What is labia majora

The labia majora are are the female counterpart, or homologue of the male scrotum; that is, they derive from the same embryonic structure. The labia majora are a pair of rounded folds of skin and adipose that are part of the external female genitalia. The singular term is labium majus. Anteriorly the labia majora unite to form the mons pubis. The mons pubis overlies the inferior aspect of the pubic symphysis and is anterior to the vestibule and the clitoris. Posteriorly, the labia majora do not unite and are separated by a depression termed the posterior commissure, which overlies the position of the perineal body.

The labia majora are covered by pubic hair and contain an abundance of adipose tissue, sebaceous (oil) glands, and apocrine sudoriferous (sweat) glands.

There is a wide range of normal genitalia and the appearance varies from woman to woman. The labia majora can range in width from one fourth of an inch to 2 inches. The labia minora often extend past the labia majora, but it also is normal if they do not. Some women have labia that are uneven in size. All of these differences are normal.

Figure 1. Labia majora

Footnote: Female anatomy. A =Prepuce of clitoris. B= Glans of clitoris. C = Labia majora. D = Vestibule of vagina. E = Hymen. F= Posterior commissure of the labia. G = Labia majora. H = Vaginal orifice. I= Urethral orifice. J = Labia minora.

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Labia majora hair

Most women have the same general pattern of pubic hair—an upside-down triangle. But there can be differences in the amount and texture of pubic hair among women. Some women choose to remove some or all of their pubic hair, but there is no medical or hygienic reason to do so. Some ways for removing the hair can increase the risk of infection. Injury can occur during shaving or waxing.

Labia majora function

The labia majora function is to cover and protect the inner, more delicate and sensitive structures of the vulva, such as the labia minora, clitoris, urinary orifice, and vaginal orifice.

Labia majora surgery

Labia majora alteration is sought by women bothered by puffy, prominent majora at one extreme, and deflated, sagging majora at the other (Figure 2). Fatty fullness without skin redundancy may occasionally be effectively treated by liposuction ². Improvement is usually modest. Small diameter cannulas (<3 mm) should be used, and superficial plane maintained. Prolonged postoperative edema is common.

Women with flat majora, or deflated majora with minimal skin excess, may seek augmentation. It is easily achieved utilizing standard autologous fat grafting techniques ². Usually several grafting sessions are necessary to achieve the desired result. In general, no more than 20 cc of fat should be injected into each labium at one sitting ³. One must use caution in augmenting labia majora with significant skin redundancy, as an unacceptable degree of bulging and labial prominence may result.

Ptotic, deflated labia majora, are best treated by reduction rather than augmentation ². Surgical excision of redundant labia majora, yields consistently excellent results and high patient satisfaction. Although others suggest that excision should be from the central portion of the majora ¹ or laterally at the vulva-thigh crease ⁴. The medial incision is in the sulcus between the minora and majora, with the lateral incision in the majora. Incisions are made along the full anterior-posterior length of the majora. Cresenteric excision of the redundant width of the majora is performed. The resulting scar, located within the interlabial sulcus, is virtually imperceptible ⁵. The extent of resection should be conservative to avoid pulling the introitus/vaginal orifice open. It is therefore determined with the patient supine in maximum frog leg position. Pinching of redundant labia majora, without tension on the introitus, is done. The lateral incision line is then marked. Up to 50% of the horizontal width of the majora may be safely excised in women with marked majora ptosis or redundancy (Figure 3). Resection should always be in a superficial plane: skin and subcutaneous tissue only. The labia majora are very vascular. Absolute hemostasis prior to closure is essential to avoid hematoma formation.

Figure 2. Big labia majora

Footnote: Photograph of a 29-year-old woman with deflated, redundant labia majora.

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Figure 3. Redundant labia majora (before and after labia majora reduction surgery)

Footnote: (A) Preoperative photograph of a 35-year-old woman with redundant labia majora. (B) Postoperative photograph obtained 3 months after bilateral labia majora reduction using the described technique (note the absence of visible scars).

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In combined labiaplasty procedures, the majora should be done first. For labia minora edge excision techniques, use of a traction suture placed in the most prominent portion of the labium is helpful. Clitoral hood folds, if present, should be excised first, followed by minora excision. Resection of redundant labial tissue posterior to the introitus may occasionally be difficult with the patient in frog leg position. It can be facilitated, if necessary, by placing gauze pads between the buttocks (posterior to the anus) to separate them and increase visualization of the posterior perineum. The operating table may also be placed in a slight Trendelenburg position if further exposure is needed. I perform the procedures using number 15 scalpel blades and a needle-point electrocautery. Absolute hemostasis is essential. A single-layer closure with interrupted 4.0 Vicryl Rapide (Ethicon, Somerville NJ) in a “close as you go” fashion is advised. For wedge resection techniques, a two-layer closure is suggested to reduce incision dehiscence risk. I recommend 4.0 Monocryl (Ethicon, Somerville NJ) for the subcutaneous layer.

