Clitoral inclusion cyst: a complication of type I female genital mutilation

Surgical management of a huge post-circumcision epidermoid cyst of the vulva presenting unusually in a postmenopausal woman: a case report

BACKGROUND

Epidermoid cysts of the external genitalia are one of the late complications of female genital mutilation. These cysts are usually small and painless. The presentation of a giant vulvar cyst in a postmenopausal woman has not been reported; the surgical management of a large cyst is often challenging.

CASE PRESENTATION

A 60-year-old, para VI, Ethiopian woman presented with an 18 cm by 12 cm sized, fluctuant, multi-lobulated, mobile, non-tender vulvar mass involving the mons pubis. She had undergone genital cutting and sewing during her childhood. Informed consent was obtained for surgery and the vulvar cyst was excised successfully without any significant bleeding or injury to the adjacent structures. Her postoperative course was smooth and histopathology confirmed epidermoid cyst of the vulva.

CONCLUSIONS

Huge epidermoid vulvar cysts following genital mutilation are rare and presentation in a postmenopausal woman has not been reported. Practitioners in areas where female genital mutilation is prevalent should be aware of the peculiar anatomic and technical aspects of the surgical removal of these giant vulvar cysts for successful therapeutic and cosmetic outcomes.

Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review

BACKGROUND

Because female genital mutilation/cutting (FGM/C) leads to changes in normal genital anatomy and functionality, women are increasingly seeking surgical interventions for their FGM/C-related concerns.

AIM

To conduct a systematic review of empirical quantitative and qualitative research on interventions for women with FGM/C-related complications.

METHODS

We conducted systematic searches up to May 2016 in 16 databases to obtain references from different disciplines. We accepted all study designs consisting of girls and women who had been subjected to FGM/C and that examined a reparative intervention for a FGM/C-related concern. We screened the titles, abstracts, and full texts of retrieved records for relevance. Then, we assessed the methodologic quality of the included studies and extracted and synthesized the study data.

OUTCOMES

All outcomes were included.

RESULTS

Of 3,726 retrieved references, 71 studies including 7,291 women were eligible for inclusion. We identified three different types of surgical intervention: defibulation or surgical separation of fused labia, excision of a cyst with or without some form of reconstruction, and clitoral or clitoral-labial reconstruction. Reasons for seeking surgical interventions consisted of functional complaints, sexual aspirations, esthetic aspirations, and identity recovery. The most common reasons for defibulation were a desire for improved sexual pleasure, vaginal appearance, and functioning. For cyst excision, cystic swelling was the main reason for seeking excision; for reconstruction, the main reason was to recover identity. Data on women's experiences with a surgical intervention are sparse, but we found that women reported easier births after defibulation. Our findings also suggested that most women were satisfied with defibulation (overall satisfaction = 50-100%), typically because of improvements in their sexual lives. Conversely, the results suggested that defibulation had low social acceptance and that the procedure created distress in some women who disliked the new appearance of their genitalia. Most women were satisfied with clitoral reconstruction, but approximately one third were dissatisfied with or perceived a worsening in the esthetic look.

CLINICAL TRANSLATION

The information health care professionals give to women who seek surgical interventions for FGM/C should detail the intervention options available and what women can realistically expect from such interventions.

STRENGTHS AND LIMITATIONS

The systematic review was conducted in accordance with guidelines, but there is a slight possibility that studies were missed.

CONCLUSION

There are some data on women's motivations for surgery for FGM/C-related concerns, but little is known about whether women are satisfied with the surgery, and experiences appear mixed. Berg RC, Taraldsen S, Said MA, et al. Reasons for and Experiences With Surgical Interventions for Female Genital Mutilation/Cutting (FGM/C): A Systematic Review. J Sex Med 2017;14:977-990.

Vulvar Epidermal Inclusion Cyst as a Long-term Complication of Female Genital Mutilation

We present a case report of a patient with epidermal inclusion cyst as a late complication of female genital mutilation (FGM). We describe the management of the patient, and a review of the literature. We report the clinical and pathological findings in a 37-year-old female patient from Nigeria, with a clitoral mass of 1 year duration. She declared to have an FGM since she was 5 years. The lesion was excised successfully with good cosmetic results. Histological examination revealed epidermal cyst with the presence of granular layer. An epidermal inclusion cyst can develop as a long-term consequence of FGM.

