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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 4  |  Page : 131-133

Epidermal inclusion cysts of the clitoris following female genital mutilation: Case series and review of literature


1 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital; Department of Obstetrics and Gynaecology, 68 Nigerian Army Reference Hospital, Lagos, Nigeria
2 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, Lagos, Nigeria
3 Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital; College of Medicine, University of Lagos, Lagos, Nigeria
4 Department of Obstetrics and Gynaecology, 68 Nigerian Army Reference Hospital, Lagos, Nigeria
5 Department of Obstetrics and Gynaecology, 68 Nigerian Army Reference Hospital, Lagos, Nigeria; University of Wisconsin-Madison, Madison, Wisconsin, USA

Date of Submission04-Dec-2022
Date of Decision16-Dec-2022
Date of Acceptance26-Dec-2022
Date of Web Publication22-Feb-2023

Correspondence Address:
Dr. Aloy Okechukwu Ugwu
Department of Obstetrics and Gynaecology, Lagos University Teaching Hospital, P. M. B. 12003, Surulere, Lagos
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/njecp.njecp_20_22

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  Abstract 


We present two cases of inclusion cysts of the clitoris following female genital mutilation (FGM) in a 5 and 35 years old, respectively. According to the World Health Organization, FGM is a violation of the rights of women and girl child. It is even more worrisome as evidence exists suggesting more involvement of health-care personnels in this act. The recent belief in some cultures that there may be decreased risk of complications following medicalization of the procedure may be untrue. The patients had an uneventful postoperative period and were discharged home afterward.

Keywords: Clitoris, epidermal cyst, female genital mutilation, Lagos Nigeria, medicalization


How to cite this article:
Ugwu AO, Owie E, Olamijulo JA, Okorafor UC, Odo CC, Okoro A C. Epidermal inclusion cysts of the clitoris following female genital mutilation: Case series and review of literature. Niger J Exp Clin Biosci 2022;10:131-3

How to cite this URL:
Ugwu AO, Owie E, Olamijulo JA, Okorafor UC, Odo CC, Okoro A C. Epidermal inclusion cysts of the clitoris following female genital mutilation: Case series and review of literature. Niger J Exp Clin Biosci [serial online] 2022 [cited 2023 May 29];10:131-3. Available from: https://www.njecbonline.org/text.asp?2022/10/4/131/370247




  Introduction Top


Female genital mutilation (FGM), also known as female circumcision or genital cutting, is a culturally determined practice, mostly performed in many parts of Sub-Saharan Africa and Asia.[1] It includes all procedures that involve complete or partial excision of the female external genitalia, or any other injury to the female genitals for nonmedical reasons.[1] There are four types of FGM, type 1 is the partial or total removal of the clitoral glans, type 2 is partial or total removal of the clitoral glans and the labia minora, with or without removal of the labia majora, type 3 is infibulation, whereas all other harmful procedures to the female genitalia for nonmedical purposes, for example, pricking, piercing, incising, scraping and cauterizing the genital area is type 4.[1]

So many reasons abound for FGM which varies from one ethnic group to the other, some of these reasons may be based on superstitious beliefs, to ensure perpetual virginity and preservation of chastity, to improve fertility, reduce sexual passion and promiscuity, prevention of maternal mortality, esthetic indications, or for traditional and cultural practices;[1],[2] however, despite these reasons, the adverse effects of this harmful procedure to the mental and physical health of our women are underreported. These complications depend on the degree of the initial mutilation and can occur early following the procedure or it may occur several years later. One of such late complications includes the formation of epidermal inclusion cyst of the vulva.[2],[3] Epidermal inclusion cysts are usually solitary, asymptomatic, slow-growing tumors that can arise spontaneously but mostly following traumatic implantation of the epidermis into the dermal or subcuticular region.[4]


  Case Reports Top


Case 1

She was a 35-year-old nulliparous female who presented to our gynecology clinic with complaints of swelling in the perineal region for the past 20-year duration, with associated dyspareunia of 3 years. The swelling was initially very small at the onset before it increased to its present size. When first noticed was initially the size of a pea, which showed very slow growth over time till it reached its present size. It became more noticeable following her wedding 3 years ago. There were no urinary symptoms, she had female genital cutting at 15 years of age. No history of ingestion of hormonal drugs in any form intake. On examination, there was a well-circumscribed, mobile, round, soft, cystic, fluctuant mass measuring about 8 cm × 5 cm in the clitoral area, a little above the urethral meatus. There were no skin changes, no change in body temperature, and no signs suggestive of virilization. The hormone profile was essentially normal and ultrasound showed no vascularity. She was counseled on her condition and the possible cause. Informed consent was sought and obtained for surgical removal under spinal anesthesia. She had surgical excision and repair [Figure 1]a and [Figure 1]b.
Figure 1: (a) Clitoridal cyst in a 35-year-old before surgery. (b) Clitoridal cyst in a 35-year-old patient after surgery. (c and d) Clitoridal cyst in a 5-year-old pupil pre- and postsurgery

