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African Journal of Reproductive Health
Women's Health and Action Research Centre
ISSN: 1118-4841
Vol. 9, Num. 2, 2005, pp. 118-124
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Untitled Document
African Journal of Reproductive Health, Vol. 9, No. 2, August, 2005, pp.
118-124
Urogenital Complications among Girls with Genital Mutilation: A Hospital-Based
Study in Khartoum
Lars Almroth1, Hibba Bedri2, Susan
El Musharaf1,2, Alia Satti2, Tayseer Idris2,
M SIR K Hashim2, Gaafar I Suliman2, and Staffan Bergström1
1Division of International Health, Karolinska Institutet,
Stockholm, Sweden. 2Children's Emergency Hospital, Khartoum, Sudan
Correspondence: Lars Almroth IHCAR, Division of International Health, Karolinska
Institutet, SE-17176 Stockholm, Sweden. E-mail: L.Almroth@telia.com; Tel: +46705495195;
Fax: +468311590
Code Number: rh05031
Abstract
To explore paediatric complications of female genital mutilation
(FGM), 255 consecutive girls aged 4-9 years presenting to an emergency ward
in Sudan were included in this clinical study. Full examination, including
inspection of genitalia, was performed. Dipsticks for nitrite and leucocytes
were used to diagnose suspected urinary tract infection (UTI). Girls with a
form of FGM narrowing vulva had significantly more UTI than others, and among
girls below the age of seven there was a significant association between FGM
and UTI. Only 8% of girls diagnosed as having UTI reported urogenital symptoms.
In spite of the fact that 73% of the girls subjected to FGM were reported to
have been bedridden for one week or more after the operation, only 10% stated
immediate complications. We conclude that FGM contributes significantly to
morbidity among girls, a large share of which does not come to medical attention.
(Afr J Reprod Health 2005; 9[2]: 118-124)
Résumé
Afin d'explorer les complications de la mutilation génitale
féminine (MGF), nous avons inclu dans cette étude clinique les
filles consécutives âgées de 4 à 9 ans qui viennent
au service des urgences au Soudan. On a fait passer un examen compréhensif
y compris l'inspection des organes génitaux. Le diagnositic de la suspicion
de l'infection urinaire (IU) a été fait à l'aide de la
jauge pour les nitrites et les leucocytes. Les filles qui avaient une sorte
de vulve qui a été pincé par la MGF avaient beaucoup plus
de IU que les autres. Parmi les filles âgées de moins de sept
ans, il y avait un lien important entre MGF et IU. Il n'y avait que 8% des
filles qui avaient les symptômes de l'infection urogénitale. Malgré le
fait que 73% des filles qui avaient la MGF ont été alitées
pendant une semaine ou plus après l'opération chirurgicale, seules
10% avaient affirmé des complications immédiates. Nous concluons
que la MGF contribue de manière importante à la morbidité chez
les filles et qu'une grande majorité des cas ne viennent pas à l'hôpital.
(Rev Afr Santé Reprod 2005; 9[2]: 118-124)
Key Words: Urogenital, morbidity, FGM, UTI, Sudan
Introduction
An estimated two million girls undergo female genital mutilation
(FGM) every year. More than 130 million currently living girls and women have
experienced the mutilating operation. They live mainly in north-east Africa,
but FGM is common in a belt reaching from east to west Africa.1 Sudan
is one of the countries where the practice of FGM is widespread. About 90%
of women in northern Sudan have undergone genital mutilation.2,3 FGM
is not only a problem in Africa, however. It has been described as being practised
in southern parts of the Arabian peninsula,1 in Malaysia4,5 and
Indonesia.6 Large immigrant groups from areas where FGM is prevalent
are now present in Europe, North America and Australia.1
A WHO classification7 recognises four types of
FGM: (i) excision of part or the entire clitoris; (ii) excision of the clitoris
with partial or total excision of the labia minora; (iii) infibulation. Parts
or all of the external genitalia (the clitoris, labia minora with or without
the inner surfaces of labia majora) are excised. The raw surfaces of the labia
are brought together by sutures, or traditionally by thorns, and legs are tied
together; (iv) other mutilating practices affect the female genitalia, such
as scraping, burning or piercing.
Complications of FGM have not been well elucidated in research.
