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Labia minora hypertrophy

Labia minora hypertrophy
Literature review current through: Jan 2024.
This topic last updated: Jan 25, 2022.

INTRODUCTION — Adolescent and adult females are increasingly seeking medical and surgical attention due to concerns regarding the appearance of their external genitalia. One particular area of concern is the size and shape of the labia minora, although variations in both are consistent with normal anatomy. Clinical labia minora hypertrophy remains poorly defined, and consensus regarding criteria for surgical intervention have yet to be formally established. Interest in surgical correction of vulvar appearance may be associated with trends in pubic hair removal, exposure to idealized images of genital anatomy through digital applications or websites, social media, and growing awareness of cosmetic vaginal surgery [1-5].

The clinical manifestations, diagnosis, and treatment of hypertrophy of the labia minora will be reviewed here. Congenital anomalies of the reproductive tract and vulvovaginal discomfort syndromes are discussed separately. (See "Congenital anomalies of the hymen and vagina" and "Benign cervical lesions and congenital anomalies of the cervix" and "Congenital uterine anomalies: Clinical manifestations and diagnosis" and "Vulvar pain of unknown cause (vulvodynia): Clinical manifestations and diagnosis".)

CLINICAL FEATURES — Labia minora hypertrophy is a largely subjective condition. This issue is usually brought to medical attention due to vulvar discomfort, functional symptoms (interference with activities), or concern about vulvar appearance. Discussion with the patient about symptoms and a physical examination help to guide management.

Medical history

Symptoms — Hypertrophy of one or both labia minora can result in irritation, chronic infection, poor hygiene, or pain. In addition, the patient may complain that the labia interfere with activities including walking or sitting, sexual activity, and/or sports (eg, running, cycling, horseback riding, or swimming). Patients may describe discomfort with the fact that there is a "bulge" in their underwear. They may report that they need to "fold up" the labia and push them into the vagina to reduce the bulge.

Concerns about the appearance of the labia minora can result in considerable emotional and psychological distress [6-13]. Given the physical and emotional changes that accompany puberty, adolescents are a particularly vulnerable group. For example, adolescents may become very self-conscious about the size of the labia if they need to change their clothes in the presence of their peers [6-10,13,14]. It is also important to make sure that it is the adolescent who is distressed, not anyone else (eg, parents/caregivers, peers, sexual partner).

Psychological screening — The American College of Obstetricians and Gynecologists and the North American Society for Pediatric and Adolescent Gynecology advise that adolescents seeking labial surgery should be screened for body dysmorphic disorder and referred to a mental health professional if appropriate [1]. In one study, 9 of 49 patients who underwent labiaplasty met criteria for body dysmorphic disorder [15]. A screening questionnaire is shown in the table (table 1). (See "Body dysmorphic disorder: Assessment, diagnosis, and differential diagnosis".)

Physical examination — A systematic approach is utilized for the gynecologic examination. It is helpful for the clinician to be experienced with the pelvic examination and the normal variants of the external female genitalia.

The external genitalia are inspected (figure 1). The hair distribution, skin, labia major and minora, clitoris, urethral meatus, introitus, perineal body, and anus are evaluated. In particular, the labia minora should be fully extended laterally, inspected for asymmetry, and measured from the midline to the lateral free edge (picture 1).

The gynecologic examination is described in detail separately. (See "The gynecologic history and pelvic examination" and "Congenital anomalies of the hymen and vagina" and "Gynecologic examination of the newborn and child", section on 'History and physical examination'.)

Labial width — Labia minora hypertrophy is generally described as protuberant labial tissue that projects beyond the labia majora. However, there is no consensus among gynecologists, pediatricians, or plastic surgeons regarding the use of objective clinical measurements to confirm the diagnosis.

To evaluate the labia minora for hypertrophy, the labia should be gently extended to their full width in the medial-lateral axis (picture 1). The measurement of this width is the "stretch width."

In an early description of this condition, Friedrich classified labia minora as hypertrophic when the maximal width between the midline and the lateral free edge of the labia minora (when the labia were extended laterally by the examiner) measured greater than 5 cm [16]. Others have proposed that the width of the labia minora should be less than 3 to 4 cm [6,7]. In current practice, a stretch width of greater than 6 cm is generally felt to be consistent with hypertrophy.

On the other hand, some have argued that patients should be offered surgical correction if they present with persistent symptoms, regardless of measurements [7].

