Large inclusion cyst complicating female genital mutilation

We report a case of an inclusion cyst, resulting from female genital mutilation (FGM), which enlarged to such a degree that it restricted the patient's movement. This report aims to raise the awareness of the medical community to the dangers that arise from a common remote complication of FGM.


Introduction
Female genital mutilation (FGM) refers to all procedures involving partial or total removal of the external genitalia or other injury to the genital organs, for non-medical reasons. 1 According to the WHO classification, there are four types of FGM: type I, partial or total removal of the clitoris and/or the prepuce (clitoridectomy); type II, partial or total removal of the clitoris and the labia minora, with or without excision of the labia majora (excision); type III, narrowing of the vaginal orifice with the creation of a covering seal by cutting and positioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulations); and type IV, an unclassified category including all other harmful procedures to the female genitalia for non-medical purposes, for example, pricking, piercing, incising, scraping and cauterization. 2 FGM is performed on 89% of Sudanese women, with the most common procedure being type III. 3 Physical short-term and long-term complications have been well documented. 4,5,6 In spite of this, medicalization of FGM has increased in areas of high prevalence, which reinforces and legitimizes this practice and hinders the efforts towards its elimination. 7 We report a case of an inclusion cyst resulting from female genital mutilation which enlarged to the degree of restricting the patient's movement. This report aims to raise the awareness of the medical community to the dangers that arise from common remote complications of FGM.

Case Report
A 40-year old grand-multiparous woman presented to Kassala New Hospital (Al-Saudi) with painful genital swelling. She had experienced spontaneous vaginal deliveries, the last five years ago. She was circumcised before school age. De-infibulation, re-infibulation and episiotomy were performed after each delivery. Three years ago, she noticed a painless swelling in her vulva which was gradually increasing in size. She did not tell anybody about it. Sexual intercourse became difficult, thus she abstained for almost two years. Her movement became restricted, and after being unable to walk due to severe pain for a few days, she decided to seek treatment. She was afebrile, with pulse 80 beats per min, blood pressure (BP) 130/70 mmHg. Local examination showed a large cystic swelling originating in the circumcision line and covering the introitus (Figure 1). A diagnosis of inclusion cyst at the site of circumcision was made. Her hemoglobin concentration was 10.7 g/dL and her urine analysis was clear.
After inserting an indwelling Foley catheter, the cyst was excised under spinal anesthesia through a vertical incision in the skin. The cyst was easily removed by dissection along the lines of cleavage. The cyst measured 11¥10.6 cm and weighed 1.9 kg. The redundant skin was excised and the edges were approximated. There were no complications following surgery and the patient was discharged on Day 2 after surgery.

Discussion
The development of inclusion cyst along the line of the scar has been reported as a remote complication of FGM. 8,10-12 These result from the embedding and proliferation of keratinized epidermal cells of hair follicles and sebaceous glands within a circumscribed space of the dermis in the stitched area. 8,9 This is likely to occur during reinfibulation, which is a secondary form of FGM performed on women who have undergone deinfibulation (being cut open) to allow childbirth. 13,14 Reinfibulation is usually performed by almost all birth attendants in northern Sudan, as FGM is practiced by more than 90% of the female population. 3 The complications after reinfibulation might be severe because the process exposes the woman to a repeated risk of tissue damage. 13 Multiparous women usually have heavily scarred and deformed perineums due to repeated episiotomies, deinfibulations and reinfibulations and more frequently present with inclusion cyst formation. 14 Reinfibulation is the most likely cause in this case.
These cysts grow slowly, usually without symptoms, may become infected causing pain and discomfort. They may grow to a size that causes coital difficulty but rarely reach a size that restricts movement, as in this case. Kroll and Miller reported a large inclusion cyst in a Somali woman that required the use of both hands so it could be carried while walking. 15 Apart from this inconvenience, inclusion cysts cause disfigurement, anxiety, shame and fear of cancer. They may become infected, which causes severe pain and requires emergency surgery. It is important that health professionals become aware of the complications of FGM and recognize its seriousness. Surgical treatment of inclusion cyst complications from FGM was described by Rouzi. 10 The operation consists of dissection of the cyst and approximation of the skin. It is an easy operation that health professionals must know how to perform.
In conclusion, this is a neglected inclusion cyst that had been left to reach a serious stage. We recommend encourageing patients with FGM complications to seek medical advice and discourage birth attendants carrying out reinfibulation after childbirth.