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Prof. Somashekhar Nimbalkar
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On Sep 2018




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"Journal of Clinical and Diagnostic Research is at present a well-known Indian originated scientific journal which started with a humble beginning. I have been associated with this journal since many years. I appreciate the Editor, Dr. Hemant Jain, for his constant effort in bringing up this journal to the present status right from the scratch. The journal is multidisciplinary. It encourages in publishing the scientific articles from postgraduates and also the beginners who start their career. At the same time the journal also caters for the high quality articles from specialty and super-specialty researchers. Hence it provides a platform for the scientist and researchers to publish. The other aspect of it is, the readers get the information regarding the most recent developments in science which can be used for teaching, research, treating patients and to some extent take preventive measures against certain diseases. The journal is contributing immensely to the society at national and international level."



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Saraswati Dental College
Lucknow
On Sep 2018




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On Aug 2018




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Dr. Arundhathi. S
MBBS, MD (Pathology),
Sanjay Gandhi institute of trauma and orthopedics,
Bengaluru.
On Aug 2018




Dr. Mamta Gupta,
"It gives me great pleasure to be associated with JCDR, since last 2-3 years. Since then I have authored, co-authored and reviewed about 25 articles in JCDR. I thank JCDR for giving me an opportunity to improve my own skills as an author and a reviewer.
It 's a multispecialty journal, publishing high quality articles. It gives a platform to the authors to publish their research work which can be available for everyone across the globe to read. The best thing about JCDR is that the full articles of all medical specialties are available as pdf/html for reading free of cost or without institutional subscription, which is not there for other journals. For those who have problem in writing manuscript or do statistical work, JCDR comes for their rescue.
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Reviewing articles is no less a pain staking process and requires in depth perception, knowledge about the topic for review. It requires time and concentration, yet I enjoy doing it. The JCDR website especially for the reviewers is quite user friendly. My suggestions for improving the journal is, more strict review process, so that only high quality articles are published. I find a a good number of articles in Obst. Gynae, hence, a new journal for this specialty titled JCDR-OG can be started. May be a bimonthly or quarterly publication to begin with. Only selected articles should find a place in it.
An yearly reward for the best article authored can also incentivize the authors. Though the process of finding the best article will be not be very easy. I do not know how reviewing process can be improved. If an article is being reviewed by two reviewers, then opinion of one can be communicated to the other or the final opinion of the editor can be communicated to the reviewer if requested for. This will help one’s reviewing skills.
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Dr. Mamta Gupta
Consultant
(Ex HOD Obs &Gynae, Hindu Rao Hospital and associated NDMC Medical College, Delhi)
Aug 2018




Dr. Rajendra Kumar Ghritlaharey

"I wish to thank Dr. Hemant Jain, Editor-in-Chief Journal of Clinical and Diagnostic Research (JCDR), for asking me to write up few words.
Writing is the representation of language in a textual medium i e; into the words and sentences on paper. Quality medical manuscript writing in particular, demands not only a high-quality research, but also requires accurate and concise communication of findings and conclusions, with adherence to particular journal guidelines. In medical field whether working in teaching, private, or in corporate institution, everyone wants to excel in his / her own field and get recognised by making manuscripts publication.


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Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
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In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
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Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."



Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011




Dr. Shankar P.R.

"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."



Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011
Anuradha

Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.


Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020

Important Notice

Case Series
Year : 2022 | Month : May | Volume : 16 | Issue : 5 | Page : QR01 - QR04 Full Version

Labial Agglutination in Different Age Groups: A Case Series


Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/51913.16325
Sukumar Mitra, Damayanti Banerjee, Debdatta Chakrabarty, Seema Das

1. Assosciate Professor, Department of Obstetrics & Gynecology, Medical College and Hospital, Kolkata, West Bengal, India. 2. Post Graduate Resident, Department of Obstetrics & Gynecology, Medical College and Hospital, Kolkata, West Bengal, India. 3. Assistant Professor, Department of Community Medicine, Medical College and Hospital, Kolkata, West Bengal, India. 4. Senior Resident, Department of Obstetrics & Gynecology, RG Kar Medical College and Hospital, Kolkata, West Bengal, India.