DIAGNOSIS — The diagnosis of labia minora hypertrophy is a clinical one. In general, the diagnosis is based on the presence of symptoms that interfere with daily activities and/or distress associated with labia minora that are within the size range considered hypertrophic.

There are no standard diagnostic criteria for labia minora hypertrophy. Clinicians generally use labial width (measurement of medial-lateral axis of the labia minora when gently stretched to full width) measurements. Although there are no "standards" for normal labial width, there can be a wide variation in "normal" [17]. A stretch width of greater than 6 cm is generally felt to be consistent with hypertrophy.

MANAGEMENT — The initial approach to management is patient counseling and self-care instruction. If symptoms persist after extensive counseling and instruction in vulvar care, then surgical correction may be offered. Patients should be aware that surgical correction may result in scarring and potentially lead to chronic vulvar pain and dyspareunia, although complications are rare [6,18]. In addition, surgery is considered elective and cosmetic results vary.

Counseling — Most often, concerns regarding labial asymmetry or hypertrophy can be alleviated through reassurance that variation in size and shape is a variant of normal anatomy [19,20]. Some patients may have seen photos of modified vulvas on the internet, and this may impact their perception of normal anatomy [21]. An excellent website for patients to be able to observe the variation of normal can be found at the "Large Labia Project," which has self-taken images submitted by females around the world [22].

As noted above, the patient should be screened for body dysmorphic disorder and referred for treatment, if appropriate (table 1). (See 'Psychological screening' above.)

Managing functional symptoms — Functional symptoms can often be conservatively managed through counseling about vulvar hygiene (eg, use of mild soaps, avoiding irritants, use of "natural" sanitary pads that do not contains chemicals) and avoidance of form-fitting clothing, especially thongs or tight-fitting underwear (table 2). (See 'Medical history' above and "Vulvar dermatitis", section on 'General measures'.)

Labiaplasty — The goal of labiaplasty is resection of the hypertrophic tissue and creation of symmetrically reduced labia while improving functional concerns [23-25]. Surgical correction of labia minora hypertrophy is reserved for patients who have persistent symptoms despite counseling and vulvar care instruction and who have been screened and found not to have body dysmorphic disorder. The procedure can be safely performed under local anesthesia, moderate procedural sedation, or general anesthesia; in our practice, we perform the procedure under general anesthesia.

This procedure may be considered in adolescents younger than 18 years, if medically indicated. Clinicians should be aware of local and federal criminal laws. Surgical alteration of the labia in minors that is not deemed medically necessary may be considered "female genital mutilation" under federal law in the United States [26]. The emotional maturity level of the patient should also be evaluated when determining the appropriate age for a surgical procedure. Decisions regarding surgical treatment of adolescents require involvement of a parent or guardian. (See "Consent in adolescent health care" and "Female genital cutting", section on 'Reinfibulation'.)

Prior to surgical incision, the labia are gently extended laterally so that the area can be marked; care should be taken not to overstretch the tissue as this can result in excess removal and overreduction.

Several surgical techniques have been described [18,24]. The main techniques are:

A curvilinear excisional or straight line procedure using an anterior-posterior incision of the protuberant labial tissue and oversewing of the incised edge (picture 2) [27]. This is the simplest technique and our usual procedure of choice. We typically use an interrupted suture of 4-0 Vicryl or 4-0 Monocryl.

In our practice, we use the curvilinear technique because it has the fastest recovery and is usually associated with excellent results. It should be noted, however, that the labial edges may be replaced with scarred suture lines that cause chronic irritation and discomfort. Furthermore, the natural contour of the labia minora may be compromised. Of note, if this technique is used, great care should be taken to avoid the area of the clitoris, clitoral hood, and frenulum (and the dorsal nerves which innervate this area).

Several other techniques have been described that attempt to preserve the natural contour of the labia minora and reduce the amount of exposed scar tissue. These alternative techniques involve a wedge resection with subsequent reanastomosis. While maintaining symmetry, a V-shaped segment is carefully resected. The raw edges are reapproximated using interrupted or a running subcuticular fine absorbable suture (picture 3) [6,7,9,28]. If we use this technique, we typically use an interrupted suture of 3-0 Vicryl. A modification of the wedge resection is the addition of a 90 degree Z-plasty, which spreads the tension over the suture line and reduces the risk of wound dehiscence [29]. In one case series, labiaplasty was performed using an Nd:YAG laser [30].

