Case Report

Clitoral Cyst: A Rare Cause of Urination Discomfort

Kouka SCN^1*, Cisse M¹, Gueye L², Thiam M², Diop M¹, Jalloh M³, Tessa V¹, Diallo Y¹, Cisse ML² and Sylla C¹

¹Department of Urology, Faculty of Health Sciences, University Iba Der Thiam of Thies, Senegal

²Department of Gynecology, Faculty of Health Sciences, University Iba Der Thiam of Thies, Senegal

³Department of Urology, University Cheikh Anta Diop De Dakar, Senegal

Submission:January 19, 2024;Published:February 09, 2024

*Corresponding author: Saint Charles Nabab Kouka, Department of Urology, Faculty of Health Sciences, University Iba Der Thiam of Thies, Senegal, Email: saintkouka@yahoo.fr

How to cite this article: Kouka SCN, Cisse M, Gueye L, Thiam M, Diop M, et al. Clitoral Cyst: A Rare Cause of Urination Discomfort. JOJ Urology & Nephrology, 2024; 8(4): 555746 DOI:10.19080/JOJUN.2024.08.555746.

Abstract

Excision is female genital mutilation (FGM) which consists of the total or partial removal of the clitoris, sometimes accompanied by mutilation of the labia minora. The authors report the case of a giant clitoral cyst after female external genitalia mutilation occurring in a young woman 29-year-old several years after having undergone excision. The vulvar location of this large mass was the cause of uncomfortable urination and aesthetic discomfort. Surgical excision of this mass gave good aesthetic and satisfactory functional results in this patient.

Keywords: Clitoral Cyst; Urination Discomfort; Surgical Treatment; Long-term complications; Surgical excision

Abbreviations: FGM: Female Genital Mutilation; WHO: World Health Organization

Introduction

The WHO, UNICEF, and UNFPA issued a joint statement in 1997 defining Female genital mutilation (FGM) as “all procedures involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural or other non-therapeutic reasons” [1]. FGM is a violation of the human rights of girls and women [1-3]. The World Health Organization (WHO) estimates that more than 200 million girls and women alive today have undergone female genital mutilation (FGM) in 30 countries in Africa, the Middle East and Asia countries [1]. In Senegal, nearly 2 million girls and women have undergone FGM, and it is most often practiced on young girls between childhood and the age of 15 [4]. The practice of FGM leads to several gynecological, obstetrical, urological, psychological, psychosexual, and social complications as evidenced by several publications [4-8]. Urological complications can be painful urination, repeated acute urinary retention due to hematocolpos, chronic urinary and vulvovaginal infections, urogenital fistula due to obstructed delivery, infertility, and bladder stones due to stagnation of urine. Clitoral cysts are a rare complication that can cause uncomfortable urination [8]. The cost of treating the health complications of FGM in 27 high-prevalence countries amounts to US$1.4 billion per year [1]. We report the case of an epidermoid cyst of the clitoris causing urination problems in a young woman who underwent FGM during her childhood.

Case Report

We report the case of an epidermoid cyst of the clitoris causing urination problems in a 29-year-old woman who underwent FGM during childhood. Physical examination in the gynecological position revealed a large, pedunculated, painless, soft, non-pulsatile, smooth mass appended to the clitoris and covering the urethral meatus, the vulva and the perineum (Figure 1). On examination of urination in a squatting sitting position, it obstructed the urethral meatus, and we noted an absence of urination stream and uncomfortable urination. The treatment consisted of excision of the mass under loco-regional anesthesia (Figure 1). The postoperative course was simple with a resumption of sexual activity after 45 days and urination was normal. Histological examination of this mass showed a single cystic cavity containing keratin without inflammatory reaction and an absence of signs of malignancy. After one year of regular follow-up, the patient did not present a recurrence.

Discussion

According to the WHO, 200 million girls and young women around the world will have undergone some form of female genital mutilation in 2023 [1]. In Senegal the national prevalence of excision varies depending on the region and nearly 2 million girls and women have undergone FGM. In total, 25 per cent of girls and women have undergone this practice, ranging from more than 90 per cent in t Kedougou region [2]. The prevalence of FGM varies according to socio-cultural level, socio-economic level, level of education, according to place of residence and from one ethnic group to another [1,2]. In Senegal, 16 per cent of girls under the age of 15 have undergone FGM. Most FGM is performed on girls under 5 years old, and rarely after 10 years [2]. In Senegal, although prohibited, types I and II FGM are still practiced in certain communities still anchored in traditions [2, 5-7]. In 2016 WHO and UNICEF Classified FGM into 4 categories [1]:

WHO classification [1]:

• Type I: Partial or total removal of the clitoris (clitoridectomy) and/or the prepuce.

• Type I a: Removal of the prepuce/clitoral hood (circumcision).