Labia majora excision defects are also closed in two layers: 4.0 Monocryl interrupted sutures for the deep dermis and 5.0 Prolene (Ethicon, Somerville NJ) continuous sutures for skin. The skin sutures are removed 1 week after surgery.

Aftercare is similar for both labia majora and minora procedures:

• minimal ambulation,
• ice compacts, and
• narcotic analgesia for the first 2 days and topical antibiotic ointment application and sanitary pads as dressing for 1 week.

Daily tepid showers are permitted. Routine follow-up visits occur at 1 week, 2 weeks, 4 weeks, and 12 weeks. Vicryl Rapide sutures, if still present, are removed at 2 weeks. Vaginal penetration is not permitted for 4 weeks.

Labia majora surgery complications

Labiaplasty procedures have low complication rates ⁶. Most complications are minor and self-limited. Hematoma and wound dehiscence are most commonly reported ⁷. In a recent study of 113 women undergoing labiaplasty, only one (0.8%) experienced a complication (bleeding).2 Self-limited postoperative edema, bruising, and/or pain, resolving within 2 weeks of surgery, were reported in 13.3% of patients in that study ⁶. Wound dehiscence rarely requires repair after labial edge excision, but usually must be corrected after wedge resection to avoid minora notch deformity ⁶. Under-reduction of the labia minora, or postoperative labial asymmetry, may also occur. Lista et al ⁶ reported a 3.5% revision rate for persisting labial excess. Unaddressed clitoral hood redundancy and labial remnants posterior to the introitus, as indicated earlier, may also motivate revision requests ⁸. Prolonged edema and inclusion cyst formation, as previously indicated, can complicate central deepithelialization technique procedures. Overzealous resection with partial or complete amputation of the labium, although rare, is perhaps the most dreaded complication observed. Labial edge scalloping, usually minor, can occur after edge excision techniques. Scar contractures, although reported, are very rare.

Persisting postoperative dyspareunia is extremely rare. Rouzier et al. ⁹, in a study of 163 labiaplasties, however, reported a 1.8% incidence of dyspareunia persisting greater than 1 month postoperatively.

Labia majora irritation

The labia majora and vagina can be very sensitive to many products that women commonly use. These include some soaps, shower and bath products, laundry products, panty liners and pads, and feminine hygiene washes and sprays. Over-the-counter and even prescription medications can cause labia majora or vulvar itching and burning that may feel like a vaginal infection. If you already have a vulvar or vaginal problem, using these products may make the pain or itching worse.

Women with vaginal infections or labia majora conditions often use over-the-counter products to stop itching, burning, or pain. Although for some women these products may be helpful at times, for many women they often don’t help and may worsen the pain or itching. Many over-the-counter products for vulvovaginal problems have ingredients that can cause pain or itching. The medicines women buy to treat yeast infections can cause pain or burning, especially the 1-day products. Women often scratch or rub when they feel itchy or irritated, and this makes them feel more uncomfortable. Frequent washing with soap and other cleansing products also can increase pain or itching.

What helps or prevents labia majora irritation?

Stopping the use of everything that can cause or worsen pain or itching is the first step in allowing the skin to heal. If you have a vaginal infection or labia majora skin problem, especially one that does not get better easily or keeps coming back, avoiding all things that might cause pain or itching is an important part of your care. The recommendations that follow will be helpful to women with vaginal and vulvar discomfort. They also will improve vaginal and vulvar health for all women.

Talk to your health care provider about your specific problem and recommended treatment.

Bathing and Hygiene

• Use your hands only to wash. Do not use washcloths, loofahs, puffs, and such. Pat dry after bathing.
• Use an unscented bar soap (examples: Dove, Cetaphil, Basis, Vanicream).
• Avoid bubble baths, bath salts, and scented oils.
• Use soft, white, unscented toilet paper.
• Do not use baby wipes, personal wipes, douches, sprays, perfumes, or other feminine hygiene products. These can cause pain or itching.
• Do not douche. It is not helpful or necessary and sometimes can lead to vaginal infections.
• If you have a problem cleaning aft er a bowel movement, do not rub! Try using mineral oil or an unscented liquid soap (examples: Dove, Cetaphil, Basis, Vanicream). A make up remover that contains mineral oil, petroleum jelly, and paraffin also can be used (example: Albolene moisturizing cleanser).
• Urine leaking can cause the vulva to have a rash or become painful. If this is a problem, try to avoid using pads when you are at home and rinse the vulva with plain water when you can.

