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 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 , 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 , 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

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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 , 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 system. Bladder outflow psychological and emotional aspects Egypt which was conducted from 2009 obstruction from urethral scarring hinders of PTSD. An independent interpreter to 2012 compared a group of 251 women effective flushing out of organisms from may be required. A careful evaluation who underwent female genital mutilation the bladder. A study from Sudan reported aiming to characterise the nature of to a 181 female control group and found commencement of recurrent urinary tract the injuries enables counselling and a significantly higher prevalence of lower infections from a very young age; girls below treatment planning. urinary tract symptoms (LUTS) in the FGM seven-years-old with a history of FGM Even in an emergency situation a arm [21]. Reported LUTS include storage, had a significantly higher risk of UTI with sensitive approach is essential because voiding and post-micturition symptoms. dysuria, spraying of the urinary stream and cultural influences are strong and FGM may Storage symptoms include, in order incomplete bladder emptying [21]. Lower be a taboo issue, in addition to the issues of frequency of occurrence: increased urinary tract obstruction is most often related to psychological and psychosexual frequency of micturition, nocturia, urgency, caused by FGM type II and III [22]. effects of FGM. It is important to establish a mixed urinary incontinence, urgency urinary Urinary stasis predisposes these girls relationship so that counselling and advice incontinence, stress urinary incontinence, to stone formation which may remain are effective. voiding symptoms of intermittency, asymptomatic or have upper tract sequelae Urinary tract infections are common terminal dribbling, straining and slow such as ureteric obstruction presenting with in women following FGM and may stream, and post micturition symptoms renal colic, and renal failure [23]. be associated with bladder outflow such as a feeling of incomplete emptying Urinary retention is mostly an immediate obstruction from scarring of the introitus and most-micturition dribbling. Symptoms complication of female genital mutilation and urethra. Every effort should be made depended on the type of FGM, with the [24] and can either be a consequence of pain to establish a microbiological diagnosis, highest odds ratio for FGM type III. or bladder outlet obstruction from FGM and investigations should be directed at An anonymised survey of 30 women type III. Urethral strictures may occur from identification and correction of bladder between the ages of 24 and 40 years living damage to the urethra. The urethral meatus outlet obstruction. Investigations required in the United States and who underwent may be difficult to locate for catheterisation may include a post-micturition scan, female genital mutilation early in life when this is indicated, consequent to either ultrasound for imaging of the renal tract,

