Female genital mutilation:
a urology focus
Elinor Clarke
ABSTRACT
Female genital mutilation (FGM) is a collective term for the deliberate
alteration, removal and cutting of the female genitalia. It has no known health
benefits and can have negative physical and psychological consequences.
The number of women and girls in the UK that are affected by FGM is
unknown. Recent NHS data suggested that FGM has been evident (declared
or observed) in women who have accessed health care; however, there are
gaps in knowledge and a limited evidence base on the health consequences
of FGM. This article explores the urological complications experienced by
women who have undergone this practice, and the effects this can have on
their health and wellbeing.
Key words: Female genital mutilation  ■ Urological complications  ■ Urinary
retention  ■ Dysuria  ■ Urinary tract infections
T
his article, the third in a four-part series on female
genital mutilation (FGM), provides an overview of
FGM and explores the urological complications
that can be experienced by women and girls who
have undergone its various forms.The anatomical
proximity of the urethra to some locations on the vulva where
cutting might occur, the risk of local trauma and the possible
psychological sequelae of FGM may have implications for
urological outcomes. In this article, particular consideration will
be given to the difficulties associated with the management of
urinary retention, infection and dysuria in women who have
experienced FGM.
What is FGM?
FGM can be defined as all procedures that intentionally alter
or cause injury to the female genitalia or genital organs for
non-medical reasons (World Health Organization (WHO),
2016a). This spectrum of practices involves partial or total
removal of the external genitalia or genital glands (greater and
lesser vestibular glands) and genital organs (external clitoris).
Removal of or damage to healthy genitalia may interfere with
normal body functions and can cause immediate, short-term
or lasting effects (Leye et al, 2006; Andersson et al, 2012;Terry
and Harris, 2013; Muteshi et al, 2016; Saunby and Dean, 2016;
Elinor Clarke, RM, Senior Lecturer (Midwifery), Coventry University
Accepted for publication: September 2016
1022
WHO, 2016b). Health complications of different types of
FGM may be immediate, ongoing or long term, and may not
be apparent until marriage or childbirth (Epstein et al, 2001;
Dare et al, 2004). Health professionals are often unaware of
these negative health consequences and many are inadequately
trained to recognise and treat them properly (WHO, 2016b).
Furthermore, the evidence base is limited in terms of what is
known about health consequences of the types of FGM and
how to care for women who experience them.
FGM is illegal in the UK, where primary legislation
(Prohibition of Female Circumcision Act 1985; Female Genital
Mutilation Act 2003; Prohibition of Female Genital Mutilation
(Scotland) Act 2005; Serious Crime Act Sections 74-75) has
criminalised those who undertake this practice, do nothing
to prevent it, or travel to another country so that it can be
undertaken. Implications for health professionals include: a
mandatory requirement that all registered health professionals
must record and report FGM (Serious Crime Act 2015) and
the need to take care to avoid accusations of FGM during
surgical procedures such as episiotomies and suturing.
Classification
WHO (2008) classified FGM into types 1–4 (Table 1).The use of
a numerical classification such as this creates the impression that
either type 1 or 4 is the most severe procedure or causes more
adverse health consequences than the other types. However,
this is not the case as type 4 consists of pricking, piercing and
stretching of the labia, which may be considered less severe
than the other forms of FGM. Type 3 is generally regarded as
the most severe as it involves narrowing the vaginal orifice and
cutting and aligning the labia minora and/or labia majora (with
or without excision of the external portion of the clitoris) to
create a seal or blind pocket. Figures 1 and 2 show the differences
between the unaltered (normal) female genitalia and type 3.
Furthermore, the WHO (2008) classification is challenging
to put into practice because a clinical examination is required
to identify the type of FGM, based on what has been removed.
The wide variation in unaltered anatomy (Brodie et al, 2016)
makes identification of a specific type of FGM problematic.
The WHO (2008) classification of type 4 is open to wide
© 2016 MA Healthcare Ltd
interpretation as it refers to ‘all other harmful procedures
to the female genitalia for non-medical reasons’. This has
created ethical dilemmas and legal issues in relation to the
reporting and identification of this type of FGM. The WHO
(2016b) classification of type 4 is similarly broad and includes
British Journal of Nursing, 2016, Vol 25, No 18
 Table 1. Classification of female genital mutilation
subdivisions (Muteshi et al, 2016).These include potentially
harmful procedures to the genital area, such as pricking, pulling,
Type 1 Type 2 Type 3 Type 4 piercing, incising, scraping and cauterisation.
Partial or total Partial or total Cutting and All harmful The diversity of the types of FGM is a barrier to discussing health
removal of the removal of the apposing the labia procedures to the consequences, as each form does not share the same complications.
clitoris and/ clitoris and labia minora and/or the female genitalia
or the prepuce minora, with or labia majora, with for non-medical Prevalence
(clitoridectomy) without excision of or without excision purposes, such as
the labia majora of the clitoris pricking, piercing,
FGM is mostly carried out on girls aged 0–15 years (WHO,
(excision) (infibulation), to incising, scraping 2008). It is estimated that over 200 million girls and women
narrow the vaginal and cauterisation worldwide are living with FGM (WHO, 2016b). In 2015,
orifice and create a (also labial Unicef estimated that 30 million girls aged under 15 years are
flat skin surface stretching) at risk of FGM worldwide (Unicef, 2016). An estimate of the
Source: World Health Organization, 2008 prevalence of FGM in England and Wales suggests that more
than 24 000 girls are at risk (Dorkenoo et al, 2007).
Since April 2015, the NHS has been required to record
care episodes (Royal College of Midwives (RCM) et al, 2013)
Clitoral glands hood
during which FGM is disclosed or apparent (Department of
Health (DH), 2016). In 2015–2016, 5700 such cases were
recorded in England (Health and Social Care Information
Clitoris
Labia minora Centre (HSCIC), 2016). It is not known how many of these
had urological complications or received treatment for acute
Corpus cavernosum Skene’s glands or long-term urinary complications.