During Your Periods

• Avoid wearing panty liners or pads every day. If that is not possible, try to wear them as little as possible and not when you are at home. Use unscented panty liners or pads. Avoid any panty liners or pads that say they retain moisture. Some women find that organic panty liners or pads are helpful

Clothing and Laundry

• Always use the same brand of unscented laundry detergent. Do not use bleach, liquid fabric softeners, or fabric softener sheets that you put in the dryer.
• Wear all cotton underwear, not just cotton-crotch underwear. Do not wear girdles or thongs, and try to keep underwear loose. Pantyhose also can increase moisture and heat that can worsen pain, itching, or rashes. Try knee-high or thigh-high hose.
• Do not sit in a wet bathing suit or stay in sweaty exercise clothes.
• Leaving the vulva uncovered at night (not wearing underwear) to allow the vulvar area to be open to air can be helpful.

Over-the-counter Vulvar and Vaginal Products and Medicines

• Do not use any over-the-counter products for vulvar or vaginal itching. Avoid all products that include benzocaine (examples: Vagisil, Lanacane, Vagicaine). Over-the-counter medicines for yeast infections also can cause pain or itching, especially the 1-day products.

For Comfort

• Do not scratch! Scratching and rubbing will make your symptoms worse. If you cannot stop scratching, contact your health care provider to be evaluated.
• Keep a freezer gel pack in the refrigerator; wrap the pack in a washcloth and put it against your vulva. Refrigerated petroleum jelly (Vaseline) and cold plain yogurt put on a maxi-pad and placed next to the vulva can be soothing.
• Petroleum jelly is a wonderful moisturizer to use on the vulva aft er bathing and can be used anytime for comfort. Do not use petroleum jelly with condoms—it can break down the condom so it gets holes in it.
• A lukewarm or warm bath can be soothing. Do not put any soaps, bubble bath, or oils in the water. Check with your pharmacy for a plastic sitz bath that fi ts into the toilet and use that to sit in for soaking.
• For vulvar skin that is painful from scratching, try a “soak and seal.” Soak in a lukewarm tub or use a compress for 5 to 10 minutes, pat dry, and then apply a layer of petroleum jelly. Th e water soothes the painful skin, and the petroleum jelly keeps the area moist and soft.

For Sexual Activity

• Some birth control products you can get over-the-counter (examples: foam, film, creams, sponges) cause pain or itching for some women. If this happens to you, try a different brand or talk to your health care provider about a different type of birth control.
• A lubricant may be helpful during sex, especially for women who are postmenopausal. Use an unscented lubricant (examples: KY jelly, Astroglide, Slippery Stuff ). Do not use lubricants that will heat on contact. Do not use oils or oil-based lubricants like petroleum jelly with condoms.
• Women who are postmenopausal may find that a vaginal moisturizer is helpful (example: Replens). This is not used as a lubricant when having sex but may make sex more comfortable.

Labia majora pain

Vulvodynia is chronic pain or discomfort around the opening of your vagina (vulva) for which there’s no identifiable cause and which lasts at least three months or longer. Vulvodynia is not caused by an infection, skin disorder, or other medical condition. The pain, burning or irritation associated with vulvodynia can make you so uncomfortable that sitting for long periods or having sex becomes unthinkable. The condition can last for months to years.

If you have vulvodynia, don’t let the absence of visible signs or embarrassment about discussing the symptoms keep you from seeking help. Treatment options are available to lessen your discomfort. And your doctor might be able to determine a cause for your vulvar pain, so it’s important to have an examination.

Researchers and health care providers currently know little about why and how vulvodynia occurs—the condition and the pain have no known cause or cure. Therapies can help relieve symptoms of vulvodynia, but the condition can have some serious effects on women’s reproductive health and day-to-day life.

Vulvodynia causes

Doctors don’t know what causes vulvodynia, but possible contributing factors include:

• Injury to or irritation of the nerves surrounding your vulvar region
• Past vaginal infections
• Allergies or sensitive skin
• Hormonal changes
• Muscle spasm or weakness in the pelvic floor, which supports the uterus, bladder and bowel

Vulvodynia symptoms

The main vulvodynia symptom is pain in your genital area, which can be characterized as:

• Burning
• Soreness
• Stinging
• Rawness
• Painful intercourse (dyspareunia)
• Throbbing
• Itching

Your pain might be constant or occasional. It might occur only when the sensitive area is touched (provoked). You might feel the pain in your entire vulvar area (generalized), or the pain might be localized to a certain area, such as the opening of your vagina (vestibule).

