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Clinical case: Female genital mutilation
After reviewing this case you should be able to describe or do the following:
- What is meant by a urethrovaginal fistula. What are the causes of this condition.
- What is meant by a Foley catheter. What is the most common medical problem associated with the use of a Foley catheter.
- Some of the complications associated with female genital mutilation (FGM).
This article is based on a case report published in the Journal "Case Reports in Surgery" in 2015, by Caroline C. Jadlowiec, Beata E. Lobel, Namita Akolkar, Michael D. Bourque, Thomas J. Devers, and David W. McFadden.
It has been modified and reviewed by Joel A. Vilensky PhD, Carlos A. Suárez-Quian PhD, Aykut Üren, MD.
Case description
History
The patient was a 9-year-old prepubertal girl who complained of dysuria and an all-day constant urinary incontinence associated with continuous hypogastric pain and tenderness. She had not yet started menstruating. When she was 4-years-old she had an external genital excision (female genital mutilation [FGM]; female circumcision) and then was seen at a health clinic for massive genital bleeding.
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Physical examination
The physical examination at the current time revealed:
- an almost complete removal of the labia majora
- a complete absence of the clitoris and labia minora
- a virtually obliterated vagina (Figures 1 & 2; FGM, type III; cf. below)
The urethral orifice was not found, but the genital area was urine-stained raising the likelihood of a urethrovaginal fistula.
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Imaging
An abdominopelvic ultrasound revealed vaginal lithiasis (stones) but with normal upper urinary tract anatomy.
Management
Surgery with lithotomy (incision to remove stones) and surgery to re-establish an external urethral orifice was performed using two incisions. The reason for the two incisions is because at the beginning of the procedure the surgeons could not see the urethral orifice so they approached the urethra from inside the bladder (cystostomy) and recanalized the urethra until they could visualize its external opening.
Subsequently, the surgeons completely reversed the vaginal infibulation (closure), liberated the urethral orifice and surgically removed five vaginal lithiases (Figure 2C) with vaginal canal reconstruction.
Evolution
The patient was followed for seven days with Vaseline gauze packing through the vagina twice per day, and the Foley catheter was removed six days after surgery. A six-month follow-up exam showed that the external genital structures had healed well with normal looking structural morphology; the patient, however, would have a high risk of eventual obstetrical complications.
Surgical and anatomical considerations
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Female genital mutilation (female circumcision) is common in western African communities and in the Horn of Africa; with significant medical, sexual, and psychosocial implications (see Explanation 3).
WHO classifies Female Genital Mutilations into four types (Figure 4):
- Type 1 (clitoridectomy) – removing part or the entire clitoris.
- Type 2 (excision) – removing part or all of the clitoris and labia minora with or without removal of the labia majora.
- Type 3 (infibulation) – Removal of most of the external genital and narrowing of the vaginal opening.
- Type 4 - Other harmful procedures - Non-classified interventions such as perforation or incision of the clitoris, labia minora and labia majora; elongation of clitoris or both labia, thermic cauterization (burn) of clitoris and surrounding tissues, vaginal meatus abrasion, vaginal incision, use of corrosive substances in the vagina to cause bleeding, or traditional medicines to retract or obliterate the vaginal meatus, etc.
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Urologic complications of infibulation such as urovaginal lithiases are common. As in this case, the lithiasis complications are related to formation of epidermoid cysts on the clitoris, the vagina and/or on the external genitalia. In the case described here, the advanced vaginal retraction caused the accumulation of urine in the vagina through the urethrovaginal fistula, which was confirmed with cystourethrography. Urinary stasis contributed significantly to the formation of vaginal lithiases.
Infibulation or type III female genital mutilation remains a major public health problem in Western African despite the local and international efforts to prevent the practice.
Objective explanations
Objectives
- What is meant by a urethrovaginal fistula? What are the causes of this condition?
- What is meant by a Foley catheter? What is the most common medical problem associated with the use of a Foley catheter?
- Some of the complications associated with female genital mutilation (FGM).
Causes of urethrovaginal fistulas
A urethrovaginal fistula is an abnormal connection between the female urethra and vagina. Such a fistula typically develops after:
- incontinence surgery,
- surgical treatment of urethral diverticula,
- prolonged labor,
- or obstetric interventions.
In addition to congenital fistulas, additional causes include trauma (pelvic fractures, long-term catheterization), and tumors or complications of cancer treatment such as surgery and radiation may also a cause urethrovaginal fistula. A urethrovaginal fistula may also be caused by FGM procedures, as in this case.
Foley cathethers
A Foley catheter is a small diameter, double-lumen, rubber tube that is inserted into the bladder to drain urine. It may also be a called an indwelling catheter. Once the catheter is inserted into the bladder, a balloon at the end is inflated with air or saline solution to prevent the catheter sliding back out. In an emergency department, indwelling urinary catheters are most commonly used to enable bladder emptying in people who cannot urinate and may remain in place for prolonged periods.
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Foley catheters may allow bacteria to travel along the tube and enter the bladder resulting in a urinary tract infection (UTI). Inserting a catheter in a woman is much easier and involves much less risk of injury than in a man because of the very short urethra in women. Women are able to quickly learn to self-catheterize when it is necessary. In men, the greater length plus the curvatures of the urethra render the procedure more difficult and more likely that the urethra is inadvertently penetrated within the bulbous part of the spongy urethra. Furthermore, if the balloon is inflated without the tip of the catheter in the bladder, the balloon may rupture the prostatic or membranous parts of the urethra.
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Complications of female genital mutilation
Female genital mutilation (FGM) involves all non-medically necessary procedures that involve partial or total removal of the external female genitalia. Traditional circumcisers who often have significant influence in their communities primarily conduct these procedures. FGM is recognized as a violation of the human rights of girls and women.
FGM can cause:
- severe bleeding,
- urinary difficulties (as in this case),
- cysts,
- infections,
- complications in childbirth,
- increased risk of newborn deaths.
Further, FGM is generally done as a way to control sexuality, which is believed to be insatiable in women if some of the genitalia, especially the clitoris, are not removed. It is also thought to ensure virginity prior to marriage, and fidelity afterward, and to increase male sexual pleasure.
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