Urethra opening Health consequences and complications

(meatus) Labia majora
The first article in this series (Siddig, 2016) identified the obstetric,
Bartholin’s urogynaecological and psychosexual consequences associated
glands with FGM. Studies have shown that health professionals lack
Vagina
knowledge and training on the health consequences of FGM
(Relph et al, 2013;Terry and Harris, 2013; Zurynski et al, 2015).
Urological complications associated with FGM are identified
Anus in strategies (Unicef, 2016; WHO, 2016a), guidelines (WHO,
2016b; Royal College of Obstetricians and Gynaecologist
Andrew Bezear

(RCOG), 2015) and reviews (WHO, 2010; Iavazzo et al, 2013;

Berg et al, 2014).
Figure 1. The unaltered (normal) female external genitalia
Urinary complications
Given the proximity of the urinary system and the potential for
Clitoris
trauma to the urinary meatus during certain kinds of FGM, it is
likely that urological health consequences may be experienced.
Early research on the urinary complications of FGM comprised
Occluded urethral clinical observational studies (Shandall, 1967; Verzin, 1975; El
opening Dareer, 1983a; 1983b; Mawad and Hassanein, 1994) that used a
three-degree classification system (El Dareer, 1983b).Almroth et
al (2005) found that urogenital complications among girls (aged
Fused tissue
4–9 years) were associated with a form of FGM that narrows the
vulva. Immediate urinary complications of FGM can include
acute retention of urine, which may be compounded by fear of
Small opening
painful micturition and obstruction due to swelling, a blood clot
to allow menses or suture (Obermeyer, 2005). Retention of urine is thought to
and passage of be caused by a combination of fear, pain and local sepsis, which
urine results in oedema and occlusion of the urinary meatus. Short-
term problems also include painful micturition and difficulty
© 2016 MA Healthcare Ltd
Andrew Bezear

in voiding the bladder. Later complications are frequent urinary

tract infections (UTIs) and long-term conditions such as renal
disease and renal failure.
Figure 2. Type 3 FGM (the above two illustrations are not intended for use as an The occurrence of specific complications depends largely
identification tool in the clinical environment) on factors such as the form of cutting employed, the physical