Few studies have been appropriately designed to measure the health effects.8,9 Findings
about complications have been based on self-reported problems by adult women,
case reports or theoretical assumptions. To our knowledge, there are very few
clinical studies or other systematic research on the primary victim of the
practice the girl-child. One can argue over the necessity to conduct
research on the complications of harmful practices like FGM. After all, the
overall aim is to abolish FGM, and we already know that it causes pain and
possibly other serious complications. It is, however, often neglected in the
debate that this ancient tradition also carries positive values for those practising
it. We believe further research is important to better understand the practice
and to use correct arguments in campaigns against it, avoiding dissonance between
people's live experiences and
claims pronounced by eradication campaigns. Most of those who oppose
the practice in Sudan use medical complications as arguments.2,10-14 Research
findings would also make it possible to improve health care for girls
and women facing complications of FGM.
This paper was, therefore, written to confirm or reject
two hypotheses: firstly, that FGM has significant immediate adverse health
effects on the girl-child and, secondly, that FGM is significantly associated
with urinary tract infections in girls.
Methods
Patients
The research team worked daytime in the emergency ward
of the Children's Emergency Hospital, Khartoum, on selected days from
March to August 2004. During this period all guardians of girls aged
4-9 years presenting to the emergency ward were asked for informed consent
to participate in the study. Out of 255 consecutive cases, who all agreed
to take part in the general part of the study, 249 accepted full participation
including inspection of the genitalia. All the patients constitute our
study population, which was divided into cases with signs and symptoms
of UTI and referents without such signs and symptoms.
Social and medical history were registered. The guardians,
and the girl when appropriate, were asked about the FGM operation. Full
examination, including inspection of genitalia, was performed on those
who consented to it. Type and extent of genital operation, if present,
were registered, as well as information on other health conditions.
Diagnosis of UTI
Urine culture indicating a significant amount of bacteria
is the golden standard for diagnosing
UTI. This was not possible to arrange in this study. We rather
opted for UTI diagnosis based on dipsticks in combination with
symptoms, which has shown satisfactory sensitivity and specificity
for starting presumptive treatment in children.15,16 Urine
was analysed by dipsticks (Multistix® 5, Bayer Diagnostics
Mfg., Ltd. Bridgend, UK) for leucocytes (leucocyte esterase) and
nitrite (product of Gram-negative bacteria). Diagnostic criteria
for UTI were:
- positive nitrite test independent of symptoms,
or
- + for leucocytes (15/µl) in combination
with symptoms from the urinary tract, or
- ++ for leucocytes or more (>70/µl)
irrespective of symptoms.
Axillary temperature was measured. In the presence
of UTI criteria and fever more than 38.5°C, the case was diagnosed
as febrile UTI, assumed to be pyelonephritis in the absence of
other explanations for the fever.
Statistical Analysis
Differences between cases and referents were analysed
by calculating odds ratios (OR) with 95% confidence intervals (CI).
Ethical Considerations
The study is by its nature descriptive, and no
more examinations were performed than would normally be the case.
One can argue that inspection of the genitalia is usually not done,
which might be true, but in severely ill children presenting to
the emergency ward, inspection of genitalia should be part of the
routine examination in this age group. Otherwise important clinical
findings might be missed. In this study, even patients with mild
symptoms, which were not obviously related to the genitalia, were
asked to participate. This was necessary since it is not known
what kind of symptoms could be related to FGM. Symptoms from the
genital tract would rather be under-reported, while
symptoms from other parts of the body over-emphasised. If the
genitalia had not been inspected, this hidden morbidity could
have been overlooked.
The guardians were thoroughly informed
about the nature of the study, and they gave their
informed consent. Specially trained female Sudanese
medical doctors (AS, HB, SE, TI) did all clinical examinations
and data collection. Examination, including inspection
of the genitalia, took place in a calm and secluded
room with no other person present than the parents
and the physician on duty.
Patients who were not willing to
participate in the study had the same procedures done
as is usually the case at this hospital. Participating
cases diagnosed as having UTI received free treatment.
Before the onset of data collection the different studies
were approved by ethics committees of the Children's
Emergency Hospital, Khartoum, Sudan, and the Karolinska
Institutet, Sweden.
Findings
Out of 255 girls who were enrolled
for the study, the guardians of 249 girls accepted
full examination including inspection of the genitalia.
The median age was six years (range 4-9 years). The
most common complaints were fever (62%), followed by
cough (47%), vomiting/diarrhoea (22%) and abdominal
pain (19%). Twelve girls (4.7%) had complaints about
the urogenital area, mainly burning micturition. No
girl presented with immediate effects of recently performed
FGM operation.
Fifty two girls (20%) had undergone
FGM. For a large share of the rest, there was an intention
to do it, leaving 61 (24%) allegedly without FGM in
the future. Out of the 48 girls with FGM, on whom it
was possible to inspect genitalia to verify the form
of FGM, 13 (27%) had WHO type I, three (6.3%) had WHO
type II and 32 (66.7%) had WHO type III.
