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The Impact of FGM on the Genitourinary System: a 2021 Perspective

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The Impact of FGM on the Genitourinary System: a 2021 Perspective FEATURE The impact of FGM on the genitourinary system: a 2021 perspective BY MAYI GNOFAM AND COMFORT MOMOH wareness of female genital 200 million and every year an estimated Female genital mutilation leads to severe mutilation (FGM) in European three million girls are at risk of undergoing medical and psychological complications, countries has increased over recent the procedure. The majority of cases are and in some instances places the individual’s Adecades as a result of globalisation concentrated in the western, eastern life at risk. Apart from the life-long health- and migration of populations. The World and north-eastern regions of Africa related, ethical, moral and psychological Health Organization (WHO) describes FGM and also some countries in the Middle consequences of FGM, it has been estimated as procedures that involve partial or total East and Asia [2]. by the World Health Organization that the removal of the external female genitalia, or The reasons for performing female genital obstetric and other health-related costs are other injury to the female genital organs for mutilations vary from one region to another significant [7]. non-medical reasons. There is no medical as well as over time. Commonly cited In this review we outline some of indication for this practice, and it represents reasons are: a rite of passage to prepare a the health-related ramifications of a human rights violation, an extreme form girl for adulthood and marriage, to ensure FGM and aim to focus on aspects that of gender discrimination and child abuse premarital virginity and marital fidelity, urologists may encounter. [1]; it is illegal in the United Kingdom and to reduce a woman’s libido in order to many other countries. It has profound and prevent extramarital relationships, cultural Female genital mutilation: lifelong repercussions which include physical ideas of feminity and modesty, or a belief health consequences disfigurement, psychological trauma, that the clitoris could cause a newborn’s From a health perspective, female pain, and reproductive and urinary tract death if its head is in contact with it [3]. In genital mutilation is a major problem complications. some places community leaders, religious because of both immediate and long-term leaders, and even medical personnel uphold complications that arise from it and the Four types of female genital mutilation such beliefs [4]. need for surgical intervention; these have are described by WHO: FGM is more often undertaken been well documented in the literature. individually, but may occur in groups, and From a societal perspective, a history Type I– known as clitoridectomy, consists often accompanied by a ceremony which of partial or total removal of the clitoris: of female genital mutilation is commonly involves music, food and gifts where only associated with high rates of co-occurring Ia: removal of the clitoral hood women are allowed to be present. In the abuses such as domestic violence, or prepuce only, vast majority of instances there is no sterile forced marriage, child marriage, rape Ib: removal of the clitoris with the prepuce. environment, and analgesia and surgical and torture [7]. Type II – known as excision, consists instruments are not available. Instruments Immediate complications include soft of partial or total removal of the used include knives, clippers, scissors or tissue infections with staphylococcus and clitoris and the labia minora, with or hot objects. The same instrument is used other organisms, septic shock, tetanus without labia majora: on several women. The healing process (several documented cases), haemorrhage, IIa: removal of the labia minora only, is aided by application of ointments severe pain, and death [3,5,8-11]. The IIb: partial or total removal of the clitoris and made from herbs, milk, ashes, sugar or method in which the FGM was carried out the labia minora, animal excrement, which is thought to may determine the extent of the short-term facilitate healing. complications. Limited access to healthcare IIc: partial or total removal of the clitoris, the Despite global and regional attempts at labia minora and the labia majora. in low income economies increases the ending this practice by making it unlawful mortality. Although data on mortality of Type III – known as infibulation, consists and other interventions, the custom has girls who have undergone FGM is difficult of narrowing the vaginal opening by persisted, and the multifaceted dynamic to procure, it is thought that 1 in every 500 cutting and sewing the labia majora and / or the labia minora with or without of its societal roots has made eradication female circumcisions results in death. clitoridectomy: of FGM difficult. Although the annual Numerous delayed and long-term prevalence appears to be reducing, this complications are known to occur. IIIa: removal and apposition of practice continues to spread across the Psychological sequelae include sleep the labia minora, world with migrations of communities that disorders, sexual dysfunction, depression, IIIb: removal and apposition of practice FGM. Consequently, a substantial post-traumatic stress disorder (PTSD) the labia majora. number of women affected by FGM live and other psychological or psychiatric Type IV – Refers to any other harmful in countries such as the United Kingdom, complications [12-14]. procedure to the female genitalia, non- France, USA and Canada. It is a public health Long-term infectious complications required by medical purpose. concern that requires cultural competence include tetanus, human immunodeficiency to address, and in developed countries virus (HIV), chlamydia trachomatis, The WHO estimates that the prevalence limited understanding of the cultural, herpes simplex virus and other sexually of women who have undergone female religious and societal dynamics has made it transmitted diseases [3,15]. Continued genital mutilation worldwide is more than difficult to deal with the practice [5,6]. bacterial soft tissue infections can be urology news | MARCH/APRIL 2021 | VOL 25 NO 3 | www.urologynews.uk.com FEATURE responsible for septicaemia which can a very narrow introitus and / or meatal / lead to death. urethral scarring. A common consequence is the formation Vesicovaginal fistula (VVF) after childbirth of keloids and disfiguring scars such as occurs from ischaemic necrosis of the synechiae or dermoid cysts which can be a vesicovaginal septum as a consequence source of anxiety and shame to the woman of prolonged second stage of labour in who has had FGM. Neuromas may develop women who have suffered FGM type III or from entrapped nerves within scar tissue any type of FGM – complicated by vulvar which is a source of severe pain especially synechiae. The association between VVF during intercourse. First sexual intercourse and FGM remains debated in the absence can only take place after gradual and painful of good quality evidence, and some studies dilation or cutting of the opening left have found no significant difference in after mutilation. the incidence of VVF in women with Gynaecological complications include and without genital mutilation [25]. The cysts, haematocolpos and other menstrual occurrence of obstetric fistulae reflects problems, chronic pain, infertility, fistula the lack of access to safe and good quality and stenosis [3,12,15,16]. obstetric care. Sexual dysfunction is common, typically As this practice is illegal in many with dyspareunia, vaginismus, anorgasmia, countries where FGM continues to and other symptoms [12,15-17]. occur, complications are underreported, Childbirth for infibulated women especially in children. Victims of FGM presents the greatest challenge and is are also likely to be taken to a healthcare associated with high maternal mortality facility for treatment. In some countries, health insurance may not cover such rates and complications during labour with conditions, or the lack of affordability by poor obstetric outcomes. These women the individuals concerned adds further are at higher risk of prolonged labour, barriers to treatment. severe perineal tears and fistulae. There is reported significant impact on the quality of an increased incidence of episiotomy and life from LUTS in 63% of the sample [22]. Management strategy caesarean section in these women [15,17]. A Urinary tract infections occur early and The range of urological complications recent large retrospective study suggested may persist [12,15,16,20]. As described caused by FGM requires specialist that women who underwent infibulation above, the mutilation procedure often knowledge of FGM and its consequences, may have a significant higher risk of occurs in non-sterile environments using and a detailed appreciation of the eclampsia, but the mechanisms of such an contaminated and reused instruments anatomical aspects of reconstruction. association are unknown [18]. and is followed by application of various The multifaceted psychological and ointments and pastes. This frequently Urological aspects physical issues demand a multidisciplinary leads to infection immediately after. approach to the management, with Reports suggest urological complications Subsequently, the disfigured anatomy close collaboration between the are estimated to occur in at least a third may enable a change in the vaginal urologist, gynaecologist, microbiologist, of all female genital mutilation cases [19]. microbiota and long-term colonisation of and therapists who specialise in the A three-year cross-sectional study from the genitourinary
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