trauma More recent studies suggest that there may be etiologic factors other than estrogen insufficiency Most labial adhesions are asymptomatic and are noted by a parent at home or a physician during the child’s routine physical examination The classic physical examination finding is a flat plane of tissue marked by a central vertical line of adhesion that obstructs the view of the introitus Even when adhesions appear to have closed the vulva completely, a pinpoint opening usually remains that permits urination Some patients with labial adhesions present with symptoms such as dysuria, frequency, or refusal to void that may be a result of either the mechanical obstruction or concurrent urinary tract infection Whether associated urinary tract infections are a cause or an effect of adhesions is unclear For girls with urinary tract infections, urine cultures should be performed and appropriate medical follow-up provided Because vaginal infection is not associated with adhesions, vaginal cultures are not indicated except in patients who have concurrent vaginal discharge Treatment is not indicated for asymptomatic girls with labial adhesions because the condition spontaneously resolves early in puberty as a result of increasing endogenous estrogen For those that require therapy or if parents prefer, labial adhesions can be treated successfully with application of a small amount of estrogen cream (Premarin 0.01% or Estrace 0.01%) onto the adhesions once or twice a day for to weeks Resolution has been reported to be 50% to 89% Potential side effects include skin hyperpigmentation and breast budding; more serious complications, such as vaginal bleeding or precocious puberty, are theoretical concerns Topical betamethasone (0.05%) is an alternative management strategy with up to 68% success Labial adhesions should not be manually separated in the ED The procedure is painful and usually results in recurrence when the irritated, newly separated labia readhere Even with medical treatment recurrence rates vary from 7% to 55%, so care after separation is important Proper hygiene is recommended, as well as daily application of a bland emollient such as petroleum jelly URETHRAL PROLAPSE CLINICAL PEARLS AND PITFALLS