1024 British Journal of Nursing, 2016, Vol 25, No 18


setting, the instruments used and the skill of the person
performing the cutting. Damage to the urethra during FGM
can lead to fistula and urethral strictures (Reisel and Creighton,
2015). Some types of FGM, such as type 3, are thought to
increase the incidence of UTI due to the formation of scar
tissue, which sometimes conceals the urethral meatus.Verzin
(1975) found that bladder and urethral fistulae can result from
a poorly performed repair following childbirth.
There are no data to support or refute a correlation between the
types of FGM and specific urological complications.This is a serious
research gap that needs to be addressed. A key finding, however,
is that the genitourinary sequelae of FGM can be reported years,
sometimes decades, following the procedure (Berg et al, 2014).
Pathophysiology of urinary tract
complications
Dysuria and voiding difficulties
Difficulty with micturition during the first 24 hours following
some forms of FGM appears to be common, but is increased
in women and girls who experience extensive cutting and
the formation of a flat surface over the urinary meatus or
labial fusion (Agugua and Egwuatu, 1982). Vella et al (2015)
suggested that voiding difficulties are experienced when the
person initially tries to avoid pain by not voiding. Other studies
have also reported fear of voiding (Verzin, 1975). Reasons for
this include dysuria due to the raw edges.
In addition, the immediate aftermath of the cutting, some
girls in some communities have their legs tied together to stop
bleeding, which can increase the likelihood of the formation
of scar tissue. In these circumstances, urination is not only
physically difficult, but also is exacerbated by the fear of pain
and the stress associated with voiding.
Acute urinary retention
A tight circumcision or a completely obliterated orifice can
cause urinary retention (El Dareer, 1983b). Urinary retention is
common due to pain, swelling and inflammation (Little, 2003).
Urinary retention experienced in the first 3 days following
FGM has been attributed to postoperative pain, irritation of
the raw areas by urine and obstruction of the external urethral
meatus by skin flaps or blood clots (Vella et al, 2015).
Acute urinary retention can be relieved at home by hot water,
as medical care is not always sought (Shandall, 1967; Verzin,
1975). Bladder catheterisation is the preferred method of medical
management, but this may not be possible if the urethral meatus
has been obstructed, occluded or traumatised (Vella et al, 2015).
Urethral injuries and acute urinary retention following some
forms of FGM have been reported (Berg et al, 2014). Localised
swelling resulting from cutting the genital area, as well as the
restrictive movement and isolation following an act of FGM,
can cause difficulty in voiding the bladder. If the urethral meatus
is injured, it may develop a meatal obstruction and urinary
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strictures (Little, 2003).
Urinary tract infections
The possible mechanism for recurrent UTI is the ‘bridge of
skin’, or the closure and hiding of the urinary meatus, which
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FEMALE GENITAL MUTILATION
distorts the stream of urine, causes constant wetting of the area,
makes catheterisation difficult and leads to the inner squamous
epithelial surface becoming irritated and infected (Verzin, 1975).
It is also thought that micturition becomes increasingly difficult,
owing to the presence of scar tissue and progressive contraction.
Difficult or painful micturition is associated with infection.
Verzin (1975) observed that a tight scar may lead to the
formation of a calculus in apposition to the urinary meatus.
A calculus is formed by the build up of urinary salts, which
prevent the passage of urine. There is an assumption that type
3 FGM, which occludes or damages the urinary meatus, is
associated with an increased risk of UTI.
Iavazzo et al (2013) stated that FGM is commonly performed
on women and girls without anaesthesia and antibiotics, and
in the absence of aseptic conditions. However, whether or not
this is the case depends on the specific circumstances: in some
settings, anaesthesia is used and the procedure is carried out by
a medical professional.The risk of urinary tract complications
is thought to increase if the FGM is undertaken in unclean
circumstances or there is poor genital hygiene. For this reason,
the severity of health consequences may vary.
Following some types of FGM, urine may become stagnant,
which may lead to chronic ascending bacteria. Berg et al
(2014) identified 10 studies (n=28 940) that reported long-
term genitourinary infections.These comparative studies were
undertaken between 1969 and 2005, and focused on women
from countries with a high prevalence of type 3 FGM. The
early studies may not be relevant today.
Management of urological complications
Assessment and identification of type of FGM
Women and girls who have experienced FGM require a
culturally sensitive and non-judgemental approach. For health
educators who are unsure of how to initiate discussions, a useful
starting point is to consider general bathroom experiences,
such as the number of visits and length of time spent in there.
Conversations could progress to identification of bladder issues,
such as discomfort, pain, length of time to void and appearance
of urine.Women may complain of straining or a slowed urinary
stream (Little, 2003).These questions should be asked in order
to establish healthy behaviours and experiences. It is important
to bear in mind that women who have undergone FGM often
lack knowledge of unaltered anatomy and the function of female
genital organs (Saunby and Dean, 2016).
The size and appearance of unaltered female genitalia
varies widely throughout each woman’s lifetime. Brodie et al
(2016) noted that paediatric female genitalia have not been
well described. The relationship between the clitorial hood
and the urethral orifice and labia major, and the length and
depth of the labia minora, are poorly referenced. Brodie et al
(2016) suggested that the clitorial hood and the labia minora
are anatomically distinct structures in unaltered female genitalia.
This small study (which observed 58 girls aged 0–16 years)
provides a reference for health professionals.
Genital examination is an intimate procedure that should
