What is the treatment for vaginal adhesions?

Treatment of Vaginal Adhesions

The primary treatment for vaginal adhesions is a combination of surgical lysis followed by preventive measures to avoid recurrence, with topical corticosteroids and dilators being the mainstay of therapy. 1

Initial Assessment and Treatment Approach

Medical Management

1. Topical corticosteroids:

   • Ultra-potent topical corticosteroid (clobetasol propionate 0.05%) is the first-line treatment for vaginal adhesions, particularly those associated with lichen sclerosus 1
   • Application regimen: once daily at night for 4 weeks, then alternate nights for 4 weeks, then twice weekly for 4 weeks 1
   • For significant inflammation without erosions, apply a potent topical corticosteroid ointment once daily to the involved urogenital surfaces 1

2. Topical estrogen therapy:

   • Particularly effective for adhesions related to hypoestrogenic states 2
   • Apply precisely to the fused area twice daily until adhesions are lysed
   • After separation, apply petroleum ointment twice daily for at least 1 month 2
   • Monitor for side effects such as vulval pigmentation and breast enlargement

Surgical Management

For adhesions that do not respond to medical therapy:

1. Surgical lysis:
   • Indicated for significant adhesions causing dyspareunia or difficulty with micturition 1, 3
   • More effective than topical treatments for established adhesions 4
   • Can be performed under local anesthesia for minor adhesions 4
   • For introital narrowing, use part of the posterior vaginal wall in reconstruction to prevent further adhesions due to Koebnerization 1

Prevention of Recurrence

1. Mechanical prevention:

   • Use of vaginal dilators or tampons wrapped in Mepitel dressings to prevent formation of synechiae 1
   • Regular dilation following surgical lysis is crucial to maintain patency 3
   • For women with significant adhesions, early assessment by a vulval specialist is recommended for consideration of dilators 1

2. Topical treatments:

   • Regular application of emollients:
     • White soft paraffin ointment applied to urogenital skin and mucosae every 4 hours during acute phases 1
     • Hyaluronic acid with vitamins E and A can prevent acute and late vaginal toxicities 1
   • Regular use of vaginal moisturizers and lubricants to minimize dryness 1

3. Special considerations for specific conditions:

   • For clitoral hood adhesions forming a painful pseudocyst, subtotal or total circumcision may be required 1, 5
   • For adhesions related to radiation therapy, topical application of hyaluronic acid with vitamins E and A can reduce dyspareunia, inflammation, dryness, and fibrosis 1

Management of Underlying Conditions

1. Lichen sclerosus:

   • Long-term maintenance with clobetasol propionate 0.05% as required (most patients need 30-60g annually) 1
   • Monitor for signs of squamous cell carcinoma, which occurs in approximately 5% of cases 1

2. Post-radiation adhesions:

   • Consider hormone replacement therapy for genitourinary menopause syndrome if not contraindicated 1
   • Vaginal estrogens can reduce superficial dyspareunia and relieve urogenital symptoms 1

3. Stevens-Johnson syndrome/toxic epidermal necrolysis:

   • Use Mepitel dressings on eroded areas in the vulva and vagina 1
   • Consider catheterization to prevent urethral strictures 1

Follow-up and Monitoring

• Regular examination of the vaginal tract during healing process
• For women with lichen sclerosus, long-term follow-up is necessary due to risk of squamous cell carcinoma 1
• Address psychosexual problems that commonly occur with chronic genital disorders 1

Common Pitfalls and Caveats

• Failure to address the underlying cause of adhesions may lead to recurrence
• Inadequate post-surgical care and dilation can result in reformation of adhesions 3
• Prolonged use of topical steroids in the genital area can cause skin atrophy 5
• Surgical reconstruction without using appropriate tissue (e.g., posterior vaginal wall) may lead to Koebnerization and further adhesions 1
• Psychosexual problems are common and should be addressed, as patients may be reluctant to discuss sexual concerns 1