[Clitoral epidermoid cyst causing clitoromegaly. A rare case report]

Clitoromegaly is uncommon. It is mostly congenital, hormonal or tumoral. Epidermoid cyst is rare. It can be the consequence of trauma, but in some situations the cyst can be non-traumatic. We report the case of a 53-year-old woman who presented a misdiagnosis of clitoromegaly due to hormonal condition. Surgical exploration has highlighted an epidermoid cyst. This observation underlines the importance to evoke a cystic origin for clitoral hypertrophy and encourages us to propose imaging (ultrasound, MRI) in case of etiological doubt. The preoperative diagnosis must be made to preserve vascularization and innervation of the clitoris.

Excision of an enlarging vaginal epidermal inclusion cyst during pregnancy: a case report

OBJECTIVE

The study aimed to report the case of a patient with an enlarging and symptomatic epidermal inclusion cyst during pregnancy that required surgical excision.

MATERIALS AND METHODS

This study was a case report of a 28-year-old woman (gravida 8, para 5, aborta 2) at a gestational age of 18 weeks 5 days who reported a tender vaginal mass that had grown larger for more than a week.

RESULTS

An enlarging symptomatic cystic mass was surgically excised. Histopathologic findings of the excised mass were consistent with an epidermal inclusion cyst with surrounding moderate chronic inflammation and cyst rupture. The patient's symptoms resolved completely by her postoperative visit.

CONCLUSIONS

Although most epithelial inclusion cysts are asymptomatic and can be managed expectantly, cysts that enlarge or become symptomatic should be excised surgically.

Preputial epidermoid cyst: an atypical case of acquired pseudoclitoromegaly

OBJECTIVE

Clitoromegaly and pseudoclitoromegaly are rare conditions with both congenital and acquired causes. Acquired causes of adult onset have most frequently been reported to occur in the setting of female genital cutting or neurofibromatosis.

MATERIALS AND METHODS

Case report.

RESULTS

We describe the management of a 47-year-old postmenopausal woman who presented with a 1-year history of a progressive and painful enlargement of her clitoris. Surgical resection revealed an epidermoid, or follicular infundibular, cyst of the prepuce.

CONCLUSIONS

A review of the etiology underlying acquired clitoromegaly and pseudoclitoromegaly is presented. Previously published cases of pseudoclitoromegaly secondary to cysts are reviewed, all of which were congenital or secondary to female genital cutting, abscesses, or puberty. We report the first case of a postmenopausal woman with no previous history of female genital cutting or infection with a preputial epidermoid cyst. Local cysts or tumors should be considered in the differential diagnosis as causes of pseudoclitoromegaly.

Post genital mutilation giant clitoral epidermoid inclusion cyst in Benin City, Nigeria

OBJECTIVE

To report overall occurrence, and the mode of presentation and management of girls with post genital mutilation giant clitoral epidermoid inclusion cyst in an African subregion.

METHODS

This is a prospective experience with female patients who presented at two centers in Benin City, Nigeria, between January 2005 and December 2009 with clitoral epidermoid inclusion cyst following underground traditional female genital mutilation performed on neonates.

RESULTS

In total, 37 patients were seen with clitoral epidermoid inclusion cyst, 15 (40.5%) were post pubertal girls who could no longer cope with giant cyst that measured more than 3.5 × 6.5 cm in size at an average age of 17 (range 14-21) years. Ignorance, financial constraints, and the fear of possible prosecution by anti-female genital mutilation agencies were reasons for late presentation. Consequently, rapid increase in size of all cysts (100%), mass effect producing dragging discomfort in the vulva of 14 (93.3%) girls, social stigmatization of 12 (80%) girls by peers and spouses, sexual difficulty experienced by 10 (66.7%), and irritating bulge in the perineum of 10 (66.7%) girls, were the most common indications for surgical consultation. Outcomes of cystectomy that included total clitoridectomy performed on on an outpatient basis mainly with local anesthesia were encouraging with no incidence of recurrence recorded on 1-4 years postoperative follow-up.

CONCLUSION

Late presentation of girls with giant post genital mutilation clitoral epidermoid inclusion cysts was common. More campaigns against female genital mutilation and government policy aimed at encouraging patients with complications to seek early medical attention, and free treatment for those who present early are advocated.

