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Surgical treatment of complication of female genital mutilation in Pikine Hospital, Senegal.

Abstract

We share our experience on reconstructive for surgery female genital mutilation. This is a retrospective study of all cases of female genital mutilation surgery performed in Pikine National Hospital. We have reviewed the various indications and surgical techniques used. We collected 8 cases of clitoral cyst and 6 cases of closed vaginal opening. The surgery of clitoral cysts was to perform cystectomy followed by nymphoplasty. The closing of the vaginal opening required defibulation together with clitoroplasty according to the wishes of the patient. The anatomical and functional outcomes were satisfactory. Female genital mutilation surgery requires a good knowledge of vulvar anatomy. The various surgical indications must meet the expectations of patients to guarantee their satisfaction. (Afr J Reprod Health 2017; 21[1]: 122-125).

Keywords: Female Genital Mutilation, Complications, Defibulation, Clitoroplasty, Cystectomy

Resume

Nous partageons ici notre experience en chirurgie reconstructive pour les mutilations genitales feminines. Il s'agit d'une etude retrospective de tous les cas de chirurgie de mutilation genitale feminine realises a l'Hopital national de Pikine. Nous avons examine les differentes indications et techniques chirurgicales utilisees. Nous avons recueilli 8 cas de kyste clitoridien et 6 cas d'ouverture vaginale fermee. La chirurgie des kystes du clitoris etait d'effectuee avant de faire une cystectomie suivie d'une nymphoplastie. La fermeture de l'ouverture vaginale necessitait une defibulation avec une clitoroplastie selon les souhaits de la patiente. Les resultats anatomiques et fonctionnels etaient satisfaisants. La chirurgie des mutilations genitales feminines exige une bonne connaissance de l'anatomie vulvaire. Les differentes indications chirurgicales doivent repondre aux attentes des patientes pour garantir leur satisfaction. (Afr J Reprod Health 2017; 21[1]: 122-125).

Mots-cles: Mutilation genitale feminine, Complications, defibulation, clitoroplasty, cystectomie

Introduction

Female genital mutilation (FGM) is still very common despite being banned in many countries. In Senegal, according to UNICEF, FGM affects 26% of women aged 15 to 49 years (1-2). Like the African continent, the prevalence of FGM in Senegal varies according to place of residence and ethnicity. The proportions of circumcised girls are higher in rural areas (34%) than in urban areas (22%), and most ethnic groups concerned by these practices are the Mandingo (82%), Soninke (65%), Pular (65%) and Diola (52%). The practice remains insignificant among Serere (2%) and Wolof (0.9%) (1). FGM sometimes cause complications the treatment of which is primarily surgical; i.e. partial closure of the vaginal orifice and clitoral cysts. We report our experience on how to surgically deal with these complications. We compiled information relating to the patients admitted in our care unit for FGM complications requiring surgery. Patients who did not want surgery and those who did not require it were not enrolled in the study. We collected 8 cases of clitoral cyst and 6 cases of closed vaginal opening. The different indications and the operative techniques performed were reviewed.

Cases report

The average age of patients was 23.2 years (14-38 years). They were all from the Pular or Mandingo ethnic groups who generally carry out such practices in Senegal. Eight cases out of the fourteen were married. Three cases were discovered due to failure in intercourse attempt on wedding night. There was type 2 FGM in 69% of patients, and type 3 in 28.5% of cases (Table 1). All these women were submitted to the practice during childhood. The timeline for the development of the cyst was variable (10 to 20 years), and some of them even waited more than four years before seeing a gynecologist. The main reasons for consultation were aesthetic discomfort (8 cases), absolute impossibility of having sex (4 cases), and desire for clitoral repair (one case). The clitoral cysts were in the form of a rounded painless mass, 10 to 13 cm in diameter, seating in the nymphectomy area, blackish, renitent, non-pulsatile, sessile and movable superficially and in depth. The overlying skin was normal (Figure 1). The infibulations appeared in the form of apposition of the labia minora and majora reducing the vaginal opening into a sluice that would just let menses trickle out (Figure 2 and Figure 3). The patients with clitoral tumor had cystotomy incisions directly closed without related clitoroplasty. The purpose of defibulation was to separate labia minora from labia majora in order to obtain sufficient vagina permeability for intercourse. Two cases of clitoroplasty were made on patients' request (Figure 4). The aftermath of surgery was uneventful with healing and resumption of sexual activity after 45 days on average with extremes of 19 and 60 days. No recurrence has been met so far.

Discussion

Two types of FGM complications necessarily rely on surgery: vulvar closure (Type 3) and anatomical distortions represented by clitoral cysts. These complications are not rare but are often diagnosed late during the wedding night or when the cyst becomes annoying or unbearable. The clitoral cysts are due to sub-dermal inclusions of epithelial fragments or a reversal of the wound edges at the time of healing of the excision (3-4).

These usually aggravate Type 2 FGM as demonstrated in our report. They cause psychosexual discomfort with serious consequences on the quality of life of the couple; secondly, the swelling may have an obstructive effect by jeopardizing sexual intercourse (2,5).

