Postoperative pain after clitoral reconstruction in women with female genital mutilation: An evaluation of practices.

INTRODUCTION: More than 200 million women and girls have undergone genital mutilation. Clitoral reconstruction (CR) can improve the quality of life of some of them, but is accompanied by significant postoperative pain. OBJECTIVE: Assess and describe the management of postoperative pain after CR, and the practices amongst specialists in different countries. METHODS: Between March and June 2020, 32 surgeons in 14 countries (Germany, Austria, Belgium, Burkina Faso, Canada, Ivory Coast, Egypt, Spain, United States of America, France, the Netherlands, Senegal, Switzerland, Sweden) responded to an online questionnaire on care and analgesic protocols for CR surgery. RESULTS: At day 7 post CR, 97% of the surgeons observed pain amongst their patients, which persisted up to 1 month for half of them. 22% of the participants reported feeling powerless in the management of such pain. The analgesic treatments offered are mainly step II and anti-inflammatory drugs (61%). Screening for neuropathic pain is rare (3%), as is the use of pudendal nerve block, used by 8% of the care providers and only for a small percentage of women. CONCLUSION: Pain after CR is frequent, long-lasting, and potentially an obstacle for the women who are willing to undergo clitoral surgery and also their surgeons. Most surgeons from different countries follow analgesic protocols that do not use the full available therapeutic possibilities. Early treatment of neuropathic pain, optimisation of dosing of standard analgesics, addition of opioids, use of acupuncture, and routine intraoperative use of pudendal nerve block might improve the management of pain after CR.

Adverse obstetric outcomes among female childhood and adolescent cancer survivors in Sweden: A population-based matched cohort study.

INTRODUCTION: Cancer treatment during childhood may lead to late adverse effects, such as reduced musculoskeletal development or vascular, endocrine and pulmonary dysfunction, which in turn may have an adverse effect on later pregnancy and childbirth. The aim of the present study was to investigate pregnancy and obstetric outcomes as well as the offspring's health among childhood and adolescent female cancer survivors. MATERIAL AND METHODS: This register-based study included all women born between 1973 and 1977 diagnosed with cancer in childhood or adolescence (age <21), as well as an age-matched comparison group. A total of 278 female cancer survivors with their first childbirth were included in the study, together with 829 age-matched individuals from the general population. Logistic regression and analysis of variance were used to investigate associations between having been treated for cancer and the outcome variables, adjusting for maternal age, nicotine use and comorbidity. RESULTS: Survivors were more likely to have preeclampsia (adjusted odds ratio [aOR] 3.46, 95% confidence interval [CI] 1.58 to 7.56), undergo induction of labor (aOR 1.66, 95% CI 1.05 to 2.62), suffer labor dystocia (primary labor dystocia aOR 3.54, 95% CI 1.51 to 8.34 and secondary labor dystocia aOR 2.43, 95% CI 1.37 to 4.31), malpresentation of fetus (aOR 2.02, 95% CI 1.12 to 3.65) and imminent fetal asphyxia (aOR 2.55, 95% CI 1.49 to 4.39). In addition, deliveries among survivors were more likely to end with vacuum extraction (aOR 2.53, 95% CI 1.44 to 4.47), with higher risk of clitoral lacerations (aOR 2.18, 95% CI 1.47 to 3.23) and anal sphincter injury (aOR 2.76, 95% CI 1.14 to 6.70) and emergency cesarean section (aOR 2.34 95% CI 1.39 to 3.95). Survivors used pain-reliving methods to a higher extent compared with the comparison group. There was no increased risk of neonate diagnoses and malformations. The results showed that survivors who had been diagnosed with cancer when they were younger than 14 had an increased risk of adverse obstetric outcomes. CONCLUSIONS: The study demonstrates increased risk of pregnancy and childbirth complications among childhood and adolescent cancer survivors. There is a need to optimize perinatal care, especially among survivors who were younger than 14 at time of diagnosis.

Management of painful clitoral neuroma after female genital mutilation/cutting.

BACKGROUND: Traumatic neuromas are the result of regenerative disorganized proliferation of the proximal portion of lesioned nerves. They can exist in any anatomical site and are responsible for neuropathic pain. Post-traumatic neuromas of the clitoris have been described as an uncommon consequence of female genital mutilation/cutting (FGM/C). FGM/C involves partial or total removal of the female genital organs for non-therapeutic reasons. It can involve cutting of the clitoris and can cause psychological, sexual, and physical complications. We aimed to evaluate the symptoms and management of women presenting with a clitoral neuroma after female genital mutilation/cutting (FGM/C). METHODS: We identified women who attended our specialized clinic for women with FGM/C who were diagnosed with a traumatic neuroma of the clitoris between April 1, 2010 and June 30, 2016. We reviewed their medical files and collected socio-demographic, clinical, surgical, and histopathological information. RESULTS: Seven women were diagnosed with clitoral neuroma. Six attended our clinic to undergo clitoral reconstruction, and three of these suffered from clitoral pain. The peri-clitoral fibrosis was removed during clitoral reconstruction, which revealed neuroma of the clitoris in all six subjects. Pain was ameliorated after surgery. The seventh woman presented with a visible and palpable painful clitoral mass diagnosed as a neuroma. Excision of the mass ameliorated the pain. Sexual function improved in five women. One was not sexually active, and one had not yet resumed sex. CONCLUSION: Post-traumatic clitoral neuroma can be a consequence of FGM/C. It can cause clitoral pain or be asymptomatic. In the case of pain symptoms, effective treatment is neuroma surgical excision, which can be performed during clitoral reconstruction. Surgery should be considered as part of multidisciplinary care. The efficacy of neuroma excision alone or during clitoral reconstruction to treat clitoral pain should be further assessed among symptomatic women.