Correspondence Address :
Dr. Seema Das,
Room No. 6, Ab Hostel, Above Fair Price Shop, RG Kar Medical College Campus, Kolkata, West Bengal, India.
E-mail: cmadas0@gmail.com

Abstract

Labial adhesion or agglutination is varying degree of apposition between the labia minora which may be complete or partial. Here, a case series of five patients of different age groups ranging from toddler, prepubertal, postpartum and postmenopausal age groups were included. Most often, labial adhesions are encountered in prepubertal age group due to hypoestrogenic state. Parents most often diagnose incidentally while changing diapers. Similar hypoestrogenic environment encountered in postmenopausal state where in addition to apposition, women have co-existent genitourinary symptoms for which they seek care. Old people may be delayed in seeking care due to uncertainty. Labial adhesions among reproductive age group are quite rare. Most of the case has a past history of trauma which was not adequately managed and the agglutination developed as a remote complication. All the five patients were managed as per the severity of adhesions. Treatment included from conservative approach of oestrogen cream application to surgical adhesiolysis.

Keywords

Hypoestrogenic, Labial adhesion, Trauma

Labial adhesions are quite common in prepubertal and postmenopausal age group. Worldwide incidence is not known, as the condition is mostly asymptomatic. Exact cause is not known but mostly oestrogen deficiency is a contributing factor (1). Labial adhesions also known as labial synechia is mostly incidental entity in prepubertal and postmenopausal age group. Most often it occurs around clitoris. Labial adhesion may affect up to 2% of prepubertal girls, with the typical age of presentation was two years of age (1). Recurrent inflammation associated with infection and diabetes may be present with postmenopausal labial synechiae.

Adhesions in reproductive age group are associated with history of trauma during childbirth and such cases require surgical adhesiolysis. A study in 2007 measured the serum estradiol levels of 59 prepubertal females with labial adhesion and 60 prepubertal females with no labial adhesion showed no statistically significant difference in their oestrogen levels, hence they were against the idea that labial fusion is due to a hypoestrogenic state (1).

History and clinical examination reveals that labial agglutination consists of thin fibrotic tissue, which can range from being a small partial fusion to a complete fusion occluding the vaginal orifice. Although infrequent, the complaints include dripping of urine, dysuria, itching (1). Sometimes urinary tract infection may occur which is relieved on releasing syneciae. Preventive measures include maintenance of perineal hygiene and avoidance of irritant with proper glycemic control (1). Labial adhesion is a clinical diagnosis and hence does not require any laboratory investigations.

Case Report

Case 1

The mother of a three-year-old toddler came in gynaecology Outpatient Department (OPD) complaining of nappy rashes and itching around perineal region. She also complained of poor stream of urine for 1 week. Her mother recently noticed while bathing her that she is unable to separate the labial walls of the vulva (Table/Fig 1). There is no history of such condition present since birth. On examination there was undue adhesion of labia minora hence occluding the vaginal opening which caused the poor stream of urine.

On gentle retraction of the labia majora manually, the adhesion was separated after prior application of topical lignocaine jelly 2%. A topical application of oestrogen cream was advised. Estradiol 0.01% was prescribed to apply twice daily on the perineal region for 4 weeks. The mother was advised to maintain dry perineum following urination to avoid secondary infections on excoriated skin. The mother followed-up with the child after 1 month and on examination, the genitals appeared normal and she had no further complaints.

Case 2

A two-year-old girl was accompanied with her mother complaining about abnormal genitals of her daughter while giving her a bath.On general physical examination, the child was normal. On gentle traction of the labia with the examining fingers, the labia majora was separated (Table/Fig 2). The mother was counseled about labial adhesion and advised to apply estradiol cream 0.01% locally everyday twice daily for four weeks. She later attended OPD after 2 months with no further complaints. On perineal inspection, there was no adhesion. She was asked to maintain perineal hygiene and attend OPD if further problem arises.

Case 3

A 65-year-old postmenopausal female patient P3+0, came with complain of burning sensation during urination for 2 weeks. She was normotensive, non diabetic of average built. All three of her children were delivered vaginally. She had no past surgical history. She noticed a change in her urine stream. During micturition, she noticed splaying of urine stream and dribbling after voiding. On gentle examination of perineum: both the labia majora (Table/Fig 3)(a,b) and minora (Table/Fig 3)c was found to be fused (Table/Fig 3). She was examined in dorsal supine position and traction with examining index and thumb fingers was applied to manually dislodge the adhesions. The vaginal epithelium was atrophic with loss of rugosity and lubrication. The vaginal introitus was patent and cervix appeared normal on per speculum examination. After prescribing routine blood investigations and a urine for routine and microscopic examination, she was advised to apply Premarin Cream (conjugated equine estradiol 0.625 mg along the labia minora and vaginal mucosa twice daily for 4 weeks.

The patient followed-up after 2 months with no further complaints. She was advised to do routine exercise and maintain perineal hygiene.

