissues like the skin making this a disorder of the peripheral compartment. Under these circumstances, normally circulating androgens like testosterone are converted more efficiently to potent androgens like di-hydrotestosterone (DHT).-DHT is the active intracellular androgen in the skin and is required for expression of the androgen effects. We might therefore suppose hat in this patient there is high level of 5 alpha reductase in the skin of the external genitalia which could explain the labial fusion and the clitoromegaly. This could be confirmed by the measurement of 3-alpha diol G (androstene diol glucoronide). 3 alpha diol G is higher correlated with skin 5-alpha reductase activity. Elevation of this enzyme with normal testosterone and DHEA-S would indicate disorder of the peripheral compartment. As we were unable to estimate this enzyme our supposition remains conjectural. However, despite this, we would suggest that in some post-menopausal women, in addition to oestrogen deficiency increased 5-alpha reductase levels in the skin could result in labial fusion.
| References|| |
|1.||Nicole CS. Dwyer PL. Labial fusion causing voiding difficulty and urinary incontinence. Aust NZ J Obstet Gynaecol 1999: 39: 391393. |
|2.||Kuo DM. Chuang CK, Hsieh CC et al. Labial fusion in a thirtyyear-old woman. Acta Obstet Gynecol Scand 1998: 77: 697-698. |
|3.||Mishell DR. Brenner PF. Management of common Problems in Obstetrics and Gynaecology, 3rd ed. Blackwell Science Publications. Chapter 98: 643-656. |
[Figure - 1], [Figure - 2]