What are the treatment options for a swollen unilateral labia minora?

Treatment of Swollen Unilateral Labia Minora

The treatment approach depends entirely on the underlying cause: infectious etiologies require antimicrobial therapy, inflammatory conditions like lichen sclerosus require topical corticosteroids with long-term surveillance, and anatomic hypertrophy causing functional problems may warrant surgical reduction.

Diagnostic Evaluation Before Treatment

Before initiating any treatment, you must establish the correct diagnosis through:

• Biopsy of the affected area to confirm lichen sclerosus and rule out squamous cell carcinoma, given the 3.5-5% malignant transformation risk 1
• STI testing including gonorrhea and chlamydia nucleic acid amplification tests, particularly if there is any suggestion of Bartholin or Skene gland involvement 1
• Viral culture for HSV when ulcerations are present, and serologic testing for syphilis if papules are noted 1
• Document the duration, pattern of symptoms (chronic vs. acute), and distinguish between pruritus, pain with erosions/fissures, or other presentations 1

Treatment Based on Specific Etiology

Infectious Causes

For Bartholin gland infections (presenting with swelling, erythema, and tenderness extending into the labia minora):

• Ceftriaxone 250 mg IM single dose PLUS Doxycycline 100 mg orally twice daily for 10 days when gonorrhea or chlamydia is suspected 2
• Ofloxacin 300 mg orally twice daily for 10 days for enteric organisms or in patients allergic to cephalosporins/tetracyclines 2
• Any vaginal organism can cause infection, with STI pathogens including gonorrhea and chlamydia being common culprits 3

For herpes simplex virus causing vulvar swelling with painful ulcerations, initiate antiviral therapy based on viral culture confirmation 3

Inflammatory/Dermatologic Causes

For lichen sclerosus (presenting as porcelain-white papules and plaques with ecchymosis affecting the interlabial sulci and labia minora):

• Topical corticosteroids are the first-line treatment to inhibit chronic inflammatory processes, lessen symptoms, and slow disease progression 2
• Steroids have been shown to reverse some histological changes seen in lichen sclerosus 2
• This condition has a bimodal presentation peaking in prepubertal girls and postmenopausal women 3
• The main symptom is itch, but pain occurs with erosions or fissures 3
• Long-term surveillance is mandatory due to malignant transformation risk 1

For contact dermatitis or allergic reactions, remove the offending agent and consider topical corticosteroids for inflammation with redness and swelling 3

Traumatic Causes

For labia minora piercings causing infection, pain, bleeding, or hematoma formation:

• Remove the piercing hardware
• Treat any secondary infection appropriately
• Monitor for cyst formation and hypertrophic scarring that can cause persistent swelling 3

Anatomic Hypertrophy (Non-Inflammatory)

Surgical reduction is indicated only when there is functional impairment (difficulty with hygiene, catheterization, recurrent UTIs, or significant physical discomfort during activity), not for unilateral swelling from acute causes 4

• Surgical options include wedge excisions, edge resection, or combined techniques depending on the specific anatomy 5, 6
• Do not perform surgery for acute inflammatory or infectious swelling—this is reserved for chronic anatomic hypertrophy causing functional problems

Critical Pitfalls to Avoid

• Do not dismiss ecchymosis in prepubertal girls as definitively indicating sexual abuse without considering lichen sclerosus as a differential diagnosis 3
• Always assess for STI pathogens when Bartholin or Skene gland infections are present, as these are common culprits 3
• Never initiate treatment without establishing the diagnosis, particularly distinguishing between infectious, inflammatory, and anatomic causes
• Recognize that lichen sclerosus requires lifelong surveillance for malignant transformation, not just symptomatic treatment 2, 1
• Patients with lichen sclerosus need extensive counseling about the chronic and progressive nature of the disease, with detailed information sheets and support groups being important 2