and Filippo Murina2
(1)
Center of Gynecology and Medical Sexology, San Raffaele Resnati Hospital, Milan, Italy
(2)
Lower Genital Tract Disease Unit V. Buzzi Hospital, University of Milan, Milan, Italy
Female genital mutilation/cutting (FGM/C) is defined by the World Health Organization (WHO) as “all procedures that involve partial or total removal of the external female genitalia or other injury to the female genital organs for non-medical reasons” (WHO 2008). It is typically carried out, with or without anesthesia, by a traditional circumciser using a knife or razor. The age of the girls who undergo this procedure varies from weeks after birth to puberty (UNICEF 2013). Different types of FMG/C can be performed (Table 5.1), with different severity of vulvar/genital damage and risk of long-term consequences.
Table 5.1
The World Health Organization classification of female genital mutilation
Complete typology with subdivisions: |
Type I – partial or total removal of the clitoris and/or the prepuce (clitoridectomy) |
When it is important to distinguish between the major variations of type I mutilation, the following subdivisions are proposed: type Ia, removal of the clitoral hood or prepuce only, and type Ib, removal of the clitoris with the prepuce |
Type II – partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision) |
When it is important to distinguish between the major variations that have been documented, the following subdivisions are proposed: type IIa, removal of the labia minora only; type IIb, partial or total removal of the clitoris and the labia minora; and type IIc, partial or total removal of the clitoris, the labia minora, and the labia majora |
Note also that, in French, the term “excision” is often used as a general term covering all types of female genital mutilation |
Type III – narrowing of the vaginal orifice with creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation) |
Type IIIa, removal and apposition of the labia minora; type IIIb, removal and apposition of the labia majora |
Type IV – all other harmful procedures to the female genitalia for nonmedical purposes, e.g., pricking, piercing, incising, scraping, and cauterization |
Worldwide, an estimated 125–140 million girls and women live with FGM/C.
Common early complications of FGM/C include uncontrolled bleeding, fever, wound infection, sepsis, and death (Nour 2004). Vulvar pain, the most obvious consequence, is not mentioned in Nour’s and other’s papers, although acute vulvar and genital pain is the most likely symptom when excision is performed in an area so richly innervated with sensory nerve fibers. FGM/C is also reported to cause psychological consequences, such as anxiety, horror, posttraumatic stress disorders, and depression.
Long-term complications include dysmenorrhea, dyspareunia, recurrent vaginal and urinary tract infections, infertility cysts, abscesses, keloid formation, obstetric complications, difficulty with childbirth, and sexual dysfunctions (WHO 2006). Diagnosis requires dedicated medical skills with a nonjudgmental approach (Hearst and Molnar 2013).
Unfortunately, there is no mention of vulvar pain in the WHO 2006’s paper as well.
Excellent reviews of available literature have been carried out: 5109 papers were considered, of which 185 studies (3.17 million women surveyed) were of good quality (Berg et al. 2014). Authors have carefully described the long-term gynecologic and obstetric outcomes of FGM/C. Results indicate significantly increased risks such as:
Urinary tract infections (unadjusted RR = 3.01)
Bacterial vaginosis (adjusted OR (AOR) = 1.68)
Dyspareunia (RR = 1.53)
Prolonged labor (AOR = 1.49)
Caesarean section (AOR = 1.60)
Difficult delivery (AOR = 1.88)
Vulvar pain is not mentioned as well in this review, nor in the otherwise very accurate Canadian guidelines (Perron et al. 2013), focused most on how to manage women who underwent FGM/C, i.e., to indicate the most appropriate obstetric and gynecological care on FGC, including FGC-related complications.
Only a few recently published clinical cases report vulvar epidermoid inclusion cysts, with inguinal (Birge et al. 2015) and/or acute vulvar pain (Gudu 2014). Specifically, the first case of neuropathic pain with sensory neuropathy has been published in June 2015 (Hadid and Dahan 2015).
Key question: is this case of neuropathic vulvar pain the first ever or is this the first time when neuropathic sensory vulvar pain after FGC receives the proper descriptive name of “vulvar pain”?
Coital pain/introital dyspareunia (CP/ID) is a frequently reported symptom. Its first etiology is the biomechanical narrowing of the vaginal entrance, more frequent in type III FGM/C. CP/ID is a symptom complained of when sexual maturity is achieved and when sexual intercourse is attempted/initiated.
What’s behind dyspareunia after FGM/C? Is spontaneous vulvar pain an issue? Is provoked vestibulodynia a leading etiology of CP/ID after FGM/C? Or is coital pain “only” the consequence of the biomechanical narrowing of the vaginal entrance due to cutting and scarring per se, without the specific pathognomonic features of vulvar vestibulitis/provoked vestibulodynia (inflammation, with significant increase of (1) mast cells in the vestibular tissue; (2) degranulated mast cells, indicating a very active release of inflammatory molecules in the vestibular tissue; (3) mast cells closer to the pain nerve fibers)?
“Genital pain” wording is comprehensive, yet not enough accurate. In the available literature on FGM/C (with the abovementioned exception of a few case reports), no mentioning of vulvar pain, either spontaneous or provoked, is usually reported, in spite of the fact that the vulva is the organ more severely cut and wounded.
