Photo Essay
Focus on Signs and Symptoms
A Collage of Genital Lesions in Children, Part 6
Labial Fusion
The mother of this 11-month-old girl was concerned that her infant’s vagina was almost obscured by a membrane. This was noted incidentally a few days earlier. The mother was sure that the membrane was not there in the immediate neonatal period. Urination was unimpaired, and the infant was asymptomatic. She had no history of trauma to the genital area. Her past health was unremarkable. In particular, she had no history of unexplained fever, foul-smelling urine, or an overt urinary tract infection.
On examination, the vulva was flat. The edges of the labia minora were sealed in the midline by a thin, translucent membrane that extended from the posterior fourchette to just below the clitoris.
Labial fusion refers to partial or complete adherence of the labia minora. The condition is rare at birth and occurs most commonly in girls between 3 months and 4 years of age. The peak incidence is between 13 and 23 months, during which about 3.3% of girls are affected.
Labial fusion probably develops after denudation of the superficial squamous epithelial layer of the labial mucosa. Denudation occurs with inflammatory conditions of the labia minora, such as vulvitis or vulvovaginitis, most often secondary to poor perineal hygiene. Estrogen deficiency is associated with a reduction in the thickness of the labial epithelial cells and is a possible pathogenic factor.
Most girls with labial fusion are asymptomatic. The condition is usually discovered incidentally by a physician during a routine examination or by the mother while she is bathing the child. Labial fusion may predispose the child to asymptomatic bacteriuria or to urinary tract infection. Occasionally, the labial fusion causes urinary outflow obstruction with resultant bladder distention and hydronephrosis.
Treatment consists of precise application of a topical estrogen cream to the fused area twice a day until lysis of the adhesion is complete. Most cases resolve within 2 to 3 months. As the labia minora separate, petroleum jelly should be applied to the edges to prevent readhesion.■
FOR MORE INFORMATION:
- Leung AK, Robson WL. Labial fusion. Consultant for Pediatricians. 2004;3:31-35.
- Leung AK, Robson WL, Kao CP, et al. Treatment of labial fusion with topical estrogen therapy. Clin Pediatr (Phila). 2005;44:245-247.
- Leung AK, Robson WL, Tay-Uyboco J. The incidence of labial fusion in children. J Paediatr Child Health. 1993;29:235-236.
A 4-year-old boy was brought for evaluation of a tiny cystic mass on the penis. The lesion was first noted a year earlier when the foreskin became retractable. At that time, the child was asymptomatic and the family did not seek medical attention. There was no history of urethral discharge or meatal ulceration. Urination was normal. Past health was unremarkable.
The cystic lesion was located at the 3 o’clock position on the glans penis near the urethral meatus and measured 2 mm in diameter. It was nontender. The cyst was excised. Histological examination showed that the cyst was lined by columnar epithelium. The postoperative course was uneventful. The patient was followed up for 2 years with no recurrence of the lesion.
The cause of parameatal urethral cysts is unclear. Congenital lesions are believed to be caused by faulty separation of the foreskin from the glans or occlusion of the parameatal duct. Acquired cysts may result from an infection.
The cysts are usually asymptomatic, although they can be itchy or painful. Large cysts and those in close proximity to the urethral meatus may cause deflection and spraying of the urinary stream.
Treatment consists of complete excision of the cyst. The lesion often recurs after spontaneous rupture or aspiration.
FOR MORE INFORMATION:
- Koga S, Arakaki Y, Matsuoka M, Ohyama C. Parameatal urethral cysts of the glans penis. Br J Urol. 1990;65:101-103.
- Onaran M, Tan MO, Camtosun A, et al. Parameatal cyst of urethra: a rare congenital anomaly. Int Urol Nephrol. 2006;38:273-274.
- Yoshida K, Nakame Y, Negishi T. Parameatal urethral cysts. Urology. 1985;26: 490-491.
Hymenal Tag
The mass protruding from the introitus of this 1-month-old girl was first noted at birth. She was born to a 26-year-old primigravida at term after an uncomplicated pregnancy and normal spontaneous delivery. The mother was not taking any medications during the pregnancy. There was no history of birth trauma. No vaginal bleeding was noted.
The infant was not in distress. The flesh-colored smooth-surfaced lesion protruding from the vagina was characteristic of a hymenal tag. The rest of the examination findings were unremarkable.
Hymenal tags are present in 3% to 13% of normal female newborns. The tags are commonly located in the superior and inferior positions and tend to resolve spontaneously. New hymenal tags may appear postnatally as a result of extension of an intravaginal or external hymenal ridge.
The parents were reassured of the benign nature of the lesion and that it will resolve with time.
FOR MORE INFORMATION:
- Berenson AB, Grady JJ. A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr. 2002;140:600-607.
- Heger AH, Ticson L, Guerra L, et al. Appearance of the genitalia in girls selected for nonabuse: review of hymenal morphology and nonspecific findings. J Pediatr Adolesc Gynecol. 2002;15:27-35.
Penile Angioedema After Peanut Ingestion
A 6-year-old boy presented with a swollen penis and lip within an hour after ingesting some peanuts. The swelling was nonpruritic. The child described a sense of tightness in the lips. He had no associated rash, abdominal pain, dysphagia, stridor, dyspnea, dysuria, or abnormality in the urinary stream. He was not taking any medications. He had no history of a recent viral infection, insect bite or sting, oral or genital trauma, or blood transfusion. There was no family history of asthma, atopic dermatitis, allergic rhinitis, or angioedema.
Examination revealed no signs of an allergic reaction other than the angioedema of the lips and penis. The foreskin could be retracted, and the urethral meatus was normal. The child was treated with hydroxyzine, 10 mg orally 4 times a day. The angioedema subsided within 72 hours.
Angioedema is most commonly caused by a type I—anaphylactic or IgE-mediated—immediate hypersensitivity reaction to food (notably, peanuts, cow’s milk, eggs, chocolate, or seafood), drugs (notably, antibiotics, opiates, or sedatives), stinging insect venom, preservative, latex product, or aeroallergen. Angio edema may also be a consequence of a type II cytotoxic reaction (transfusion reaction) or a type III antigen-antibody complex reaction (serum sickness). Vibratory angioedema and exercise-induced angioedema result from hypersensitivity to a mechanical or physical factor. Hereditary angioedema is an autosomal dominant disorder associated with the absence or dysfunction of C1 inhibitor. ■
FOR MORE INFORMATION:
- Estrada JL, Gozalo F, Cecchini C, Casquete E. Contact urticaria from hops (Humulus lupulus) in a patient with previous urticaria-angioedema from peanut, chestnut and banana. Contact Dermatitis. 2002;46:127.
- Leung AK, Robson WL. Penile and oral angioedema associated with peanut ingestion. J Natl Med Assoc. 2006;98:2011-2012.
- Smith GA, Sharma V, Knapp JF, Shields BJ. The summer penile syndrome: seasonal acute