• Type I b: Removal of the clitoris with 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 II a: Removal of the labia minora only.

• Type II b: Partial or total removal of the clitoris and the labia minora.

• Type III c: Partial or total removal of the clitoris, the labia minora, and the labia majora.

• Type III: Narrowing of the vaginal orifice with the creation of a covering seal by cutting and appositioning the labia minora and/or the labia majora, with or without excision of the clitoris (infibulation).

• Type IIIa: Removal and appositioning the labia minora (with or without excision of the clitoris).

• Type IIIb: removal and appositioning the labia majora (with or without excision of the clitoris)

• Type IV: Unclassified; includes all other harmful procedures to the female genitalia for nonmedical purposes, for example: pricking, pulling, piercing, incising, scraping, and cauterization.

UNICEF classification [1]:

• Type 1: cut, no flesh removed/nicked.

• Type 2: cut, some flesh removed.

• Type 3: sewn closed.

• Type 4: type not determined/not sure/does not know.

Opening in a separate window FGM presents no advantages, rather than complications. The immediate consequences are excruciating post-excision pain, infections (local suppurations, septicemia, gangrene, tetanus, genital and reproductive tract infections, urinary tract infections, possible association with increased risk of HIV and HCV due to the use of the same surgical instrument without sterilization etc.), hemorrhages, Acute urine retention, urethral injury, death (secondary to severe bleeding or septicemia). Long-term complications are:

• Urinary complications (painful urination, recurrent urinary tract infections).

• Vulvovaginal complications (vaginal discharge, ulceration, bacterial vaginosis and other infections).

• Menstrual disorders (dysmenorrhea, irregular periods, and difficult passage of menstrual blood with the risk of hematocolpo, etc.).

• healing defects with the occurrence of keloid clitoral cysts.

• Sexual complications (dyspareunia particularly with type III FGM, decreased sexual satisfaction and lubrication during intercourse, reduced sexual desire and arousal, increased risk of anorgasmia.

• infertility (primary, ascending pelvic infections).

• obstetric complications (obstructed, hemorrhagic delivery, vesicovaginal fistulas) and deaths of newborns.

Clitoral cysts are due to an inversion of the edges of the wound, during healing after excision or to subdermal inclusions of epithelial fragments [10-14]. The wall of these skin cysts has the histological appearance of the epidermis, hence the name epidermal cysts [7,8,14]. Epidermal cysts are generally asymptomatic and sometimes revealed by an inflammatory outbreak. In the literature, the clinical manifestations of clitoral cyst are diverse, and patients may consult for a sensation of mass in the external genitalia. In our case the patient did not have any pain, but it was the urination discomfort and the aesthetic damage that led her to consult. In Senegal Diouf et al. [7] as well as Diabate et al. [15] have reported similar cases. Saha. [12] and Aggarwal et al. [13], reported an epidermoid cyst of the clitoris mimicking clitoromegaly in a 5-year-old girl. Anderson-Mueller et al. [11] reported an epidermoid cyst of the clitoris in a patient without history of previous female circumcision. The diagnosis of clitoral cysts is clinical.

Ultrasound makes it possible to clarify the cystic or nodular nature of the clitoral tumor. Currently ultrasound and MRI are recommended by certain authors to establish the pre-operative diagnosis [15, 16].

Differential diagnosis of clitoral cyst can be with clitoral tumors benign or malignant. Benign tumors include leiomyoma, pseudo-lymphoma, fibroma, angiokeratoma, hemangioma, hemangiopericytoma, granular cell tumor, and neurofibroma [13,17]. Malignant tumors reported include endodermal sinus tumor, carcinoma, sarcoma, schwannoma, lymphoma, rhabdomyosarcoma, epithelioid hemangioendothelioma, or rarely secondary metastasis [13]. Clitoral cysts usually present as swelling over the clitoris. It should be differentiated from clitoromegaly which may be due to hormonal causes [13,16]. Some authors reported the cases of epidermal cyst of the clitoris in an infant infected [14,18]. These cysts, when they are large, can cause psychosexual consequences and have an impact on the quality of life of the couple due to the impossibility of sexual intercourse [19]. Several authors [20-22] propose a surgical treatment which consists of surgical excision of the cyst, performing a clitorioplasty and providing psycho-social support. WHO carried out a study on the economic costs of treating complications of female genital mutilation and found that current costs for 27 countries where data were available amounted to US$1.4 billion over a period of one year (2018) [1].

Conclusion

The clitoris cyst is a frequent complication of FGM which can cause urinary and psycho-social consequences. Its treatment consists of performing a surgical excision. The elimination of FGM requires strengthening the response of the health sector, the development of tools and training materials for medical personnel while leading an awareness policy on the consequences and costs of these practices, to put an end to female genital mutilation.

References

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