ABSTRACT

Female genital mutilation (FGM) has been performed at least 200 million women around all over the world and this practice bring up different short- and long-term complications. We report a case of a patient with FGM history and large clitoral epidermoid cyst as a long-term complication related to FGM. The FGM practice has been criminalized and eradicated by law in many countries and it is considered as a human rights violation. Nineteen-year-old nulligravid woman from Somali presented with a genital mass. The patient has a Type 3a female mutilation history with the excision of clitoral hood when she was 5 years old. She has difficulties of walking, wearing trousers and voiding dysfunction because of the large genital mass which has been gradually progressed during last 2 years. External genital examination revealed 7-8 cm mobile, painless mass that originated from clitoris and covered by stretched clitoral and labial epidermis, clitoris was lateralized, vaginal introitus was open 2-3 cm. Magnetic resonance imaging scan suspected a benign cyst without any invasion signs. We suspected the vulvar endometrioma during transperineal ultrasound examination with ground-glass image and hypoechogenic view. We performed the total excision of the clitoral mass, clitoral reconstruction and labioplasty. Pathological findings resulted as an epidermoid cyst. FGM may cause vulvar mass including epidermoid cyst as a long-term complication. Clitoral reconstruction might be necessary for Type 3a FGM cases.

Keywords: Female genital mutilation, epidermoid cyst, clitoral mass

INTRODUCTION

According to World Health Organization (WHO), Female genital mutilation (FGM) is any procedure that involves the partial or total removal of external genitalia for non-medical reasons.¹ Approximately 200 million women had undergone FGM procedures in more than 30 countries around the world. This procedure is commonly performed due to religious and cultural tradition.² FGM is considered as violence against basic human rights.³ This procedure is commonly performed in inefficient sterilized and inadequate equipped places that usually ends up with many early complications.⁴ Women who have undergone FGM may suffer long-term compilations such as dysmenorrhea, dyspareunia, urinary obstructive pathologies, vulvar and clitoral abscesses and cysts, vaginismus, vaginal stenosis, lack of sexual satisfaction.⁵

WHO classifies FGM into 4 major groups. Type 1 is excision of the prepuce with or without excision of the clitoris. Type 2 is excision of the prepuce and clitoris with partial or total excision of the labia minora. Type 3 is excision of part or all of the external genitalia and stitching/narrowing of the vaginal opening (infibulation). Type 4 includes all other procedures with the aim of tightening or narrowing, such as pricking, piercing, or incision of the clitoris or labia; cauterization by burning of the clitoris and surrounding tissues; scraping of the vaginal orifice; cutting of the vagina.⁶ Among these types the third type is the most extreme and catastrophic method.

CASE REPORT

A 19-year-old single nulligravida woman from Somali presented with slowly progressed genital mass that has grown gradually in last 2 years causing significant discomfort. She had undergone female genital cutting procedure when she was 5 years old in Somali. The procedure had been performed by a non-medical traditional practitioner at home without any analgesic.

Perineal examination revealed 7 cm mobile, non-tender, rounded cystic mass partially obstructing urethral meatus, stretching the labia minora, originated from previously performed FGM scar on clitoris (Figure 1). During the FGM procedure the clitoral body was removed partially and eventually lateralized and the vaginal introitus was left open with 2-3 cm opening. Magnetic resonance imaging scan suspected epidermoid cyst with no invasion sign. We suspected the vulvar endometrioma during transperineal ultrasound examination with ground-glass image and hypoechoic view. Under general anesthesia the cyst was totally excised without rupturing. The cyst filled with dark brown keratinous material. After the cyst excision previously lateralized clitoris was moved to the normal anatomical area with reconstructive method and labioplasty was performed by removing the excess enlarged labial and clitoral skin. The patient did not have any functional or anatomical complaints at the first week and third month postoperative follow-up (Figure 2). Patient satisfaction was measured by the patient global impression of improvement method and it was noted scale 6. “Much worse” before the surgery and was improved to scale 1. “Very much better”.⁷ According to the female genital self-image scale (FGSIS) patient’s perception of her own genital appearance recovered from 9 points up to 27 points of FGSIS.⁸ The patient has been informed about the case report process and she has given consent for her case to be published in the scientific journal.

DISCUSSION

In the literature there have been reported only few cases clitoral giant cysts secondary to FGM as a long-term complication.