not be routinely undertaken. However, all girls with urological
symptoms should undergo a genital examination, although the
 ethics of undertaking such an examination and identifying labial
adhesions, especially in children, must be considered (Melek et al,
2016). In their study, Melek et al (2016) identified that it was not
possible to catheterise the bladder if labial adhesions were present.
They also identified labial adhesions as complete or partial, and
thick or thin. Finally, they discussed the lack of experience among
physicians of undertaking genital examinations.
Diagnosis of UTI
It is difficult to diagnose UTI in children, as the symptoms
(malaise, vomiting or unexplained fever) can be non-specific
(Harbinson, 1997). Untreated UTIs are associated with
pyelonephritis, kidney infection, renal scarring, hypertension,
kidney failure and death (Harbinson, 1997).
It has been suggested that 3-day bladder diaries are a simple
non-invasive method of evaluating people with symptoms of
infection in lower urinary tract (Lopes et al, 2015). Voiding
diaries are used to record urinary frequency, maximum and
average urine volumes, and fluid intake. Including time taken
to void in these diaries will enable comparisons of females who
have and who have not experienced FGM.
Treatment options and type of FGM
There is a lack of evidence to identify best practice for the
management of urological complications of FGM. Urodynamic
tests or interventions such as bladder catheterisation cannot
be undertaken when the nature and extent of FGM has not
been confirmed.
At present, there are no evidence-based guidelines on the
management of health consequences of FGM. WHO (2016b)
recommended deinfibulation, a surgical procedure that divides
the infibulation scar for girls and women with type 3, but
acknowledged that there is no direct evidence that this will
prevent or treat recurrent UTIs and urinary retention. While
the National Institute for Health and Care Excellence’s (NICE)
(2015) pathways and guidelines focus on women’s reproductive
health and the urological disorders associated with menopause,
stress urinary incontinence and overactive bladder, there are none
specifically on women who have experienced FGM. It may be
inappropriate, therefore, to implement some of these interventions
when caring for women living with the sequelae of FGM.
The frequency of urogenital complications increases with
the severity of mutilation and cutting, the formation of scar
tissue and the number of repairs (Muteshi et al, 2016). However,
basing health care on the type of FGM is unreliable as the
classification is extremely broad and the individual may not
know which type she has experienced (Elmusharaf et al, 2006).
Deinfibulation
Early studies (Shandall, 1967; Verzin, 1975; El Dareer, 1983b)
reported that deinfibulation might help to reduce urological
complications in certain cases. Deinfibulation was recommended
in these studies for preventing and treating urological
complications, specifically UTIs and urinary retention in girls and
women living with type 3 FGM.The WHO recommendation
number 3 (2016b) states that there is no direct evidence to
recommend deinfibulation.
1026
Specialist care
Healthcare management of urological conditions (urinary
incontinence, overactive bladder, infections) often involves
specialist care and multidisciplinary approaches/services because
of its association with renal disease. Iavazzo et al (2013) suggested
that the management of infections following FGM can create
a burden in a low-income economy.
It is essential that those involved in the care of women
who have experienced FGM understand the psychological
implications of living with it (Vella et al, 2015). Discussions
with women about health have to be undertaken, knowing that
most affected women do not attribute their health problems to
FGM (Gibeau, 1998), even in cases where there may well be
an association: the altered genitalia are considered ‘normal’. El
Dareer (1983b) stated that women were unwilling to admit to
having complications, would only report them if these were
severe and longstanding, and did not associate them with their
circumcision. Kaplan et al (2011) found that none of the patients
surveyed associated their complaint with the FGM they had
undergone when they were young.
Recommendations
Women and girls who have experienced FGM may not know
which type was undertaken.They may not be familiar with or
know about the WHO classification, which in itself has been
questioned (Abdulcadir et al, 2016).
This lack of knowledge about FGM is important as it
may result in women not seeking health care and/or not
mentioning the genital-altering procedure during routine health
consultations. Health professionals need to strengthen their
capacity to provide culturally sensitive care that meets the needs
of a diverse and international community. In addition, healthcare
providers need to be alert to possible cues from women and
girls about the nature and extent of their health and wellbeing,
and to enhance their (intercultural) communication skills in
relation to the complications of FGM (Vloeberghs et al, 2012).
Women and girls who have experienced FGM may not
associate their current health with the procedure, either because
their health has not been adversely affected or they do not
perceive any complications to be related to a procedure that took
place many years previously. By effectively listening and paying
attention to the complaints of females who have experienced
FGM, health providers can offer care that meets individual
needs (RCM, 2015;Vella et al, 2015).
Deinfibulation may help reduce urinary complications in
women with forms of FGM in which bladder catheterisation is
not possible (Melek et al, 2016; Muteshi et al, 2016), although, at
present, there is no evidence to support this.When advocating
deinfibulation, information must be provided in a culturally
sensitive way, with awareness that deinfibulation may not
be acceptable to all women who have experienced FGM. If
deinfibulation is chosen, women must be informed of the
© 2016 MA Healthcare Ltd
physical changes that will occur to the appearance of the genitals,
the impact on urination and the importance of perineal hygiene.
The data collection (mandatory recording to NHS data) at
the point of care (known as the enhanced data set) provides
information on the number of girls and women in England
British Journal of Nursing, 2016, Vol 25, No 18

