Seeing beyond the aesthetic problem of labia minora hypertrophy: a case report

A 44-year-old married woman was referred with a chief complaint of pain during sexual intercourse. She described the pain as getting “pinched” on the outer side of the vagina, especially during penetration. After vaginal penetration and during intercourse, the pain decreased but still exists. She had felt this pain since marriage (approximately 20 years) and had been getting worse for 3 months before coming to the hospital. Because of this problem, she was being avoidant of sexual intercourse, and her last sexual activity was 6 months ago. Previously, she had also felt the pain when she was wearing tight pants, riding a bicycle or motorcycle, and experiencing recurring vaginal infections since her adolescent years. She had noticed that there was something wrong with her genitalia but hesitated to seek help as she found this problem to be taboo. She also admitted that this problem had a negative impact on her marriage since she often suffered from poor genital self-image and was mocked by her spouse because of her unaesthetic appearance. The patient had just known that this problem could be treated after she mentioned it to her very close friend, then decided to check up with the doctor. No history of vaginal bleeding after sexual intercourse. She could hold urine for 3–4 h, with no urine leakage when coughing, sneezing, or laughing. Defecation regularly once a day, no history of fecal leakage, and she can control her flatulence. There was no history of previous illness or surgery before the visit. Moreover, there was no similar problem in her family. She had four children with vaginal labor; one of her children weighed 4000 grams at birth. She was in her perimenopausal phase and never experienced pain during menstruation. She used an intrauterine device for contraception for 3 years, and had no complaints regarding the usage. The Female Sexual Function Index (FSFI) score could not be determined since she has not had sexual intercourse for the past 1 month. During initial examination, her height was 152 cm, body weight of 61 kg, and body mass index of 26.4 kg/cm 2 (obesity grade I). Vital signs were within normal limits. During external genitalia examination, it was revealed that she had bilateral labia minora hypertrophy. The distance between the base and the edge of the right labia minora was 4 cm, with a width of 4 cm, while the left labia minora was 4.4 cm, with a width of 4 cm. Urethra and vaginal introitus were found normal. No signs of vulvovaginal inflammation or infection (Fig. 1 ). Her laboratory results were within normal limits, with urinalysis showing no current urinary tract infection. Figure 1. External genitalia examination. Right labia (4 cm × 4 cm) and left labia (4.4 cm × 4 cm). External genitalia examination. Right labia (4 cm × 4 cm) and left labia (4.4 cm × 4 cm). She was diagnosed with dyspareunia et causa bilateral labia minora hypertrophy, and labial reduction was done by an experienced urogynecologist, the first author, and team (Fig. 2 ). Wedge resection was chosen considering the shape of the labia, followed by subcuticular sutures with 4-0 polyglycolic. Two hours post-surgery, the visual analog scale (VAS) showed within minimum score of 2, no signs of active bleeding, nor nausea and vomiting. One day post-surgery, the VAS scale showed 1 on oral analgesics, with laboratory results post-surgery within normal limits. The patient was discharged 1 day following the surgery and was instructed to abstinence for 1 month. Figure 2. Wedge resection procedure. (A) Marking, (B) excision of the excess tissue, (C) each labia minora was reapproximated, and (D) subcuticular sutures with 4-0 polyglycolic. Wedge resection procedure. (A) Marking, (B) excision of the excess tissue, (C) each labia minora was reapproximated, and (D) subcuticular sutures with 4-0 polyglycolic. Two months after the surgery, the patient came to our clinic for a follow-up examination. She reported satisfactory of aesthetic and sexual function (FSFI-6 score of 24) (Fig. 3 ). Patient admitted no symptoms of pain, itching, or desensitized labia. Both of the labia minora showed no signs of erosion, infection with operative wound in good condition. Figure 3. (A) Initial and (B) final view. (A) Initial and (B) final view.

Dyspareunia is described as remarkable pain or tensing of the abdominal and pelvic muscles that occurs repeatedly or persistently during sexual intercourse for at least 6 months. Superficial or entry dyspareunia is pain associated with the initial penetration of the vaginal introitus, whereas deep dyspareunia is pain associated with deep vaginal penetration. Dyspareunia is a common issue in women, which remains largely untreated. Patients often hesitate to seek help albeit this problem could affect quality of life, anxiety, and depression[ 1 ]. Labia minora hypertrophy is defined as labia minora protruding beyond the labia majora. This condition may affect both or either one of the labia and cause asymmetry [ 2 , 3 ] . What was once considered an aesthetic problem could raise a concern as symptoms including pain, infection and sexual dysfunction may appear and, in some cases, surgical correction is often required[ 4 ]. HIGHLIGHTS Labial hypertrophy can cause significant functional problems, and not merely an aesthetic problem. Labiaplasty using the wedge resection technique proved effective functionally (improved sexual function with FSFI-6 score) and resulted in a satisfactory anatomical appearance without postoperative complications. Social stigma and lack of awareness are major barriers to seeking medical help. Labial hypertrophy can cause significant functional problems, and not merely an aesthetic problem. Labiaplasty using the wedge resection technique proved effective functionally (improved sexual function with FSFI-6 score) and resulted in a satisfactory anatomical appearance without postoperative complications. Social stigma and lack of awareness are major barriers to seeking medical help. Labial hypertrophy can cause significant functional problems, and not merely an aesthetic problem. Labiaplasty using the wedge resection technique proved effective functionally (improved sexual function with FSFI-6 score) and resulted in a satisfactory anatomical appearance without postoperative complications. Social stigma and lack of awareness are major barriers to seeking medical help. In this study, we would like to present an atypical case of a woman with labia minora hypertrophy causing not only an aesthetic problem but also a functional problem. This study has been reported in accordance with the SCARE 2025 guidelines[ 5 ].