Altogether, 38 girls with FGM (73%)
were reported to have been bedridden for one week
or more following the FGM operation. In spite of this, only five
of the 52 girls with FGM (10%) were said to have had
immediate complications. One of them had urine retention
and fever, and the others had shock with unconsciousness,
fever, wound infection and urine retention. All these
five FGM operations were performed by midwives. The
differences between those with and those without FGM,
regarding previous history of symptoms from the genitalia
(44% and 40% respectively) or previously having sought
medical care for genital problems (21% and 13% respectively),
were not significant.
According to the diagnostic criteria,
20 out of 51 girls with FGM (39%) and 61 out of 203
without FGM (30%) were diagnosed as having UTI (difference
not significant). Only three had positive nitrite;
the rest of the diagnoses relied on significant amounts
of leucocytes and symptoms. Among girls below seven
years of age, however, those with FGM had a significantly
higher risk of UTI than those without FGM, 20% of UTI
cases having FGM against only 4.5% of the others (OR
= 5.2; 95% CI 1.4, 20.7). UTI was not over-represented
among those who had undergone FGM during the last year,
as compared to those who had it done earlier. Girls
who were found by inspection to have a form of FGM
that narrowed the vulva had significantly more UTI,
according to the criteria, than others (57% and 30%
respectively) (OR = 3.0; 95% CI 1.2, 8.0). Only five
girls had febrile UTI/pyelonephritis two of
52 girls with FGM and three of 203 without FGM.
Most girls with UTI did not have
current complaints from the urogenital tract. Only
8% of those diagnosed as having UTI answered positively
when asked about urinary tract symptoms. In comparison,
3% of girls with other diagnoses reported such symptoms.
The possibility that UTI criteria
have low specificity for UTI, leading to some false
positive UTI diagnoses, made us test leucocytes in
urine as an independent factor, disregarding the underlying
cause. Among girls with FGM, 25% had significant leucocyturia
(more than or equal
to ++, 70/µl) as compared to 21% among those without FGM (ns). Neither form
of FGM, age at operation, nor vulva narrowing showed any association with leucocyturia.
Girls under seven years of age with FGM tended to have leucocyturia more frequently
(29%) than those without FGM (13%), but the difference was
not significant.
Discussion
This study shows a possible relationship
between FGM and urinary tract infection. While several
results indicate the existence of severe compli-cations
for the girl, it is also clear that the full extent
of morbidity impact of FGM on the girl-child is not
visible within the health care system.
Diagnosis of UTI is based on the
presence of a significant amount of bacteria in the
urine, and the most appropriate method for diagnosing
this is by culture. For various logistical and practical
reasons, it was not possible to organise this in the
current setting. We, therefore, used dipsticks in combination
with symptoms to diagnose UTI. There are, admittedly,
disadvan-tages with this strategy. Diagnosing UTI in
children by dipsticks positive for leucocyte esterase
and/or nitrite has shown high sensitivity and specificity
(88% and 96% respectively) in a meta-analysis.15 The
2+ for leucocyte esterase or positive nitrite has been
suggested as a strategy for presumptive treatment of
UTI in children.16 The high proportion diagnosed
as having UTI in the present study implies an over-diagnosis
of UTI and that these criteria do not work in the present
clinical setting. There might be several reasons for
this. Other conditions such as schistosomiasis, which
are endemic in Sudan, might also cause leucocyturia.
Genital mutilation might cause environmental
disturbances that possibly result in accumulation of
leucocytes, and the anatomical changes brought about
by the operation possibly prevent the free flow of
urine and normal cleaning when the sides
are stitched. This may explain why girls having undergone a form
of FGM narrowing the vulva were more likely to
be classified as having UTI. The results indicate
that there might be an association between FGM
and UTI, diagnosed by the stated criteria for
girls below seven years. This possible association
has to be interpreted bearing in mind the limitations
of the metho-dology. Irrespective of where the
leucocytes stem from - urinary bladder, urethra
or vulva - their presence indicates a disruption
of the normal state with, to some extent, inflammation.
Labial
adhesions and urethral
strictures are known
predisposing factors
for UTI in girls. Urethral
strictures are rare,
and usually result from
trauma. The female urethra
is well protected from
accidental trauma during
childhood,17 but
iatrogenic trauma, for
instance, during the
FGM operation, might
cause urethral stricture.
