18: Reconstruction after female genital mutilation

Abstract

The primary objective of this video is to demonstrate the surgical management of a case of female genital mutilation (FGM). FGM includes all procedures that involve partial or total removal of the external female genitalia or injury to the female genital organs for non-medical reasons. A review of clitoral anatomy and the classification scheme of FGM will also be addressed. A 44 year-old female with a history of FGM as an infant presented with dyspareunia. She experienced FGM at age 18 months as part of a traditional rite of passage for females in North Sudan. She described undergoing excision of a portion of the external vulva and then having the remainder of the two labia sewn together (infibulation). Her dyspareunia was characterized by pain with penetration as well as pain during and after intercourse. She denied any urinary or menstrual complaints. On exam, she was found to have fusion of her labia minora leaving her with an introitus of approximately two centimeters. The clitoris was neither visualized nor palpable. The urethra was not visualized. Surgical management included reconstruction of the external genitalia with placement of an autologous vaginal epithelial graft. Reconstruction was accomplished via separation of the fused labia in order to create a larger introitus. At this point of the procedure, it was clear there was no intact clitoris. A vaginal graft was placed at the level of the medial mucosal defect resulting from defibulation. The postoperative course at one month was notable for slight lateral deviation of the patient’s urine stream but no other issues. Evaluation and management of patients who have undergone FGM requires a thorough understanding of clitoral anatomy. Definitive diagnosis can only be made during surgical exploration. Providers must discuss possible outcomes of surgery with regard to functional and cosmetic outcomes with patients.