According to the latest edition of The Diagnostic and Statistical Manual of Mental Disorders, dyspareunia and vaginismus are identified as genito-pelvic pain/penetration disorders characterized by pain, anxiety, or penetration problems during intercourse. Researchers have agreed that dyspareunia is caused by a complex interaction of biological and psychological factors. In addition to vaginal atrophy, endometriosis, hormonal, and other biological conditions that can cause dyspareunia, anomalies in the genital anatomy should be taken into account [ 1 , 6 ] . Labia minora hypertrophy is a rare condition and often not considered a pathological condition. A great variation regarding the size of natural labia minora has been reported; however, a cut-off point of 4 cm measured from base to edge is considered hypertrophic[ 2 ]. The etiologic factors of labia minora hypertrophy have remained unclear. Several hypotheses, including inflammation, disease-related factors, and mechanical manipulation, are contributing to the etiology of labia minora hypertrophy[ 4 ]. Myelodysplasia, lymphangioma, chronic inflammatory disease such as Crohn’s disease or endometriosis, and the use of exogenous androgenic hormones are frequently linked to labia minora hypertrophy. This primarily concludes that estrogen circulation, inflammation, and promotion of cell growth are related. Artificial elongation of the labia minora in ethnic groups has also been reported. Self-induced wounds caused by this manipulation might stimulate both local blood flow and inflammation, potentially inducing labial tissue growth in the long term[ 7 ]. Labia minora hypertrophy is not usually regarded as a malformation since it is generally harmless; therefore, labiaplasty is generally considered a cosmetic procedure. However, reported issues of pain, infection, sexual dysfunction, and psychological problems related to this condition have raised concerns that it is more than an aesthetic problem[ 4 ]. Entry dyspareunia has been reported in 43% of the patients who underwent surgical reduction of labia hypertrophy[ 2 ]. Another study reported a higher proportion, 95% of sexually active patients expressed discomfort during sexual intercourse due to this condition. Embarrassment, anxiety, poor genital self-image, and partner’s influence are the psychological aspects caused by labial hypertrophy[ 8 ]. The trouble of maintaining personal labial hygiene warrants irritation and infection problems. Furthermore, one’s quality of life might be impaired by pain or discomfort when wearing tightly fitting clothes, or when engaging in activities like riding a motorcycle or bicycle[ 4 ]. In most cases, labia minora hypertrophy only requires reassurance, but surgeries are occasionally needed. The indications for surgical treatment are varied, being the most common ones are problems with sexual intercourse, infection, difficulty in wearing tight-fitting pants, pain while performing activities such as cycling, and aesthetic complaints[ 9 ]. Wedge resection, central epithelium removal, and straight-line resection are three common techniques of labia minora reduction. The concepts of protection, symmetry, minimally invasiveneness, and adequate blood supply to the flap should be taken into account while selecting a surgical approach[ 10 ]. Studies often report the high level of satisfaction, which accounts for up to 91% improvements in the cosmetic aspect and 96% in the relief of discomfort. Immediate complications are hematoma, wound dehiscence, and infection. Careful hemostasis and postoperative hygiene could prevent such issues[ 9 ]. In this case, dyspareunia was the result of labial hypertrophy, a condition that is often overlooked initially. Another study has also reported amenorrhea associated with post-caesarean niche (isthmocele), a condition that is not usually related. These reports note the importance of broadening the physician’s knowledge of anatomical variations and their clinical consequences[ 11 ]. In our patient, labia minora hypertrophy has influenced sex life, psychological and physical aspects; thus, a surgical reduction was proposed. A wedge resection was chosen, considering the shape of the labia and the patient’s concern towards aesthetic and functional aspects. The advanced age at which the operation was carried out indicates the difficulty of patients in seeking consultation. A rare case of Herlyn–Werner–Wunderlich syndrome in Syria also highlights the potential socio-cultural burden that rare gynecological disorders may impose in relation to stigma, delayed diagnosis, and limited awareness[ 12 ].

Labia minora hypertrophy often only requires reassurance; however, a surgical reduction should be proposed if the patient has aesthetic or functional concerns. Labia minora hypertrophy can lead to functional, aesthetic, and sexual discomfort. Labial reduction is a simple surgical procedure to manage labial hypertrophy, with a high degree of patient satisfaction.