whose lives are affected by FGM. Health Education England
(HEE) have a responsibility to commission services to meet
the physical and mental health needs of these females. Data
collection on care episodes should be used to identify service
needs to reduce health inequalities in the UK.
In addition to care, healthcare providers can offer support and
safeguarding (DH, 2016), and report cases of FGM in females
aged under 18 years (Serious Crime Act, 2015). Education and
training for all health professionals are required to improve
awareness of the consequences of FGM.There is also a need for
further research to broaden knowledge on urinary complications
of FGM and their management.
Conclusion
The health risks associated with FGM may be immediate and
long term, and are likely to vary considerably depending on
factors such as the type performed, the circumstances under
which it was carried out, the instruments used, and the age
of the woman. The urological consequences can be acute or
prolonged, with implications for the individual, her family and,
potentially, her day-to-day life.
The sensitive and complex nature of FGM presents ethical,
research, clinical and theoretical challenges. Health professionals
have a responsibility to provide safe, culturally sensitive and
personalised care.The healthcare needs of women and girls who
access the NHS in the UK may be compromised if healthcare
workers lack the knowledge and skills required to do this. Finally,
there is a need for high-quality research to identify the care
needs of women and girls who have experienced FGM.  BJN
Declaration of interest: this article is supported by Hollister.
Acknowledgements: the author would like to thank the reviewers for
their constructive comments during the writing of this article.
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FEMALE GENITAL MUTILATION
KEY POINTS
■■ Female genital mutilation (FGM) can have negative physical and
psychological consequences
■■ FGM is a criminal offence in UK
■■ Urological consequences of FGM may include immediate and long-term
health complications
■■ FGM contributes to health inequalities experienced by women and girls
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CPD reflective questions

■■ Why is the diversity of the types of female genital mutilation (FGM) a barrier to discussing its health consequences?
■■ Reflect on how a health professional can provide culturally sensitive care that meets the needs of a diverse and
international community
■■ Consider factors such as the severity of mutilation and cutting to explain how the frequency of urogenital
complications may increase

Practice Leadership in Mental Health

and Intellectual Disability Nursing
Edited by Mark Jukes. Foreword by Ben Thomas
This book clearly locates where the challenges are, not only in
the present within mental health and learning disability nursing,
but in terms of leadership and professional nurse imperatives
for the future in support of, and working in partnership with
service users and other stakeholders.

Both mental health and learning disability nurses are challenged

in terms of where they appear to be best placed. A raft of
policies has resulted in nurses addressing and collaborating
with a new host of commissioning bodies and having to
respond to “vulnerability” within an increasing hostile society,
and where social exclusion is being overtly presented in a
variety of environments and situations.

This book focuses on primary, secondary and tertiary concerns

and challenges as they impact upon people with mental health
needs and learning disabilities.

• Succinctly identifies the context of policy and ideology in

support of working with service users, and where mental
health and learning disability nursing has value and relevance
Practice Leadership
• Identifies the priorities for leadership capability across
in Mental Health
primary, secondary and tertiary health services and Intellectual
*Low cost for landlines and mobiles

• Illustrates strategies to promote leadership capability across Disability Nursing

mental health and learning disability nursing
Edited by Mark Jukes
Foreword by Ben Thomas
ISBN-13: 978-1-85642-506-3; 210 x 148 mm; paperback;
250 pages; publication 2013; £19.99
© 2016 MA Healthcare Ltd

Order your copies by visiting or call

www.quaybooks.co.uk +44 (0) 333 800 1900*

1028 British Journal of Nursing, 2016, Vol 25, No 18

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