One of these cases has been reported a 40-year-old multipara woman with FGM history and 11x10.6 cm cyst weighed 1.9 kg which was significantly massive clitoral inclusion cyst.⁹

Another case has been reported a 19-year-old woman circumcised at birth and as a late complication she had enlarging vulvar mass that arose after the onset of puberty.¹⁰ Other reports are about two women aged 39 and 27 with childhood circumcision history and epithelial inclusion cyst of clitoris.¹¹

Foldes and Louis-Sylvestre¹²published 453 patients who had undergone ritual childhood surgeries and later requested reconstructive clitoral repair surgery. This study claimed the repair surgery with preservation of clitoris provides promising sexual satisfaction and cosmetic results.¹²

FGM procedures are still performed as a part of a religious and cultural traditions all over the world as it brings up early and late complications. The UN has banned the FGM procedures since 2012 to eliminate this practice.¹³ FGM is outlawed in the United States as the new immigrants might be imprisoned up to 5 years who attempt or arrange FGM for their daughters.¹⁴

Clinicians are facing more and more long-term complications of FGMs due to increasing immigrants and globalization of cultural traditions.

Although female genital cutting is an important cultural and religious tradition for some nations and societies, determining the medically expected short-term and long-term complications would be beneficial and discussing more issues and cases will be profitable to create perception of avoiding FGM procedures for themselves and for their daughters.

CONCLUSION

Vulvar or clitoral epidermoid cysts should be kept in mind as a long-term complication following FGM Type 3a cases. Reconstruction of normal perineal anatomy should be aimed.

Ethics

Informed Consent: The patient has been informed about the case report process and she has given consent for her case to be published in the scientific journal.

Authorship Contributions

Surgical and Medical Practices: G.A., T.D., O.D., M.Y., Concept: G.A., T.D., O.D., M.Y., Design: G.A., T.D., O.D., M.Y., Data Collection or Processing: G.A., O.D., Analysis or Interpretation: G.A., O.D., M.Y., Literature Search: T.D., Writing: G.A., T.D., M.Y.

Conflicts of Interest: The authors declare that there is not any conflict of interest regarding the publication of this manuscript.

Financial Disclosure: The authors declared that this study received no financial support.

References

UNICEF. Female genital mutilation/cutting: a statistical overview and exploration of the dynamics of change, UNICEF, New York 2013.

The Lancet. Changing culture to end FGM. Lancet. 2018;391(10119):401.

Doucet MH, Pallitto C, Groleau D. Understanding the motivations of health-care providers in performing female genital mutilation: an integrative review of the literature. Reprod Health. 2017;14(46):1-15.

Dirie MA, Lindmark G. The risk of medical complications after female circumcision. East Afr Med J. 1992;69(9):479-482.

Ozumba BC. Acquired gynetresia in eastern Nigeria. Int J Gynaecol Obstet. 1992;37(2):105-109.

Nour NM. Female genital cutting: a persisting practice. Rev Obstet Gynecol. 2008;1(3):135-139.

Srikrishna S, Robinson D, Cardozo L. Validation of the Patient Global Impression of Improvement (PGI-I) for urogenital prolapse. Int Urogynecol J. 2010;21(5):523-528.

Ellibes Kaya A, Yassa M, Dogan O, Basbug A, Pulatoglu C, Caliskan E. The Female Genital Self-Image Scale (FGSIS): cross-cultural adaptation and validation of psychometric properties within a Turkish population. Int Urogynecol J. 2019;30(1):89-99.

Aziem-Abdallah-Ali A, Mohammed AA, Mohammed Ali AK. Large inclusion cyst complicating female genital mutilation. Clin Pract. 2011;1(4):e121.

Kroll GL, Miller L. Vulvar epithelial inclusion cyst as a late complication of childhood female traditional genital surgery. Am J Obstet Gynecol. 2000;183(2):509-510.

Kristensen IB. Epitelial inklusionscyste ved clitoris som senkomplikation i forbindelse med kvindelig omskaering [Epithelial inclusion cyst of the clitoris as a late complication of childhood female circumcision]. Ugeskr Laeger. 2008;170(1):59.

Foldes P, Louis-Sylvestre C. Résultats de la réparation chirurgicale du clitoris après mutilation sexuelle: 453 cas [Results of surgical clitoral repair after ritual excision: 453 cases]. Gynecol Obstet Fertil. 2006;34(12):1137-1141.

Morgan J. Working towards an end to FGM. Lancet. 2015;385(9971):843-844.

Macready N. Female genital mutilation outlawed in United States. BMJ. 1996;313(7065):1103.