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followed by targeted investigations such Conclusion 17. Lurie JM, Weidman A, Huynh S, et al. Painful gynecologic as cystourethroscopy, urethrograms and obstetric complications of female genital Urologists need to be aware of the mutilation/cutting: A systematic review and meta- or uroflowmetry. specific and complex issues related to analysis. PLoS Med 2020;17(3):e1003088. FGM is commonly associated with long- female genital mutilation. This is a global 18. Bellizzi S, Say L, Rashidian A, et al. Is female genital term infections which include blood borne health problem and is not uncommonly mutilation associated with eclampsia? Evidence from infections such as HIV and hepatitis B and C, a nationally representative survey data. Reprod Health encountered in the United Kingdom. 2020;17(1):68. vaginal infections, and chronic genital Women who have had FGM are more 19. Pycha A, Pycha A, Ladurner C, et al. Urological abscesses. Systematic evaluation with likely to be from economically deprived sequelae of female genital mutilation. Urol Ausg A microbiology guidance is important. backgrounds and have complex social, 2018;57(10):1214-20. Management of urinary retention religious and societal issues. Careful and 20. Dehghankhalili M, Fallahi S, Mahmudi F, et al. requiring catheterisation may pose Epidemiology, Regional Characteristics, Knowledge, and sensitive evaluation should be followed by Attitude Toward Female Genital Mutilation/Cutting in difficulties in the presence of a sealed vulva, counselling and education on interventions Southern Iran. J Sex Med 2015;12(7):1577-83. such as is frequently encountered in women that aim to prevent future complications. 21. Almroth L, Bedri H, El Musharaf S, et al. Urogenital who have had FGM type III / infibulation. In some countries, healthcare systems Complications among Girls with Genital Mutilation: A These women may be found to have a small Hospital-Based Study in Khartoum. Afr J Reprod Health and insurance providers do not recognise 2005;9(2):118-24. scarred vaginal opening or ‘pin-hole orifice’. defibulation and clitoral reconstruction 22. Okwudili OA, Chukwudi OR. Urinary and Genital Tract In situations where the usual techniques as therapeutic procedures and classify Obstruction as a Complication of Female Genital prove impossible, an alternative technique them as cosmetic surgery, which creates Mutilation: Case Report and Literature Review. J Surg Tech Case Rep 2012;4(1):64-6. known as the retraction technique has been barriers to treatment. There remains a lack described [26] which involves exposure of 23. Nour NM. Urinary Calculus Associated With Female of data on the urological outcomes of FGM Genital Cutting. Obstet Gynecol 2006;107(2):521-3. the urethral meatus with a Langenbeck reversal surgery, and prospective studies are 24. Rouzi AA, Sahly N, Alhachim E, Abduljabbar H. Type retractor or a Sims speculum placed urgently required for this. I Female Genital Mutilation: A Cause of Completely underneath the FGM scar and upward and Closed . J Sex Med 2014;11(9):2351-3. outward traction to expose the external 25. Browning A, Allsworth JE, Wall LL. The relationship urethral meatus. Failing this, emergency References between female genital cutting and obstetric fistulae. 1. Momoh C. Female genital mutilation challenges for Obstet Gynecol 2010;115(3):578-83. defibulation may be required. professionals. Eur Urol Today 2016:38. 26. Rouzi AA, Sahly N, Bahkali N, Abduljabbar H. Retraction Defibulation refers to the surgical 2. World Health Organization. Classification des mutilations technique for urinary catheterization of women with reopening of the vulva. This may be sexuelles féminines. female genital mutilation. Eur J Obstet Gynecol Reprod required for access to the urethra, or prior 3. Oa A. Final Report on Position of Female Circumcision in Biol 2013;169(2):296-8. to childbirth if not already done prior Nigeria. News - Women’s International Network. 1981. 27. Collinet P, Sabban F, Lucot J-P, et al. Prise en charge des 4. Ali C, Strøm A. “It is important to know that before, mutilations génitales féminines de type III. J Gynécologie to intercourse. Also known as Gabbar’s there was no lawalawa.” Working to stop female Obstétrique Biol Reprod 2004;33(8):720-4. defibulation surgery, this may be performed genital mutilation in Tanzania. Reprod Health Matters. 28. Effa E, Ojo O, Ihesie A, Meremikwu MM. Deinfibulation under local anaesthesia and has been 2012;20(40):69-75. for treating urologic complications of type III female reported to improve urinary symptoms [27]. 5. Vella M, Argo A, Costanzo A, et al. Female genital genital mutilation: A systematic review. Int J Gynecol mutilations: genito-urinary complications and ethical- Obstet 2017;136(S1):30-3. Defibulation should be scheduled soon after legal aspects. Urologia 2015;82(3):151-9. 29. Duncan D. Intermittent self-catheterisation for diagnosis to avoid emergency surgery. An 6. Retzlaff C. Female genital mutilation: not just over there. urolgical problems caused by FGM. Br J Nurs alternative is the use of a CO2 laser which J Int Assoc Physicians AIDS Care 1999;5(5):28-37. 2016;25(18):S26-S31. has been found to be particularly effective 7. Wikholm K, Mishori R, Ottenheimer D, et al. Female 30. Nour NM, Michels KB, Bryant AE. Defibulation to treat for the commonly encountered epidermal Genital Mutilation/Cutting as Grounds for Asylum female genital cutting: effect on symptoms and sexual Requests in the US: An Analysis of More than 100 Cases. function. Obstet Gynecol 2006;108(1):55-60. inclusion cyst [10]. There is however little J Immigr Minor Health 2020;22(4):675-81. 31. Foldes P. Reconstructive plastic surgery of the clitoris or no data on the urological outcomes of 8. Knight R, Hotchin A, Bayly C, Grover S. Female genital after sexual mutilation. Progres En Urol 2004;14(1):47-50. defibulation [28]. Urethral strictures have mutilation--experience of The Royal Women’s Hospital, been successfully managed by the use of Melbourne. Aust N Z J Obstet Gynaecol 1999;39(1):50-4. clean intermittent self-catheterisation [29]. 9. Barstow DG. Female genital mutilation: the penultimate gender abuse. Child Abuse Negl 1999;23(5):501-10. AUTHORS There is hardly any data on the outcomes of 10. Penna C, Fallani MG, Fambrini M, et al. Type III female urethral reconstructive surgery after FGM genital mutilation: clinical implications and treatment [30]. In this case, defibulation is also the by carbon dioxide laser surgery. Am J Obstet Gynecol cornerstone of the management but other 2002;187(6):1550-4. specific procedures may be considered 11. Toubia N. Female Circumcision as a Public Health Issue. Mayi Gnofam, NEJM 1994;331(11):712-6. (urethral dilatation or urethroplasty). 12. Andro A, Cambois E, Lesclingand M. Long-term Consultant in Obstetrics and Gynaecology, Centre Surgical management of FGM may involve consequences of female genital mutilation in a Hospitalier Intercommunal European context: Self perceived health of FGM clitoral reconstruction as described by Le Raincy-Montfermeil, women compared to non-FGM women. Soc Sci Med Foldes [31]. This team from France reported Montfermeil, France. 2014;106:177-84. reduction in pain and restoration of sexual 13. Behrendt A, Moritz S. Posttraumatic stress disorder and function in a series of nearly 3000 women memory problems after female genital mutilation. Am J with limited results, depending on the extent Psychiatry 2005;162(5):1000-2. Comfort Momoh, MBE 14. Utz-Billing I, Kentenich H. Female genital mutilation: an (WHO type) of mutilation. Less than a third FGM / Public Health injury, physical and mental harm. J Psychosom Obstet (29%) of the women returned for follow-up Specialist, Global Comfort, Gynecol 2008;29(4):225-9. London, UK. at one year. The authors report restoration 15. Berg RC, Underland V, Odgaard-Jensen J, et al. Effects of dignity and wellbeing of the women of female genital cutting on physical health outcomes: Declaration of competing a systematic review and meta-analysis. BMJ Open concerned. Surgery is however difficult in the interests: None declared presence of scarred or removed tissue and 2014;4(11):e006316. 16. Berg RC, Underland V. Gynecological Consequences the reported outcomes of this case series Acknowledegment: of Female Genital Mutilation/Cutting (FGM/C). Report Figures courtesy of -Rainbo. have been challenged in a letter to the editor from Norwegian Knowledge Centre for the Health Services in the same issue of The Lancet. (NOKC) No. 11-2014.

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