Surgical management of complete labial fusion in a postmenopausal woman with application of a fish skin graft: A case report

Abstract

Advanced genitourinary syndrome of menopause (GSM) can lead to complete labial fusion (CLF) in postmenopausal women, which in turn may cause urinary retention, recurrent urinary tract infections, and diminished urinary flow. This report presents the case of a 72-year-old woman with CLF and a diminished urinary stream. She was treated through surgical labial separation, following the application of a fish skin biograft. This case is seemingly the first report of the application of such a biograft for labial fusion. The technique offers a minimally invasive approach for preventing re-adhesion, promoting tissue regeneration, and reducing complications in postmenopausal women with advanced labial adhesions.

Highlights

• •Severe GSM can lead to complete labial fusion, which may cause urinary retention, recurrent UTIs, or a weak urinary stream.
• •Possibly the first case report of the use of a fish skin biograft for surgical labial separation in a postmenopausal woman with CLF.
• •The Atlantic cod biograft has a similar matrix to human skin, which aids healing, reduces inflammation and infection risk.
• •This case shows a promising, less invasive surgery for severe labial fusion in postmenopausal women, avoiding complex reconstruction.

1. Introduction

Genitourinary syndrome of menopause (GSM) is a condition associated with a decline in estrogen levels during menopause, which can result in symptoms such as vaginal dryness, vulvar atrophy, urinary tract infections (UTIs), and increased urinary urgency and frequency. In more severe instances, complete labial fusion (CLF)—also referred to as labial adhesion or labial agglutination—can occur. Patients with CLF may experience urinary retention, recurrent UTIs, increased urinary frequency and urgency, or diminished urinary flow [1]. Treatment options for mild cases typically include the application of topical estrogen cream, with or without steroids. Severe cases or those that do not respond to topical treatment may require surgical intervention [2].

This report presents the case of a 72-year-old postmenopausal, Caucasian woman with CLF who was treated through the lysis of severe labial adhesions, followed by the application of a dermal graft using fenestrated fish skin biograft - a surgical and wound care application that has been approved by the US Food and Drug Administration.

2. Case Presentation

A 72-year-old postmenopausal Caucasian woman was referred by her primary care doctor for urinary retention and a diminished urinary stream for the past six weeks. Her medical history included hypertension, a heart valve replacement, and a 15-year history of smoking but no pelvic prolapse or urinary issues. She denied experiencing symptoms of gross hematuria, suprapubic pain, kidney stones, or recurrent urinary tract infections. She had been sexually inactive for many years and was applying estrogen cream to the vaginal area twice a week for GSM.

Upon vaginal exam, a pinpoint opening overlying the area of the urethral meatus secondary to severe labial adhesions/fusion of the labia minora was found (Fig. 1). Renal bladder ultrasound returned no abnormal findings. Cystoscopy was then conducted by passing a 16 French flexible cystoscope through the pinpoint opening in the severe labial adhesion. Pancystourethroscopy, as well as a vaginoscopy, were unremarkable. During follow-up, the patient elected for surgical intervention.

Fig. 1.

Preoperative image showing complete labial fusion with a pinhole opening.

Under general anesthesia, the patient was positioned into dorsal lithotomy. Blunt and sharp lysis was performed along the midline scar line to completely separate the severely scarred tissue. Spot electrocautery confirmed hemostasis. A Foley catheter was inserted once the urethral meatus was exposed.

To promote wound healing and minimize risk for recurrent complete surface area fusion, a fenestrated fish skin biograft (Kerecis Marigen Fenestrated Fish Skin Biograft) was introduced and trimmed into two separate pieces to be applied along the inner lining of each raw medial surface area of the labia minora. Interrupted 2–0 Vicryl on CT-2 sutures were placed to lay the graft material flat and allow a gap between. The graft was positioned in a parallel manner to maintain a patent vaginal introitus (Fig. 2).

Fig. 2.

The surgical placement of the fenestrated fish skin biograft. The graft was placed along the inner lining of each raw medial surface area of the labia minora.

The patient was discharged with a Foley catheter and successfully passed a fill and pull three days later. During her three-week follow-up, the patient reported a strong urinary stream and had a post-void of 53 mL. She was instructed to apply estrogen cream every other night.

The patient followed up after 3 months with no evidence of refractory adhesions upon pelvic exam and was instructed to decrease estrogen cream to 3 times a week. At 6-month and 1-year follow-ups, no recurrence of labial fusion was evident, and she continued to endorse a strong urinary stream (Fig. 3).

Fig. 3.

Twelve-month postoperative results: pelvic examination demonstrates no recurrence of labial fusion and the integration of the graft into the labial tissue.

3. Discussion

This 72-year-old postmenopausal woman who presented with CLF was successfully treated with surgical labial separation, with the application of a fenestrated fish skin biograft. Based on the information and research available, this is the first report of the application of such a biograft for surgical labial separation.

