Labial adhesions — The etiology and frequency of labial adhesions (also called labial agglutination and synechia vulvae) are unknown. They can be partial, involving only the upper or lower labia, or complete. A small pinhole orifice may be present that functions as a means for urine to exit from behind the fused labia.
Labial adhesions may be asymptomatic or cause a pulling sensation, difficulty with urination, recurrent urinary tract infections, or recurrent vaginal infections. No treatment is necessary if the adhesions are asymptomatic, involve only a small portion of the labia, and are not affecting the urine stream. The adhesions may resolve when estrogen production increases at puberty.

***Labial adhesions should be treated if they affect urination by diverting a normal stream of urine. Treatment consists of topical estrogen cream (eg, Premarin cream) applied twice daily at the point of midline fusion where there is a thin white line [21]. With the application of the estrogen cream, great care should be taken so as not to traumatically tear the adhesion.

Therapy is continued until the labial adhesions resolve. Breast bud formation is a possible side effect, which will resolve after the cessation of the topical estrogen cream. This complication is less likely if the cream is applied sparingly and directly to the adhesion.

The response of labial adhesions to topical estrogen therapy was illustrated in a retrospective review of 109 girls (three months to 10 years of age) [22]. Topical estrogen therapy was successful in 79 percent of patients after a mean duration of four months. Minimal breast development occurred in six girls (5 percent), and vaginal bleeding in one (<1 percent). In our experience, labial adhesions resolve in nearly all girls treated with correct technique for two to six weeks. Successful separation should be followed by attention to hygiene, daily baths, and the application of a bland ointment, such as A&D Ointment or white petroleum jelly, for 6 to 12 months. 

Two studies have reported efficacy with the use of betamethasone 0.05 percent cream twice daily for several weeks in a total of 19 prepubertal girls [23,24]. If used, care must be taken to avoid prolonged use of topical steroids to the vulva. Estrogen cream remains the primary therapy pending further study.
Failure of medical therapy tends to occur with thick adhesions (3 to 4 mm in width) with no thin translucent raphe [25]. The most common reason for medical failure is placement of the cream in the wrong location or placement of too small an amount of cream.

Surgical intervention for labial adhesions is reserved for rare patients with complete obstruction of urine flow in whom estrogen cream cannot be applied for psychosocial reasons or has been unsuccessful after an adequate trial (as described above). With these indications, the authors have performed only one surgical separation in the past 10 years. When necessary, surgical separation is performed with sedation and/or anesthesia and followed by topical estrogen cream for one to two weeks and then application of a bland emollient (eg, white petroleum jelly) for 6 to 12 months