Case 4

A P1+0, 23-year-old female patient came with chief complaints of not able to properly participate in sexual intercourse since 2 years. Initially, shy and anxious, on investigation she revealed that the problem of apareunia developed following delivery of her only child two years back at home being attended by local untrained Dai. Following delivery she had an episode of bleeding from her genitalia for which she was advised to apply some ointment locally by general practitioner. The wound gradually healed and she was relieved of her bleeding episode and gradually recovered. She had lactational amenorrhea for 9 months. Thereafter, her menstrual function returned initially irregular followed by regular cycles. She also revealed that she was unable to participate in sexual intercourse at all after delivery. On general and systemic examination, no major abnormalities were detected.

On local examination, the vaginal introitus was not visualised properly. Both the labia minora were fused hence occluding the vaginal introitus in posterior two-thirds of vaginal introitus leaving anterior one-third of the orifice patent. Per rectal examination did not reveal any collection in the vagina which ruled out haematocolpos (Table/Fig 4)(a). Pelvic ultrasonography showed a normal shaped uterus without any evidence of haematometra or haematocolpos. Both the ovaries were found normal in shape and size, without any signs of pelvic endometriosis. After evaluating the clinical as well as haematological parameters and taking informed consent, surgical adhesiolysis was planned. Under general anaesthesia in lithotomy position, the operation was performed. An indwelling catheter was placed in the bladder (Table/Fig 4)(a).

A longitudinal midline incision was made in the agglutinated labia minora. Immediately, it was found that the agglutinated minora was just making a membrane like shield only at the level of vaginal orifice and the vaginal canal was absolutely normal exposing the cervix and fornices (Table/Fig 4)(b,c,d). The scar tissue around the incision line was excised and the margins of the wound sutured with interrupted 2-0 synthetic delayed absorbable suture and the anatomy was reconstructed. A barrier was made of pre sterile foam within a condom and was placed in the vagina to prevent approximation of the wound and was kept in-situ for three days postoperatively. This was done to prevent recurrence. After three days, the barrier and the indwelling catheter were removed and the patient was discharged on 5th postoperative day. She was under antibiotic coverage for 7 days. A follow-up was done after one month and an absolutely normal functional vagina was observed.

Case 5

A 29-year-old female patient, with a history of vaginal birth at home one year back came to the OPD with the complaint of painful intercourse. On further investigation, she narrated the delivery was conducted by a Dai. A small laceration near the introitus was left unsutured. She was advised to apply an antibiotic ointment. Months later, she noticed that she is no longer able to continue intercourse with her husband and was feeling discomfort during the act. She was still breast feeding and her menstruation has not yet resumed. Surgical correction was planned after preanaesthetic fitness was approved.

In lithotomy position under spinal anaesthesia, after foley’s catheterisation, the opposed labia minor was stretched using allis forceps (Table/Fig 5)(a). The scar tissue was excised (Table/Fig 5)(b) and the labia minora was separated to visualise normal vaginal canal (Table/Fig 5)c. The wound margins were sutured with vicryl 2-0 and a vaginal toileting was done at the end of procedure. She was discharged after 3 days and the Foleys was removed. On follow-up, the perineum was found to be healthy and a normal vaginal canal was restored.

Discussion

Labial adhesions (agglutination) are quite common in prepubertal years of girls, especially during the nappy years. It's a varying length thin membrane fusion of the labia minora. It starts at the back of the fourchette and moves towards the clitoris. If the fusion is complete, the vaginal entrance is hidden. Because labial agglutination is not a developmental defect, it is not linked to any genital tract abnormalities (2). (Table/Fig 6) describes the findings of different published studies/case reports (2),(3),(4),(5),(6).

The patient may experience physical and emotional trauma as a result of manual separation (5). Case 1 and case 2 girl toddlers were calmed with the presence of her mother during the separation of labial manually. A retrospective study comparing medical treatment of oestrogen alone, betamethasone cream alone or combination of both for 2 to 4 weeks showed no significant differences among the group (6).

The GSM of menopause is characterised by symptoms involving the vulva, vagina, and lower urinary tract, which are mostly caused by a decrease in oestrogen levels as women age advances (6),(7). In the literature, conservative treatment is recommended for patients of postmenopausal age with partial labial fusion, and only if this fails surgical treatment is recommended (8),(9).

Hypoestrogenism (10), vulvar inflammation related to local infection, irritation, trauma, vaginal herpes, lichen sclerosus (8),(9), and absence of intercourse are all factors in the causation of labial agglutination. The adhesion may be partial or complete and generally moves upwards from posterior fourchette towards the clitoris. Most of the cases of postmenopausal adhesions are asymptomatic and are diagnosed during pelvic examination for other concurrent reasons (11).