Vulvar closure is especially due to infibulation with obstruction of the rima vulvae. Ways of achieving this differ across regions; however, the complications are similar: urinary problems, repeated genital infection and especially apareunia. Whatever the complications, surgical treatment should comply with one fundamental principle: it must be adapted to the area where the patient lives, hence responding to the patients' main concern that is to recover the anatomy they are accustomed to (restoration of the labia minora without clitoroplasty). Indeed, these patients did not expect to undergo clitoroplasty because they grew up and developed their sexuality without their clitoris. This reconstruction of the clitoris might be experienced as a loss of sexual identity. The two patients who requested for clitoral restoration did not have the same upbringing as the rest of the patients. A recent systematic review of Abdulcadir et al (6) recommends that women seeking clitoral reconstruction be made aware of the scarcity of available data on the effectiveness of this surgical technique. Further research is also needed on the safety and efficacy of the procedure for identifying the long-term results which could be beneficial to women.

Conclusion

In Senegal, the prevalence of FGM / C, which is 26%, has not been significantly reduced despite the strategies for its abandonment. Anatomical complications such as clitoral cyst or vaginal closure are usually the only reasons for consulting. The demand for clitoris repair is exceptional. Clitoral cysts and vaginal closures secondary to FGM require a simple intervention that meets the wishes of the patient. However, a good outreach strategy should be set up to deal with these complications in due course.

Conflicts of Interest

The authors declare no conflict of interest

References

(1.) Agence Nationale de la Statistique et de la Demographie (ANSD) [Senegal], et ICF International. 2012. Enquete Demographique et de Sante Continue (EDS-Continue 2012-2013). Calverton, Maryland, USA: ANSD et ICF International.

(2.) Diouf AA, Mbaye M, Gueye M, Coly AN, Moreira PM, Moreau JC, Diouf A. Traitement chirurgical des kystes clitoridiens compliquant des mutilations genitales feminines J Gynecol Obstet Biol Reprod 2014;43:328-331

(3.) Suzanne F, Dauplat J, Giraud B. Les tumeurs benignes de la vulve et du vagin. In : Encycl Med Chir Paris, Gynecologie ; 1992 [510A104.7.12].

(4.) Collinet P, Sabban F, Lucot JP, Boukerrou M, Stien L, Leroy JL. Prise en charge des mutilations genitales feminines de type III. J Gynecol Obstet Biol Reprod 2004;33:720-4.

(5.) Moreira PM, Moreira IV, Faye EHO, Cisse L, Mendes V, Diadhiou F. Trois cas de kystes epidermiques de la vulve apres mutilations genitales feminines. Gynecol Obstet Fertil 2002;30:958-60.

(6.) Abdulcadir J, Rodriguez MI, Say L. A systematic review of the evidence on clitoral reconstruction after female genital mutilation/cutting. Int J Gynaecol Obstet; 2015 May;129(2):93-7..

Abdoul A Diouf (1,*), Moussa Diallo (1), Aissatou Mbodj (1), Omar Gassama (2), Mamour Gueye (2), Jean C Moreau (2) and Alassane Diouf (1)

Gynecology and Obstetrics Department, National Hospital of Pikine, Senegal (1); Gynecology and Obstetrics Clinic, Aristide Le Dantec Hospital, Dakar (2)

(*) For Correspondence: Email: dizzefr@yahoo.fr; Phone: 00221 77 651 40 15

Table 1: Profile of Patients with FGM

Case   Age     Parity  Type    Background     Complications
      (years)          of FGM  circumstances

 1    22       0       2       -              Cyst
 2    25       1       2       -              Cyst
 3    25       2       2       -              Cyst
 4    31       2       2       -              Cyst
 5    38       1       2       -              Cyst
 6    24       1       2       -              Cyst
 7    19       0       2       -              Cyst
 8    19       0       2       -              Cyst
 9    20       0       3       Apareunia      Closure of vulva
10    14       0       2       -              Cyst
11    20       0       3       Apareunia      Closure of vulva
12    26       0       3       Apareunia      Closure of vulva
13    27       2       2       -              Anorgasmia
14    15       0       3       Dysuria        Closure of vulva

Case  Actions


 1    Cystectomy
 2    Cystectomy
 3    Cystectomy
 4    Cystectomy
 5    Cystectomy
 6    Cystectomy
 7    Cystectomy
 8    Cystectomy
 9    Cystectomy
10    Cystectomy
11    Defibulation
12    Defibulation and clitoroplasty
13    Clitoroplasty
14    Defibulation
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Article Details
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Title Annotation:A CASE REPORT
Author:Diouf, Abdoul A.; Diallo, Moussa; Mbodj, Aissatou; Gassama, Omar; Gueye, Mamour; Moreau, Jean C.; Di
Publication:African Journal of Reproductive Health
Article Type:Case study
Geographic Code:6SENE
Date:Mar 1, 2017
Words:1506
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