Spontaneous labial adhesion
is associated with local
inflammation, and in
the combination of the
hypoestrogenic conditions
of the pre-pubertal vulva,
the condition might cause
vulvo-vaginitis,18 asymptomatic
bacteriuria19 and
recurrent UTI.18,20 Theoretically,
any form of FGM where
the two sides heal together
to any degree would be
similar to labial adhesions
as risk factor for vulvo-vaginitis,
asymptomatic bacteriuria
and recurrent UTI. There
have been case reports
and descriptive studies
indicating a relation
between UTI and FGM,5,21,22 but
until now no systematic
study on this possible
association in girls. In
adults, however, UTI
has been shown to be
significantly associated
with FGM. Among pregnant
women, 22.9% of those
with FGM had E. coli in
their urine culture,
compared to 4.6% among
controls.23 In
a large unselected sample
from Sudan 1962-1966
(n = 4024), 28% of women
with FGM type III had
positive urine cultures,
compared to 8% of those
with FGM type I or without
FGM.24
The
anatomical changes due
to FGM, leading to micturition
problems, difficulties
in emptying the bladder
due to strictures or
painful micturition,
provide a plausible theoretical
framework
for an association between FGM and UTI. The FGM operation could,
however, also alter the local environment in
the vulva, leading to increased risk of infections.
In a study performed in Khartoum in 2004 we demonstrate
a highly significant association between the
anatomical extent of FGM and primary infertility.25 Laparoscopic
post-inflammatory adnexal changes were not the
only explanation for the strong association,
since infertile cases without such adnexal pathology
showed similar association. Thus, one can hypothesise
that the FGM operation leads to other physiological
or functional changes in the genitalia. This
hidden pathology in the girl-child does not present
clinically until the young woman is unable to
conceive, which poses a challenge to both paediatricians
and gynaecologists.
The
complications for girls
described in literature
derive mainly from data
reported by adult women.
To the best of our knowledge
there are only a few
published studies carried
out on girls. Descriptive
hospital-based studies
from Nigeria found that
the commonest presenting
complications following
genital mutilation in
girls relate to micturition
(dribbling incontinence,
straining and retention
of urine and urinary
tract infections)22 and
that unintentional labial
fusion with sequalae
is common.21 Early
complications, such as
haemorrhage, septicaemia
and tetanus were encountered,
but not to the degree
the authors expected.21 Kabira
et al26 reported
an unpublished study
from Kenya indicating
that FGM contributes
to high rates of school
dropout for girls. A
study on the Somali Family
Health Survey shows excess
female child mortality
in the age group 5-15
years, which is when
FGM is performed.27 Other
factors than FGM, such
as favouring sons when
feeding and seeking medical
care for children, could
contribute to this excess
mortality. The authors,
however, also found that
the more severe forms
of FGM (assuming that
daughters had the same
form of FGM as their
mother) had higher child
mortality than less severe
forms.
In the
present study we found
no clinical signs of
current direct complication
of FGM, which may be
due to the small sample
size. However, there
were also very few immediate
complications reported.
In clinical paediatric
practice in Sudan, it
is rare to see complications
of FGM. There may be
several reasons for this,
for instance: (i) reluctance
among mothers/family
members to seek paediatric/medical
care in cases of immediate
complications after FGM;
and (ii) non-recognition
of the entity of FGM
as genital trauma within
the field of paediatrics.
The
findings that only 8%
of girls with UTI reported
urogenital symptoms and
that only 10% stated
immediate complications
related to the operation,
in spite of the fact
that 73% of the girls
subjected to FGM had
been bedridden for one
week or more after the
operation, imply that
symptoms from this part
of the body are under-reported.
A previous study from
Sudan had shown that
only a small fraction
of immediate complications
were brought to medical
attention.28 The
under-reporting of symptoms
from the urogenital tract
clearly shows the importance
of asking specific questions
relating to this area,
routinely performing
urinalysis, irrespective
of complaints, and inspecting
the genitalia on more
liberal grounds. Even
though genital inspection
should be a part of the
routine examination of
paediatric patients,
such inspection is, according
to our observations,
rarely done. This reluctance
to ask about symptoms
from the genital tract
and to inspect the genitalia
implies a failed diagnosis
with inappropriate treatment,
which in turn might increase
the risk of further complications.
In
conclusion, female genital
mutilation contributes
significantly to morbidity
in childhood. A large
share of this does not
come to medical attention
because symptoms are
under-reported or not
taken into account by
the doctor. Due to lack
of scientific studies
on how genital mutilation
affects girls there is
scant knowledge of which
signs, symptoms and disease
entities relate to
FGM, but awareness about this entity of genital trauma in girls
needs to be raised
among paediatricians
and others working
with children.
Acknowledgements
This
study was funded
by the Swedish
International Development
Agency (Sida/SAREC),
the Regional Research
Council of Northeast
Skåne, Sweden,
and the Department
of Paediatrics,
Centralsjukhuset,
Kristianstad, Sweden.
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