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Case 2

She is a 5-year-old pupil who developed a 3-year history of clitoral enlargement following “female circumcision” in a maternity home. Physical examination revealed a 5 cm × 3 cm clitoral cyst. Her ultrasound scan showed a normal-sized uterus. It depicted uniform parenchymal echo texture. Both adnexae were free. The Pouch of Douglas was empty. Using high-resolution techniques, perineal examination showed an enlarged clitoris with a thickened wall and a cystic space within and showed no vascular supply. Her hormone profile was within normal values, no evidence of virilization. Her parents were counseled on her condition and the possible cause. Informed consent was sought and obtained for surgical removal under general anesthesia. The vulva and perineum were cleaned with antiseptic solution and draped. Following the insertion of size 6 Foley catheter, the surrounding skin of the clitoral cyst was infiltrated underneath with adrenaline. An inverted U-shaped incision was made on the mucocutaneous junction. The skin was held with Allis tissue forceps and gently dissected off the cyst. The cyst was gently enucleated intact with the aid of a blunt dissection. The redundant skin was trimmed and the remains of the clitoral tissues were reconstructed using vicryl 3/0. The blood loss was negligible and hemostasis was well secured. The cyst was submitted for histological examination [Figure 1c and d].


  Discussion Top


FGM has become a social norm in some cultures, the family pressure to conform to what others do and believe in, as well as the need to be integrated and accepted socially in a community, and the fear of being rejected may be some of the motivations to those who perpetuate this act. People have come to believe that it is part of raising a girl child, and a way to prepare her for adulthood and marriage, worst still is the recent medicalization of the procedure.[1]

Clitoridal inclusion cyst is one of the numerous cysts that can occur in female external genitalia. It usually occurs following the history of trauma or FGM.[4]

The widely accepted pathophysiology of the formation of clitoridal inclusion cyst is that it occurs following invagination of the epithelial islands of cells during the time of tissue healing at the site of the excised clitoris.[5] This implanted epidermal fragments may contain active sebaceous glands which will lead to subsequent cyst formation from accumulated sebaceous secretions.[5] Others have also suggested that the use of herbal concoctions after excision or surgical site infection may have a role in its development. It is usually asymptomatic as in our 5-year-old infant which was discovered by the parents but may present with pain or dyspareunia when it became inflamed from repeated trauma as in our second case who had dyspareunia following repeated coital activity after wedding. Ultrasound imaging of the cyst may suggest benign lobulations and septations in a cystic swelling with minimal or no vascularization.[2],[5],[6],[7]

The common differential diagnosis of clitoridal inclusion cyst includes Gartner's duct cyst, cyst of the canal of Nuck and cyst of Skene's glands. Clitoral enlargement can also occur in disorders of sexual development.[5]

The mainstay of treatment is surgical excision with enucleation of the cyst and its capsule or marsupialization of the walls.


  Conclusion Top


The practice of FGM is sometimes motivated by cultural beliefs about what is considered acceptable sexual behavior by communities, this impression needs to be corrected as it is a violation of women rights, especially the recent medicalization of the procedure.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
World Health Organisation (WHO). Female Genital Mutilation: Fact Sheet; 2016. Available from: http: https://www.who.int/news-room/fact-sheets/detail/female-genital-mutilation.[Last accessed on 2022 Nov 11].  Back to cited text no. 1
    
2.
Birge O, Erkan MM, Serin AN. Case report: Epidermoid inclusion cyst of the clitoris as a long-term complication of female genital mutilation. J Med Case Rep 2019;13:109.  Back to cited text no. 2
    
3.
Johnson LT, Lara-Torre E, Murchison A, Garcia EM. Large epidermal cyst of the clitoris: A novel diagnostic approach to assist in surgical removal. J Pediatr Adolesc Gynecol 2013;26:e33-5.  Back to cited text no. 3
    
4.
Prasad I, Sinha S, Bharti S, Singh J, Dureja S. Epidermal inclusion cyst of the clitoris: A case report. Cureus 2022;14:e29066.  Back to cited text no. 4
    
5.
Orisabinone IB, Oriji PC. Large clitoridal inclusion cyst following female genital mutilation/cutting – A case report. Gynecol Obstet Case Rep 2020:6;1-3.  Back to cited text no. 5
    
6.
Rabiu A, Abubakar IS. Retention clitoral cyst following female genital cutting; Clitoral cyst excision: A case report. Trop J Obstet Gynaecol 2019;36:136-9.  Back to cited text no. 6
  [Full text]  
7.
Al-Ojaimi EH, Abdulla MM. Giant epidermoid inclusion cyst of the clitoris mimicking clitoromegaly. J Low Genit Tract Dis 2013;17:58-60.  Back to cited text no. 7
    


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