Labial adhesions are primarily observed in prepubescent girls, with an incidence of approximately 2 % [2]. Similar incidence rates in postmenopausal women, however, have never been recorded. These adhesions are associated with an estrogen-deficient environment in the labia and sexual inactivity. Other risk factors include poor hygiene, recurrent UTIs, labial trauma, and dermatological conditions, such as eczema, seborrheic dermatitis, and lichen sclerosus [3]. Patients may be asymptomatic or present with symptoms such as recurrent UTIs, urgency, frequency, and urinary retention. CLF has also been associated with pseudo-incontinence or diminished urinary stream. Mild cases can be treated with estrogen creams, with or without steroids, but if they are unsuccessful, surgical separation will be needed [4].

A retrospective chart review of 109 prepubescent girls found that the rate of refractory labial adhesions following surgical or manual separation is 10 % [5], although other studies have reported rates between 14 % and 20 % [3,6,7]. Once again, due to limited data for postmenopausal women, the refractory rate remains unknown, although it is also a major concern in this population. Several methods have been reported for separating labial fusions and preventing refractory adhesions in postmenopausal women.

Serial Hegar dilators and vaginal digitations are one of the least invasive operative techniques for manual labial adhesion separation in the operating room. No sharp dissection is required, but refusion of the labia is a serious concern. Therefore, application of estrogen cream with daily digital separation is essential, with long-term follow-ups to ensure refusion does not occur [8]. Although this technique does not involve sharp dissection or suturing—two factors that can lead to morbidity, scarring, and recurrence—it does require ongoing maintenance and carries a high risk of refusion if not properly managed in the postoperative period. Another study suggested using uterine cervical dilators to separate the lower part of the adhesion, and then the remainder of the adhesions are separated through the inside using fine curved forceps [9].

Simple surgical approaches have also been suggested, including separation via a combination of blunt dissection and cautery with no need for sutures [10] and blunt dissection with labia minora suturing, followed by application of hydrocolloid dressings during the postoperative period, 1, 2 and 4 weeks after surgery [7]. Although the first approach may be less invasive, it carries a risk of adhesion if postoperative care is insufficient, as well as the potential for infection, which could increase the likelihood of recurrence and complications. Using hydrocolloid dressings on the labia, as in the second approach, reduces the risk of infection and adhesions. However, it requires multiple follow-ups for dressing changes, making it challenging to monitor wound healing. Dressings may also stick to the wound or cause allergic reactions.

Finally, more intricate surgical techniques and reconstructive surgery have been reported to separate labial adhesions in postmenopausal women. Johnson et al. used full-thickness thigh flap grafting to prevent contraction and scarring [11]. Another case study conducted reconstruction using the vulvoperineal flap. While this technique prevents recurrence in an environment using tissue that is not easily affected by estrogen, the invasive nature of this technique increases the risk of complications, such as flap ischaemia, infection, and wound healing complications [12]. A Z-plasty technique has also been shown to help prevent re-adhesion; however, in patients with long adhesions, performing a Z-plasty can be challenging. As a result, a study combined both Z-plasty and Y—V plasty techniques to effectively separate long adhesions. Three main postoperative concerns that were found for this approach were the cosmetic aspect, infection, and varying suture point [6,13].

In the present case, a simple and minimally invasive surgical technique involving blunt dissection was employed to separate the labial adhesions. To prevent recurrence and promote wound healing, a fenestrated fish skin biograft was integrated into the labial tissues. This piscine acellular dermal xenograft is derived from the Atlantic cod (Gadus morhua). This fish skin molecular structure has proven to be similar to mammalian skin. Unlike mammalian skin grafts, fish skin does not require intense sterilization due to its diminished risk of viral disease transmission to humans. Therefore, the graft maintains its structure of glycosaminoglycans, proteoglycans, fibronectin, growth factors, and omega-3 polyunsaturated fatty acids through the sterilization process [14].

To the best of the authors' knowledge, there have been no studies where such a biograft has been applied to labial tissue, but there have been several reports of how the preserved lipid mediators can integrate into human tissue, promote healing, decrease inflammation and prevent infection.¹⁴ By directly integrating the graft into the labial tissue, no dressing changes or adhesives were necessary, and tissue regeneration occurred, which prevented significant scarring or cosmetic complications. Postoperative follow-up showed no infections, and no recurrence of labial adhesions was observed after 18 months. The primary limitations of this approach include potential allergic reactions to fish, the cost of the graft if not covered by insurance, and the requirement for ongoing estrogen therapy.

4. Conclusion

In conclusion, advanced GSM can lead to severe CLF in postmenopausal women, which can cause infection, urinary retention, and pseudo-incontinence. This case study reports a unique way to prevent re-adhesion, promote tissue healing, and avoid postoperative infection by applying a biograft after blunt labial dissection. As a relatively straightforward surgical procedure, this method may offer a new treatment option for postmenopausal women with CLF.

Contributors

Julia Grace Fitzgerald contributed to patient care, conception of the case report, acquiring and interpreting the data, drafting the manuscript, undertaking the literature review and revising the article critically for important intellectual content.

Nidhi Chawla contributed to revising the manuscript critically for important intellectual content.

Neil John Kocher contributed to patient care, conception of the case report and revising the manuscript critically for important intellectual content.

All authors approved the final submitted manuscript.

Patient consent

Written informed consent was obtained from the patient for the publication of this case report and the accompanying images.

Provenance and peer review

This article was not commissioned and was peer reviewed.

Funding

This work did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Declaration of competing interest

The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.