Epidermal inclusion cyst of the clitoris 30 years after female genital mutilation

OBJECTIVE

To present a case report of a patient with epidermal inclusion cyst as a late complication of female circumcision, the management of the patient, and a review of the literature.

DESIGN

Case report and literature review.

SETTING

University hospital.

PATIENT(S)

A 37-year-old female from Guinea with a large clitoral mass of 6 months' duration.

INTERVENTION(S)

Complete history and physical exam of the patient and subsequent surgical resection of the cyst.

MAIN OUTCOME MEASURE(S)

Diagnosis, surgical management, and postoperative sexual function and emotional well-being.

RESULT(S)

Resolution of swelling and discomfort, satisfactory postoperative sexual function and emotional well-being.

CONCLUSION(S)

There should be awareness of one of the relatively common delayed complications of female genital circumcision and familiarity with its surgical management. Overall, surgical management appears to be effective, and there is no documented risk of recurrence.

Epidermoid cyst of the clitoris: an unusual cause of clitoromegaly in a patient without history of previous female circumcision

STUDY OBJECTIVE

To describe a rare cause of clitoromegaly.

SETTING

University Medical Center.

PARTICIPANTS

Patient.

INTERVENTION

Magnetic resonance imaging, surgical resection of the cyst, clitoroplasty.

RESULTS

Clitoroplasty with removal of the intradermal cyst and resolution of pain.

CONCLUSIONS

A 17-year-old immigrant female presented with clitoral pain associated with clitoromegaly. Epidermoid cysts are usually solitary, asymptomatic, slow-growing, proliferations of epidermal cells that are commonly present on the neck, scalp, face, or trunk. There have only been four reported cases of epidermoid cysts of the clitoris not associated with female genital mutilation. The cyst in this case was removed by local excision, and the patient's pain has resolved.

[Contribution of ultrasonography to the diagnosis of non-hormonal acquired clitoromegalia: a case report]

We report the case of a 30-year-old woman, consulting for a painful clitoromegaly which developed progressively and rapidly. The gyneco-endocrinological assessment ruled out hyperandrogenism. Ultrasound examination of the clitoris revealed the presence of a clitoral cyst. Acquired clitoromegaly is a symptom which occurs in severe hyperandrogenism. Other organic etiologies include clitoral cysts of various nature and solid tumors. An ultrasonographic examination should be included in the diagnostic work-up for acquired clitoromegaly.

Female genital mutilation

PURPOSE OF REVIEW

The purpose of this review is to aid the healthcare practitioner in caring for children, girls, and women who have undergone female genital mutilation or who are at risk for female genital mutilation.

RECENT FINDINGS

The bulk of the literature published in the area of female genital mutilation over the past year addresses the laws, social needs, immigration status and assimilation of African women who immigrate into western countries. Clinicians continue to publish case reports of complications and the surgical management of type III female genital mutilation during labor. Additionally, as people continue to try to eliminate female genital mutilation through human rights campaigns and the legal system, they have also become increasingly aware that understanding the motives behind this traditional practice may be an avenue towards change.

SUMMARY

The fundamental understanding of female genital mutilation will allow the clinician to address the emotional and physical needs of the children, girls, and women who have undergone this traditional practice or who are at risk for undergoing this practice. This understanding will allow the practitioner to individualize the history and physical examination, and to provide appropriate management with recognition and treatment of complications. Increased knowledge of the laws against female genital mutilation will allow the healthcare provider to educate and advise at-risk girls and women as well as their parents.

Female genital mutilation in developing countries: an agenda for public health response

There is uncertainty regarding reasons for persistence of the practice of female genital mutilation (FGM) and the best strategies for intervening effectively. In spite of strong international condemnation, the persistence of FGM in many countries suggests that it can only be effectively eliminated when its practitioners are presented with a safe alternative that preserves their culture and, at the same time, protects the health and well being of women. Recognizing that there is no simple solution to the problem, this paper argues that interventions for preventing FGM should be non-directive, culture-specific and multi-faceted to be of practical relevance. Such interventions should not only motivate change, but should also help communities to establish practical means by which that change can occur. Potentially effective prevention interventions targeted at local practitioners of FGM, parents, at-risk adolescents, health and social workers, governments, religious authorities, the civil society, and communities are presented.