Vulvar tissue might look slightly inflamed or swollen. More often, your vulva appears normal.

A similar condition, vestibulodynia, causes pain only when pressure is applied to the area surrounding the entrance to your vagina.

Vulvodynia complications

Because it can be painful and frustrating and can keep you from wanting sex, vulvodynia can cause emotional problems. For example, fear of having sex can cause spasms in the muscles around your vagina (vaginismus). Other complications might include:

• Anxiety
• Depression
• Sleep disturbances
• Sexual dysfunction
• Altered body image
• Relationship problems
• Decreased quality of life

Vulvodynia diagnosis

Before diagnosing vulvodynia, your doctor will ask you questions about your medical, sexual and surgical history and to understand the location, nature and extent of your symptoms.

Your doctor might also perform a:

• Pelvic exam. Your doctor visually examines your external genitals and vagina for signs of infection or other causes of your symptoms. Even if there’s no visual evidence of infection, your doctor might take a sample of cells from your vagina to test for an infection, such as a yeast infection or bacterial vaginosis.
• Cotton swab test. Your doctor uses a moistened cotton swab to gently check for specific, localized areas of pain in your vulvar region.

Vulvodynia treatment

Vulvodynia treatments focus on relieving symptoms. No one treatment works for every woman. For many, a combination of treatments works best. It can take time to find the right treatments, and it can take time after starting a treatment before you notice relief.

Treatment options include:

• Medications. Steroids, tricyclic antidepressants or anticonvulsants can help lessen chronic pain. Antihistamines might reduce itching.
• Biofeedback therapy. This therapy can help reduce pain by teaching you how to relax your pelvic muscles and control how your body responds to the symptoms.
• Local anesthetics. Medications, such as lidocaine ointment, can provide temporary symptom relief. Your doctor might recommend applying lidocaine 30 minutes before sexual intercourse to reduce your discomfort. Using lidocaine ointment can cause your partner to have temporary numbness after sexual contact.
• Nerve blocks. Women who have long-standing pain that doesn’t respond to other treatments might benefit from local nerve block injections.
• Pelvic floor therapy. Many women with vulvodynia have tension in the muscles of the pelvic floor, which supports the uterus, bladder and bowel. Exercises to relax those muscles can help relieve vulvodynia pain.
• Surgery. In cases of localized vulvodynia or vestibulodynia, surgery to remove the affected skin and tissue (vestibulectomy) relieves pain in some women.

Lifestyle and home remedies

The following tips might help you manage vulvodynia symptoms:

• Try cold compresses or gel packs. Place them directly on your external genital area to ease pain and itching.
• Soak in a sitz bath. Two to three times a day, sit in comfortable, lukewarm (not hot) or cool water with Epsom salts or colloidal oatmeal for five to 10 minutes.
• Avoid tightfitting pantyhose and nylon underwear. Tight clothing restricts airflow to your genital area, often leading to increased temperature and moisture that can cause irritation. Wear white, cotton underwear to increase ventilation and dryness. Try sleeping without underwear at night.
• Avoid hot tubs and soaking in hot baths. Spending time in hot water can cause discomfort and itching.
• Don’t use deodorant tampons or pads. The deodorant can be irritating. If pads are irritating, switch to 100 percent cotton pads.
• Avoid activities that put pressure on your vulva, such as biking or horseback riding.
• Wash gently. Scrubbing the affected area harshly or washing too often can increase irritation. Instead, use plain water to gently clean your vulva with your hand and pat the area dry. After bathing, apply a preservative-free emollient, such as plain petroleum jelly, to create a protective barrier.
• Use lubricants. If you’re sexually active, apply a lubricant before having sex. Don’t use products that contain alcohol, flavor, or warming or cooling agents.

Alternative medicine

Stress tends to worsen vulvodynia and having vulvodynia increases stress. Although there’s little evidence that alternative techniques work, some women get some relief from yoga, meditation, massage and other stress reducers.

Coping and support

You might find talking to other women who have vulvodynia helpful because it can provide information and make you feel less alone. If you don’t want to join a support group, your doctor might be able to recommend a counselor in your area who has experience helping women cope with vulvodynia.

Sex therapy or couples therapy might help you and your partner cope with vulvodynia’s affect on your relationship.

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