A disadvantage of the V-shaped excision technique, in our experience, is that there are cases in which there is extensive prolonged swelling, most likely from an adverse effect on lymphatic drainage.

There is no consensus on the optimal surgical technique given the lack of comparative and long-term follow-up data [31]. In a survey of surgeons who perform labiaplasties, the most commonly performed technique was the curved linear resection (53 percent) followed by the central wedge resection (36 percent) [32].

Complications — Potential complications of labiaplasty include infection, bleeding, and wound dehiscence [33]. There are few data regarding the rate of complications following labiaplasty. In two large case series (n = 407 and 451), reoperation rates were 2.9 and 7.1 percent, respectively; indications for reoperation were wound dehiscence or dissatisfaction with appearance [34,35].

Postoperative care — Postoperatively, the patient should keep the area clean and dry, avoid strenuous activity, wear loose clothing, and protect the vulvar area from friction for 7 to 14 days. An athletic support cup may be worn inside the patient's underwear to reduce the risk of friction and disruption of the suture line [28]. However, in our experience, use of a support cup postoperatively may result in a slower recovery and a higher chance of suture wound breakdown, although no long-term follow-up studies have been published.

Outcome — Labiaplasty is a simple surgical procedure that can be associated with a high degree of patient satisfaction and improved self-esteem. There are few studies of labiaplasty outcomes; representative studies include:

In one labiaplasty case series (n = 163), the majority of patients underwent bilateral surgical correction using a V-shaped wedge resection technique [6]. The most common motives for surgical correction were aesthetic complaints, discomfort with certain types of clothing, entry dyspareunia, and difficulty participating in athletic activities. Most patients reported relief of discomfort (96 percent) and aesthetic improvement (91 percent). There were no major perioperative complications. Minor complications were temporary (median duration 28 days) and included postoperative discomfort (45 percent) and entry dyspareunia (23 percent). Eleven patients (7 percent) underwent a second procedure because of small wound dehiscences, which compromised the aesthetic result.

In a prospective study of 26 patients who underwent labiaplasty, most reported functional success (much to very much improved: 54 percent versus no change: 12 percent) [15]. Improvement on a genital appearance satisfaction scale was found in 96 percent (24 of 25) at three months. At 11 to 42 months, 91 percent had improvement on the genital appearance scale and 26 percent reported adverse effects (eg, aesthetic concerns, discomfort, urinary spraying, or reduced sexual arousal).

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Gynecologic surgery".)

INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)

Basics topic (see "Patient education: Dyspareunia (painful sex) (The Basics)")

SUMMARY AND RECOMMENDATIONS

Labia minora hypertrophy is generally described as protuberant labial tissue that projects beyond the labia majora. It is usually a variant of normal anatomy. (See 'Clinical features' above.)

There are no standard diagnostic criteria for labia minora hypertrophy. Clinicians generally use labial width measurement and presence of symptoms to make treatment decisions. (See 'Clinical features' above.)

Common symptoms include irritation, chronic infection, pain, and interference with sexual activity or sports. In addition, concerns about aesthetic appearance can result in considerable psychological and emotional distress. (See 'Clinical features' above.)

Adolescent and adult females seeking labiaplasty should be screened for body dysmorphic disorder (table 1). (See 'Psychological screening' above.)

Adolescent and adult females with absent or mild symptoms from labia minora hypertrophy can often be managed with reassurance or counseling regarding personal hygiene and avoidance of form-fitting clothing. (See 'Counseling' above.)

Surgical correction of labia minora hypertrophy is reserved for patients who have persistent symptoms despite counseling and vulvar care instruction and who have been screened and found not to have body dysmorphic disorder. Surgical correction may lead to scarring, chronic vulvar pain, and dyspareunia. In addition, surgery is elective and cosmetic results vary. (See 'Labiaplasty' above.)

The emotional maturity level of the patient should also be evaluated when determining the appropriate age for a surgical procedure. Decisions regarding surgical treatment of adolescents require involvement of a parent or guardian. In some settings, there are laws regarding genital surgery in adolescents. (See 'Labiaplasty' above and "Consent in adolescent health care".)

In adolescent and adult females with labia minora hypertrophy who undergo labiaplasty, we suggest a curvilinear excisional procedure with an anterior-posterior incision (Grade 2C). A V-shaped wedge resection is also a reasonable option. (See 'Labiaplasty' above.)

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