Saturday, 23 March 2013

Female Genital Mutilation: Common complications


I thought I should add this following my article on the risk of HIV/AIDS on female genitally mutilated women which was attacked by a reader who thinks male circumcision carries more risk of HIV/AIDS.  On the contrary more women are HIV infected than men around the world. I am still surprised at how some people jump to compare male circumcision (based on a small figure of US males) and female genital mutilation without thinking of the people in the African interior where FGM is practised with no chance of anaesthesia except the powdered poultice from the cutters.  In my articles I never say male circumcision is good but my platform is for the girls and women who are genitally mutilated and live with the scars for the rest of their lives. Here is why:-

Complications following FGM, especially if the girl is infibulated, are common and many are well documented. These may be immediate or late. The major immediate complications are, of course, haemorrhage from the dorsal artery, shock and then infection, urinary retention and tetanus, which can lead to mortality.

Some late and long-term complications seen are urinary incontinence, cysts, urogenital tract infections; severe dyspareunia, pelvic inflammatory disease, infertility, and obstetrical problems such as delayed or obstructed second stage labour, trauma, and haemorrhage. Haemorrhage was also seen as a late complication especially in the newly married girl who was tightly infibulated and was subjected to forcible sex by the husband or who the husband defibulated using various instruments such as scissors, blades or knives.

In the research done by Dirie and Lindmark in Somalia on 290 women (mean age 22 years, range 18 to 54), 88% of research subjects had excision and infibulation, the remainder fell into the less mutilating categories. Sixty-nine percent had this procedure performed at home and 52% of these were performed by an untrained person. The immediate main complication reported by 112 women in the study was hemorrhage, infection, urinary retention, and septicaemia. Five women reported severe schock and two of them required blood transfusions. Those women with urinary retention were treated by splitting the infibulation scar and were reinfibulated a few weeks later. The late complication of which 108 women complained, were as follows: 36 with clitoral cysts, 29 requiring excision; 57 with pain on micturition; and 15 subjects had poor urinary flow.

Hemorrhage is an immediate as well as a late complication. For hemostasis the girl's legs are tied together and sometimes a poultice of crushed medicinal herbs is applied.

The urinary retention reported by the women in the Dirie/Lindmark study occurred within the first 3 days after the operation and the reason given by the authors was that the girls tried to avoid passing urine because of the pain that urine causes when it irritates the raw surfaces. The retention was also due to skin flaps, blood clots or, in several cases the urinary meatus was sutured while closing the vulva.

Recurrent urinary tract infections and urinary problems were numerous, and according to Dirie/Lindmark, these were caused because the meatus was covered by the infibulation, causing vaginal discharge to accumulate and favor the growth of bacteria. The women reported that they were given antibiotics by their doctor and this helped. DeSilva reported that urinary tract infection with Escherichia coli was common in these women.

The most common late complication of FGM that was reported by Dirie and several other authors was vulvar swelling, which was due to epidermal cyst formation that develops along the scar tissue and in the excised clitoral region.

Hanly discusses 10 patients that attended the hospital in Tabuk, Saudia Arabia. All patients were immigrants into the Kingdom from Africa. Six patients presented with a large painless mass in the infibulation scar. Two complained of pain, one gave a history of a white continuous secretion for the scar site, and one complained of severe dyspareunia and had a cyst measuring 5.5 X 5 cm. The pathological finding in eight patients was of an implantation dermoid, in the other two patients the cyst had ruptured.

Mayad discusses the fibrous connective tissue tumours called fibromata. These form in the same areas as the dermoid cysts and also can grow to be large and pedunculated.

Sexually Transmitted Diseases, Pelvic Inflammatory Disease and Infertility

Pelvic inflammatory disease (PID), a common complication of sexually transmitted disease (STD) is accompanied by abdominal pain, infertility, and ectopic pregnancy. Research indicates that PID is a major problem worldwide and in some African countries, 22 to 44% of women admitted to the hospital for gynaecological problems had PID. In women 20-29 years old, 7 to 25% of them were childless.

The most prevalent organisms were Neisseria gonnorrhoeae and Chlamydia trachomatis. However, it is now believed that FGM plays a significant role in the development of PID. For the woman who has been infibulated there are added risks of infection and resulting infertility. It has been reported by Sami and El Dareer that chronic pelvic disease was three times more prevalent in the infibulated women. Chronic retention of urine, menstrual flow, and repeated urinary tract infections with E. coli are the consequences of poor drainage, which results from a space formed behind the vulva skin. This then becomes an excellent reservoir for the growth of pathogenic organisms such as the E. coli.

Shandall and DeSilva  reported a high incidence of candiasis, which was more frequent with infibulation, and urine cultures showed the presence of mixed organisms, specifically E. coli.

 Shandall has suggested three main causes of PID in the infibulated woman, namely:

 (1) infection at the time of infibulation,

 (2) interference with drainage and

(3) infection from spliting the infibulation and resulting in resuture after labor. The infections then spread to the inner reproductive organs causing infertility.

Rushwan states that FGM should be recognized as an important etiological factor for PID.

 Another reason for infertility is acquired gynetresia which according to Ozumba, is directly related to infibulation. In a study done by Ozumba in Eastern Nigeria on 78 women 59 patients (76%) had acquired gynetresia caused by infibulation. Sexual intercourse is generally difficult and the process of deinfibulation painful and can take 2-12 weeks to complete or even up to 2 years during which time the women seeks medical help for infertility.

It is estimated that 2-25% of the cases of infertility in the Sudan are due to infibulations, either as a result of chronic pelvic infection or because of difficulty in having sexual intercourse and lack of penetration. In this society the psychological and social impact of being sterile are profound because a woman's worth is frequently measured by her fertility, and being sterile can be cause for a divorce.

Women who have had FGM (especially infibulations) done have a small opening, just large enough for the passage of urine and blood. Penetration or intercourse is difficult, often resulting in tissue damage, lesions, and postcoital bleeding. These tears would tend to make the squamous vaginal epithelium similar in permeability to the columnar mucosa of the rectum, thus facilitaing the possible transmission of HIV. The vaginal introitus is narrowed to increase the man's sexual enjoyment and ensure fidelity and virginity. However, because of this many women experience severe dyspareunia. Other common reasons for the dyspareunia are epidermal or dermoid cysts, which form along the incisional site. These can be a small as a pea or as large as a football.

These often become infected, painful, and a common reason for the woman seeking medical help. Dyspareunia can also be a result of neuromata that are formed when the dorsal nerve ending is trapped in scar tissue, resulting in immense pain and severe dyspareunia.

So when Dr al- Ghawaabi and all the accomdationist talks of benefits of FGM one wonders which planet they are from. FGM has no medical benefits. Who would chop a head off to cure a headache?


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