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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.

  1. Case description
    1. History
    2. Physical examination
    3. Imaging
    4. Management
    5. Evolution
  2. Surgical and anatomical considerations
  3. Objective explanations
    1. Objectives
    2. Causes of urethrovaginal fistulas
    3. Foley cathethers
    4. Complications of female genital mutilation
  4. Sources
+ Show all

Case description


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.

Figure 1 - Normal adult female external genitalia

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.

Figure 2 - Female genital mutilation - A. External genitalia of the patient in this case. B. Vaginal stones removal (with lithotomy) through the vaginal orifice. C. Removed stones.


An abdominopelvic ultrasound revealed vaginal lithiasis (stones) but with normal upper urinary tract anatomy.


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.


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

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.
Figure 4 - Classification of female genital mutilation

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.

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