Labial agglutination is an uncommon condition. The labia are attached in the midline, and it is usually diagnosed in early childhood. However, apart from the anatomical malpresentation, there are no clinical sequelae; it is a benign condition that does not necessitate any intervention. In postmenopausal labial fusion (PMLF), the labia are similarly attached to the midline, but there is a predominant symptom of incontinence. In PMLF, the fused labia do not permit a free urinary flow. Urination is performed through the urethra, but urine is collected in the vagina, because there is only a tiny, needle-hole opening that permits the drainage of the urine. As a consequence, the affected females present mainly with the symptoms of voiding dysfunction and continuous urinary incontinence.

This a retrospective chart review of cases of women with PMLF that presented in a tertiary urogynecology center from 2011 until 2018. Exclusion criteria: (1) previous pelvic floor surgery, including obliterative procedures, (2) previous pelvic floor radiotherapy, (3) subjects who had only narrowing of the introitus. All women had routine gynecological examination, and ultrasound investigation of the internal genitalia and the pelvic floor. Incomplete bladder emptying was defined as >100ml postvoid residual (PVR) by bladder scan at initial evaluation. All data were collected in Microsoft EXCEL.

Six postmenopausal women with PMLF were included in the study (Table 1). Mean age was 71.3-years-old, mean parity 2.0 children. None of the women was on oral hormonal replacement therapy. All women presented with lower urinary tract symptoms, predominantly difficulty in voiding associated with post-micturition dribbling and continuous urinary incontinence. Two women (patient #4 and #5) reported being unable to have vaginal coitus. None of the patients had increased PVR. All women had a complete obliteration of the introitus; the urethral meatus was completely occluded in all patients and even a pediatric urinary catheter cold not be allowed to be passed, therefore multichannel urodynamics could not be performed. A lysis of the adhesions including bilateral surgical excision of the agglutinated part of the labia was performed under local anesthesia and intravenous sedation. Histology showed no malignancy or vulvar dystrophy; chronic inflammatory changes and hyperkeratosis were common findings in most patients. Post-operatively, local estrogens were applied. Mean follow-up was 2.7 years. All patients reported cure from the incontinence and there was no recurrence.

Table 1
	         Age	Parity	Vaginal Deliveries	Intervention	       Histology	Follow-up (Years)
#1	           72	            2	                 2	                          Surgical	    No Malignancy	            6
#2	           50	            1	                 1	                          Surgical	    No Malignancy	            4
#3	           80    	    3	                 3	                          Surgical	    No Malignancy	            4
#4	           66	            1	                 1	                          Surgical 	    No Malignancy	            3
#5	           74	            2	                 2	                          Surgical	    No Malignancy	            1
#6	           86             3	                 3	                          Surgical	    No Malignancy	            0
Average	   71.3	   2.0	        2.0			                                                                           2.7

PMLF is a rarely reported condition. However, a number of women who have continuous incontinece and difficulty in voiding could suffer from this enity. Many of these women may not seek medical help because the symptoms are gradual, benign, and they may themselves explain them because of their growing older. However, because manual separation of the labia with no sedation may be very painful, difficult, and may have not permanent results, a surgical approach was adopted in this study. In the long-term follow up, the results were satisfactory and there were no recurrences. In PMLF, urination takes place normally; the urine is voided through the urethra but the flow cannot be performed because of the oblterated introitus. Therefore, the urine is collected within the vagina, which serves as a temporary urinary reservoir. However, there is not permanent urinary obstruction, because the obliterated introitus presents a small opening that permits urinary dribbling and complete drainage.

PMFL is a rare condition that needs surgical treatment. In our case series, this condition was not associated with local pre-malignant or malignant conditions. In the long-term follow-up there are good results.

Int Urogynecol J 2003; 14: 360-1
Int Urogynecol J 2008; 19: 253-6
Int Urogynecol J 2009; 20: 251-2