Most of the cases are managed by topic oestrogen formulations. Medical treatments for genitourinary problems, such as topical steroid ointments for the treatment of vulvar lichen sclerosus or other inflammatory illnesses, may be used in combination with other drugs (12). If a patient's response to medical treatment is inadequate, or if a scarred or thick adhesion exists, surgical separation is indicated (13).

Labial adhesions after childbirth are seldom mentioned in the literature. Significant perineal swelling, according to Lin Y et al., may increase adhesion development by mechanically pressing the labia together (14). Topical oestrogen treatment cannot be suggested based on the current literature. As a first-line treatment for postpartum labial adhesions, surgical dissection under local anaesthesia should be attempted (14).

Conclusion

Labial adhesion or agglutination of varying degree occurs predominantly in prepubertal and postmenopausal age group. Topical oestrogen application is the main stay of treatment in non traumatic adhesions. In paediatric age group, suspicion of sexual assault has to be kept in mind and proper counseling of the parents to keenly observe any behavioural changes in the child has to be done. Institutional delivery of all pregnant mothers has to be strengthen and proper postpartum follow-up to include perineum care instruction and postpartum exercises.

References

1.
Gonzalez D, Anand S, Mendez M. Labial Adhesions [Internet]. Ncbi.nlm.nih.gov. 2022 [cited 20 January 2022]. Available from: https://www.ncbi.nlm.nih.gov/books/NBK470461/
2.
Bussen S, Eckert A, Schmidt U, Sütterlin M. Comparison of conservative and surgical therapy concepts for Synechia of the Labia in pre-pubertal girls. Geburtshilfe und Frauenheilkunde. 2016;76(4):390-95. doi:10.1055/s-0035-1558101 [crossref] [PubMed]
3.
Pushpawati, Singh V, Sinha S, Singh A. Labial agglutination in a pubertal girl. Journal of Clinical and Diagnostic Research. 2018;12(1):QD01-QD02. [crossref]
4.
Wakode SR, Bhat VN. Postpartum labial adhesion-a case report. Int J Reprod Contracept Obstet Gynaecol. 2021;10(6):2528-30. [crossref]
5.
Singh P, Han HC. Labial adhesions in postmenopausal women: presentation and management. Int Urogynaecol J. 2019;30(9):1429-32. doi: 10.1007/s00192-018-3821-1. Epub 2018 Nov 28. PMID: 30488271. [crossref] [PubMed]
6.
Tanvir T, Meeta M, Singh A. Complete labial fusion causing pseudo-urinary incontinence: a long-term sequelae of genitourinary syndrome. J Midlife Health. 2020;11(4):257-59. doi: 10.4103/jmh.JMH_34_20. Epub 2021 Jan 21. PMID: 33767568; PMCID: PMC7978044. [crossref] [PubMed]
7.
Eroglu E, Yip M, Oktar T, Kayiran SM, Mocan H. How should we treat prepubertal labial adhesions? Retrospective comparison of topical treatments: estrogen only, betamethasone only, and combination estrogen and betamethasone. J PaediatrAdolesc Gynaecol. 2011;24(6):389-91. [crossref] [PubMed]
8.
Girton S, Kennedy CM. Labial adhesion: a review of etiology and management. Postgrad Obstet Gynaecol. 2006;26:01-05. doi:10.1097/00256406-200612150-00001 [crossref]
9.
Kaplan F, Alvarez J, Dwyer P. Nonsurgical separation of complete labial fusion using a Hegar dilator in postmenopausal women. Int Urogynaecol J. 2015;26:297-98. https://doi.org/10.1007/s00192-014-2535-2. [crossref] [PubMed]
10.
Gandhi J, Chen A, Dagur G, Suh Y, Smith N, Cali B, et al. Genitourinary syndrome of menopause: an overview of clinical manifestations, pathophysiology, etiology, evaluation, and management. Am J Obstet Gynaecol. 2016;215:704-11. https://doi.org/10.1016/j.ajog.2016.07.045. [crossref] [PubMed]
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DOI and Others

DOI: 10.7860/JCDR/2022/51913.16325

Date of Submission: Sep 16, 2021
Date of Peer Review: Dec 14, 2021
Date of Acceptance: Feb 21, 2022
Date of Publishing: May 01, 2022

AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes

PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Sep 17, 2021
• Manual Googling: Dec 02, 2021
• iThenticate Software: Jan 10, 2022 (18%)

ETYMOLOGY: Author Origin

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