Management of a Total Coalescence of the Labia Majora in an 11-Year-Old Girl Following a Female Genital Mutilation: A Case Report ()
1. Introduction
“Female genital mutilation/excision” includes “all interventions resulting in partial or total removal of the external female genitalia and/or any other lesion of the female genitalia performed for non-therapeutic purposes” [1] . Long considered to be essentially African practices, female genital mutilation (FGM) affects, to varying degrees, all continents. They have started to decline, but slowly and in varying ways depending on the country.
It is still a current practice in several African traditions. It constitutes a violation of human rights, in particular because of its harmful consequences for the health of the people who suffer from it [2] [3] [4] [5] [6] .
Woldwide, FGM has already affected more than 130 million women, and is still practiced each year on more than two million little girls [7] [8] .
In Africa, FGM often underestimated [9] [10] [11] [12] , is estimated to be practiced in 28 countries [3] [13] , with a very disparate prevalence: 5% in Niger [14] , 20% in Senegal [15] and 29% in Ghana [16] . This is why a joint program UNFPA/UNICEF was funded by the Global Fund to reduce by 40% the current prevalence of FGM in five years (2008-2012) in 17 countries including Burkina Faso [17] .
In Burkina Faso, the practice of FGM has experienced an upsurge in rural populations, with a prevalence rate increasing from 72% in 1999 [18] to 77% in 2003 [17] and 77.5% in 2005 [19] . Considering the extent, the persistence and the gravity of FGM, a series of measures have been taken: call for the abolition of FGM in 1985, creation of a provisional committee to fight against FGM in 1988, then the creation of a national committee to fight against FGM in 1990, adoption of a law prohibiting FGM in 1996, establishment of a national day against FGM since 2000, and a toll-free number to denounce FGM in 2005. Despite this arsenal of measures, FGM continues to be practiced clandestinely on younger and younger girls, and even on babies. It has therefore become more pernicious and unfortunately the source of many complications.
We report a case of sequelae of female genital mutilation with total coalescence of the labia majora in an 11-year-old patient who underwent remedy with vulvar opening and repositioning of the urethra.
2. Clinical Case
Miss K. A., aged 11, resident in sector 12 of Ouahigouya, consulted for permanent urinary incontinence which has been evolving for about 6 months. The patient reportedly received traditional treatment of an unspecified nature without success. Faced with the persistence of the symptoms, the patient went with her grandmother at the Regional Teaching Hospital of Ouahigouya on 01/19/2021 for better care.
The medical examination showed:
- A good general condition, a temperature at 37.2˚C, a blood pressure of 117/72 mmHg, a height of 1 m 26 cm, a weight of 25 kg, colored and anicteric mucous membranes;
- A supple and depressible abdomen;
- Vulva and perineum: 3rd degree excision sequelae: infibulation (removal of the clitoris, small labia minora) with total coalescence of the labia majora letting urine flow permanently through a small hole.
The diagnosis of sequelae of female genital mutilation with the coalescence of the labia majora is set (Figure 1).
A preoperative assessment with a pre-anesthetic consultation was requested.
The results showed:
- A Positive O Rhesus blood group;
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Figure 1. Sequelae of femalegenital mutilation with coalescence of the labia majora.
- The blood count: White blood cells: 6360/µL; Red blood cells: 4.72 × 106/µL; Hemoglobin level: 11.6 g/dl; Hematocrit rate: 37.6%; Platelets: 255,000/µL;
- Urea: 2.7 mmol/L; Creatinine: 40.2 µmol/L; Blood sugar: 4.59 mmol/L.
The anesthetic risk assessment concluded ASA I, Alteimer II, Apfel: 2; No particular risk.
The patient was operated on under general anesthesia and an opening of the vulvovaginal orifice was made, with suturing of the edges with Vicryl 3/0 in two semi-stitches, a repositioning of the urethra after placing an indwelling urinary catheter. Neomycin ointment was prescribed for local application twice a day as postoperative care. The urinary catheter was kept for 6 days (Figure 2).
The outcome was favorable and the patient was discharged on D6 after removal of the urinary catheter and continued local care with Neomycin ointment and with an appointment on D14 (Figure 3) and D30.
3. Discussion
FGM has no health benefits, and girls and women who have undergone FGM are at risk of suffering complications throughout their lives. The practice is painful and traumatic [20] and is often performed under bad septic conditions by a traditional practitioner with little knowledge of female anatomy or how to manage possible side effects [21] . In addition, the removal or alteration of healthy genital tissue interferes with the body’s natural functioning and can have several immediate and long-term consequences on genito-urinary health [21] [22] [23] . Evidence indicates that the risk of side effects is greater with type III FGM than with types I and II, and that these events tend to be greatly underreported [21] .
Regarding the risk of obstetric complications from FGM, a WHO study group that analyzed the issue in 2006 concluded that it was significantly higher among women with FGM than among others, and that it was proportional to the forms of mutilation [24] . These harmful consequences can also affect the health of newborns [25] .
For many girls and women, FGM is a traumatic experience that can leave
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Figure 2. After remedy (opening vulvovaginal orifice and urethral reimplantation).
lasting psychological sequelae and lead to various mental health problems [26] [27] .
Since some types of FGM involve the removal of sexually sensitive structures, especially the clitoral glans and part of the labia minora, some women report a decreased sexual response and satisfaction. In addition, the cicatrization of the vulvar area can cause pain, especially during sexual intercourse [21] [27] .
In addition, some care and exploration may be hindered due to anatomical alterations, especially gynecological examination, cytological analyses, post-abortion uterine evacuation, placement of the intra-uterine device (IUD), and use of pads, especially with type III FGM.
It is difficult to provide precise data on the direct consequences of FGM on health due to the small size of samples and to the methodological limitations of available studies. Despite these limitations, the amount of data has grown over the past ten years, which has recently made it possible to carry out systematic reviews and meta-analysis in order to synthesize it.
In our clinical case, the complication was long-term in the form of infibulation with permanent urinary flowing. This complication is probably due to the lack of asepsis in the area of the lesions and the non-use of healing ointment.
The management of most immediate or short-term complications requires medical resuscitation, local care, local antiseptics, antibiotics, and long-term complications most often require surgical remedy.
In our case, the management was surgical with an opening of the vulvovaginal orifice, with suturing of the edges and repositioning of the urethra for which local care was necessary. This allowed perfect healing after 2 weeks.
4. Conclusion
Female genital mutilation is the cause of many complications and sequelae sometimes serious that often require multidisciplinary management (resuscitator, gynecologist-obstetrician, surgeon and psychologist). The success of this care requires proper training of the various stakeholders.
Ethical Considerations
We have obtained parental consent for taking pictures and those were reassured that they could only be used in a science-related purpose.