Even the most recent and accurate papers on research gaps (Abdulcadir et al. 2015a) and on clinical inadequacies in treatment and follow-up (Rouzi and Alturki 2015) do not mention the issue of vulvar pain/vulvodynia after FGM/C. Abdulcadir quotes the “clitoral reconstruction” to relieve clitoral pain in 40 % of women treated by Thabet and Foldès. However, vulvar pain is not mentioned at all in this paper. Only a brief sentence on the improvement of “vulvar appearance” and body image after deinfibulation is reported.
Abdulcadir does mention vulvar pain in two cases of clitoral reconstruction (Abdulcadir et al. 2015b). The current literature seems therefore quote pain only when the clitoris is involved. However, it is very likely that pain is perceived as well in the introitus, given the high percentage of apareunia and introital dyspareunia after FGM/C.
Clitoral reconstruction seems very promising in restoring a better sexual function after FGM/C (Vital et al. 2016).
Case reports on “clitoral neuromas” after FGM/C indicate that neurologic complications are present. Fernández-Aguilar and Noël (2003) published the very first clinical case indicating that vulvar pain caused by a neuroma of the clitoris is a serious complications of FGM/C. One more case has been described (Abdulcadir et al. 2012), but a systematic research has not yet been published. Complications leading to vulvar pain are therefore very likely to be underreported.
Specific investigations on acute and chronic vulvar pain after FGM/C should be carried out, with focus on characteristics and vulnerabilities that could predict an evolution toward vestibulodynia, clitorodynia, vulvodynia, and introital dyspareunia. Attention should be paid at the first medical evaluation when a child who underwent FGM/C undergoes pediatric clinical evaluation for whatever reason.
5.1 Vulvar Pain After Female Genital Mutilation/Cutting: A Lifespan Perspective
5.1.1 Children
One sixth to one fifth of those 125 million girls and women are prepubertal, which translates into around 20 million children who recently underwent genital cutting. What are their current symptoms? Is vulvar pain an issue? In which percentage does acute vulvar pain, subsequent to cutting, shift into chronic vulvar pain/vulvodynia? Unfortunately, vulvar pain/vulvodynia is almost not mentioned at all in the available literature, and no word/research is spent on vulvar pain in children who underwent FGM/C. Does acute and chronic vulvar pain exist after FMG/C? Or is this issue invisible? That is, is it still under the threshold of clinical perception?
When clinician/pediatricians talk about “genital pain” after FGM/C, do they include vulvar pain? If yes, why not using a most appropriate wording? If not, why is there such a scotomization of the pain that is most likely to be elicited, given that the cutting acts exactly on that organ called vulva (the clitoris is indeed an anatomic part of it) and primitive suturing involves the labia minora?
Without attention to this specific symptom, with the appropriate wording/naming, no identification is possible of the subset of children at higher risk of long-term vulvar pain/vulvodynia/dyspareunia, and no early intervention can therefore be offered. Specific research on acute and chronic vulvar pain in prepubertal children undergoing genital cutting is urgently needed.
5.1.2 Adolescents
Three million girls in Africa are estimated to be at risk of FGM/C annually. A survey on 258 girls and women who had undergone FGM, most between 10 and 14 years of age, was carried out in Sierra Leone (Bjälkander et al., 2012). Complications were reported by 218 respondents (84.5 %), the most common ones being excessive bleeding, delay in or incomplete healing, and tenderness.
Fever was significantly more often reported by girls who had undergone FGM before 10 years of age compared with those who had undergone the procedure later. Out of those who reported complications, 187 (85.8 %) sought treatment, with 89 of them visiting a traditional healer, 75 a Sowei (traditional circumciser), and 16 a health professional. In spite of this very high rate of complications, no mention of acute or chronic vulvar pain is reported.
5.1.3 Adult, Premenopausal Women
FGM/C, according to the extension of the cutting, does remove the glands of the clitoris and part of the clitoral shaft. FGM/C usually does not remove the deeper part of the cavernosal bodies, currently defined as the “bulbs of the clitoris” (O’Connel and De Lancey 2005; O’Connell et al. 2008), and formerly called “bulbocavernosal bodies” deep under the labia minora, unless a very radical and dramatic mutilation is performed. Usually, the crura of the clitoris deep along the crural bones bilaterally and the part of the cavernosal bodies that surround the lower third of the urethra (considered to be the smaller size equivalent of the male corpus spongiosum of the urethra) are not removed.
Data on sexual outcomes and specifically vulvar pain in women who underwent FGM/C are conflicting. Catania et al. (2007) investigated 137 adult women affected by different types of FGM/C: 58 young FGM/C ladies living in the West; 57 infibulated women; 15 infibulated women after the operation of defibulation were studied, with semistructured interviews and the Female Sexual Function Index. Surveyed women affected by different types of FGM/C reported orgasm almost always 86 %, always 69.23 %; 58 mutilated young women reported orgasm in 91.43 %, always 8.57 %; after defibulation 14 out of 15 infibulated women reported orgasm.
The group of 57 infibulated women investigated with the FSFI questionnaire showed significant differences between study group and an equivalent group of control in desire, arousal, orgasm, and satisfaction with mean scores higher in the group of mutilated women. No significant differences were observed between the two groups in lubrication and pain (Catania et al. 2007). The maintenance of a consistent part of the cavernosal unit, in spite of the brutal cutting, may explain why the majority of women who underwent FGM/C may experience orgasm, according to this research. The very recent study of Abdulcadir et al. (2016) on anatomy and sexual function after FGM/C was carried out on 15 women with FGM/C and 15 controls using magnetic resonance imaging and validated questionnaires.
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