Surgical Treatment of Complication of Female Genital Mutilation in Pikine Hospital, Senegal.

We share our experience on reconstructive for surgery female genital mutilation. This is a retrospective study of all cases of female genital mutilation surgery performed in Pikine National Hospital. We have reviewed the various indications and surgical techniques used. We collected 8 cases of clitoral cyst and 6 cases of closed vaginal opening. The surgery of clitoral cysts was to perform cystectomy followed by nymphoplasty. The closing of the vaginal opening required defibulation together with clitoroplasty according to the wishes of the patient. The anatomical and functional outcomes were satisfactory. Female genital mutilation surgery requires a good knowledge of vulvar anatomy. The various surgical indications must meet the expectations of patients to guarantee their satisfaction.

[Clitoral reconstruction after female genital mutilation at CHU Yalgado of Ouagadougou, Burkina Faso. About 68 patients operated]. / Reconstruction clitoridienne après mutilation génitale féminine au CHU Yalgado de Ouagadougou, Burkina Faso. À propos de 68 patientes opérées.

OBJECTIVE: The objective of this survey was to assess the results of a new clitoral transposition technique in the obstetrics and gynecology department of CHUYO. MATERIALS AND METHOD: A cohort of 68 women victims of genital mutilation has received clitoral reconstruction by a new technique of transposition of the clitoris. They were operated and followed for 12 months in CHUYO gynecology ward in Ouagadougou. We evaluated the management of pain, anatomical aspect, functional and occurrence of complications. RESULTS: Anatomically have no new increase was within a neoclitoris, and a very satisfactory ratio of 100 % of women with clitoral massif visible in the 12th month assessment. Functionally, before clitoral reconstruction half of the women had mild pain or discomfort during sexual intercourse. However, clitoral reconstruction after the 6th month and 12th month this pain or mild discomfort were 3.18 % and 0 % respectively. In addition, we noted a sensitive neoclitoris in all women, after one year. Very few postoperative complications were observed in this series compared to previous series. CONCLUSION: These results are of interest in this new clitoral transposition technique in favor of women victims of genital mutilation.

Tumor de la vulva, vulvectomía radical / Vulvar tumor, total vulvectomy

Los tumores de la vulva no son una rareza entre los cánceres que afectan a las féminas, pero tampoco son de los más frecuentes. Se presenta el caso de una mujer de 59 años, que en el año 2000 se le diagnostica carcinoma epidermoide del clítoris, en 2004 se vuelve a intervenir por recidiva tumoral, y en 2009 acude a nuestra consulta nuevamente y es cuando se decide realizarle vulvectomía y resección de vagina y todo el sistema ginecológico. Concluyó la intervención con una talla vesical extraperitoneal. El tumor se extiende hasta la porción inicial de la vagina y uretra. Se trata de un tumor maligno, bien diferenciado, que se ha comportado en una forma no habitual, con recidivas locales, cuando en apariencia el tumor había sido resecado en toda su extensión, y en esta última oportunidad, a pesar de ser un estadio avanzado, no hemos encontrado metástasis ni multicentricidad del tumor. La evolución posoperatoria fue sin complicaciones y se dio de alta al quinto día(AU)

The vulvar tumors are not uncommon among the different types of cancer involving females, but neither are the more frequent ones. This is the case of a female aged 59 that in 2000 is diagnosed with epidermoid carcinoma of clitoris, in 2004 is re-operated on by tumor relapse, and in 2009 she came again to our consultation and a vulvectomy, vagina resection and all gynecological system are carried out. Intervention concluded with an extraperitoneal vesical cutting. The tumor extends up to the initial portion of vagina and urethra. It is a malignant and well-differentiated tumor behaved in non habitual way with local relapses, when apparently the tumor was resected in all its extent, and in this last change, despite and advanced stage, there were neither tumor metastases nor multi-centralization. The postoperative course was free of complications receiving the discharge at fifth day(AU)

Clitoral epidermoid cyst secondary to blunt trauma in a 9-year-old child.

Epidermoid cysts are slowly growing tumors arising from invagination of the epidermis into the dermis traumatically or spontaneously. This implantation in the clitoris is most commonly induced by female genital mutilation. The reported cases with spontaneous onset of this clitoral lesion are scarce. Trauma other than female circumcision predisposing to the onset of the cyst has not been mentioned before. A nine-year-old girl was presented for swelling in the pubic region with the onset following an accidental trauma; the diagnosis was determined to be epidermoid cyst of the clitoris after a brief preoperative evaluation and an accurate surgical management.

[Clitoridal reconstruction after female circumcision]. / Chirurgie réparatrice du clitoris après excision rituelle.

Ritual sexual mutilations affect 140million of women around the world with over three millions new cases per year. France is not spared with 55,000 mutilated women living on our territory. There is a simple, reliable and reproductible reconstructive surgical technique described by the French urologist Pierre Foldès. This technique is still unknown by patients and plastic surgeons. Through a clinical case, the authors discuss the principles, results and key points of this procedure.