Female Genital Cutting

Female Genital Cutting
By:Safa Magid

Female Genital Cutting(FGC)
* Also known as: female circumcision & female genital mutilation
* Female circumcision is the term preferred by cultures who practice this custom

FGC -Definition
* Procedure involving partial or total removal of the external female genitalia or other injury to the female genital organs whether for cultural, religious, or other non-therapeutic reasons.

WHO Classification of FGC
* Type 1: Excision of prepuce w/ or w/o excision of all of the clitoris
* Type 2: Clitoridectomy and partial or total excision of labia minora
* Type 3: Infibulation, includes removing all or part of ext. genitalia and re-approximation of remnant labia majora, leaving a small interoitus for passage of urine and menstrual blood

* Type 1 and Type 2 are the most common forms
* Type 1 and Type 2 account for 80% of the cases
* Infibulation accounts for 15% of the cases

FGC
* Currently ~ 130 million women and girls have had the procedure
* An estimated 2 million girls worldwide are at risk per year

FGC in the US

* Data from 2000 census suggests:
228,000 women and girls are with or at risk for FGC in the United States
* CA, NY, and MD have the most female immigrants and refugees from countries where FGC is prevalent.
* Occurs mostly in 28 sub-Saharan African countries
* FGC is practiced by Christians, Muslims, and adherents to traditional African religions
* Also practiced in Middle East and Asia

Origins and History
* Origins remain unclear
* FGC practiced in Pre-Islamic Arabia, ancient Rome, and Tsarist Russia
* Female circumcision was discovered in ancient Egyptian mummies in 200 B.C.
* Practiced in the United States until the 1970’s to tx hysteria, lesbianism, and erotomania

FGC and Religion
* Christianity:
FGC is not an obligatory religious requirement
* Islam:
FGC is not an obligatory religious requirement

FGC-Procedure
* Performed between the ages of 5-10, or prior to marriage
* Performed by a member of community who is not a healthcare worker
* Often performed w/o anesthesia
* However in metropolitan areas the use of anesthesia is more common

FGC Procedure
* Performed w/o surgical instruments. Razor blades or other instruments which may or may not be sterile are used
* Depending on socio-economic factors FGC may also be performed in a health care facility by qualified health personnel
* WHO is opposed to medicalization of all types of female genital mutilation.
* Reasons currently practiced:
o Rite of passage to womanhood
o Maintains chastity
o Ensure marriageablity
o Belief that it improves hygiene
o Social pressure to adhere to custom
o Belief that it is a religious requirement

Complications
* Prevalence of complications is unknown
* Rate of complications increase with severity of procedure( i.e. women with type III have > complications that women w/type I)
* A study of 120 Somalian women suggests rate of complications are inversely proportional to the age of the child when FGC was performed
* Women who had FGC btwn the ages of 5-8, had more complications than their 9-12 y.o counterparts
* Long and short term complications
* Some women with FGC do not experience complications

Short term complications
* Hemorrhage
* Severe pain
* Shock
* Infection
* Urine retention
* Ulceration of genital region injury to adjacent tissue
* HIV?-Possibly transmitted due to use of unsterilized equipment

Long Term Complications
* Cysts and abscesses
* Post-partum fistulaes: vesico-vaginal
* Keloid scar formation
* Damage to the urethra resulting in urinary incontinence
* Dyspareunia and sexual dysfunction
* Infertility
* Difficulties with labor.

Case Report

* 16 y.o female presents w/severe dysmenorrhea
* PE revealed the absence of a clitoris and fused labia majora with a 1cm opening
* Physicians initially thought pt had corrective surgery for ambiguous genitalia
* Later determined that while visiting Africa with her mother she had FGC performed
* Perinealography revealed:
o Filling of the vagina,urethra, and bladder simulating a urogenital sinus.
o Dilated vagina suggested obstruction
Perinealography

Case Report
* Defibulation procedure was performed
* The patients symptoms of dysmenorrhea eventually resolved

FGC and Obstetric outcomes
* WHO Study

FGC & Length of maternal hospital stay
* FGC and length of maternal hospital stay
o FGC Type I- RR: 1.15
o FGC Type II-RR:1.51
o FGC Type III-RR:1.98

FGC and Mental Health
* Anxiety
* Depression
* PTSD
* Feeling of incompleteness

Defibulation
* Corrective procedure
* Involves division of the fused labia majora with suturing of each labia for hemostasis
* Thus the infibulated scar, which is a flap obstructing the introitus and urethra, is removed
* WHO Indications for defibulation:
* Urinary retention
* Recurrent UTI’s or kidney infections
* Dysmenorrhea
* Dyspareunia or apareunia
* Prior to coitus
* Prior to labor
* It is also reasonable that defibulation can be performed to alleviate any mental health consequences for women who do not meet the WHO indications

Approach to patients with FGC
* Some physicians remain unfamiliar w/FGC & have expressed their shock during PE
* Some women report being reprimanded by physicians for having the procedure done
* Despite the fact the majority had FGC while they were children and were not given a choice

Patients perspective of FGC
* Many pts w/FGC who have immigrated to the West do not feel as if they abused
* Some feel that FGC was done “for them” and not an attack against them

Patients perspective of FGC
* 1st generation pts born in the West who had FGC while traveling abroad often have very different views than their foreign born counterparts
* HC workers may need to modify their approach depending on the pts perspective

Legality of FGC
* U. S. passed a law in March 1997:
* Made performing any medically unnecessary surgery on the genitalia of a girl younger than 18 years of age a federal crime.
* Reinfibulation was not included as a federal crime, so it may be performed with absorbable sutures in a running fashion if a woman chooses the procedure


Resources for pts and HC providers
* African’s Women’s Health Center
o Established in 1999 by Dr. Nawal Nour a Sudanese-American OB/GYN
o Goal of clinic is to provide culturally appropriate holistic care to African women who are refugees who may or may not have undergone FGC
o Defibulation is performed at this clinic

Resources for pts and HC providers
* WHO
* Website with information about FGC
* Includes fact sheet about FGC and guidelines for healthcare workers
* http://www.who.int/topics/female_genital_mutilation/en/
* http://www.who.int/reproductive-health/publications/rhr_01_18_fgm_policy_guidelines/index.html

Dedicated to all of my sisters who have had FGC.
To those who have suffered physical or mental consequences, I am inspired by your courage and strength.

References
Female Genital Cutting.ppt

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Wound Healing, Dressing, and Drains

Wound Healing, Dressing, and Drains
By: Dr. Aidah Abu Elsoud Alkaissi

Wound healing
* Etiology of wounds:
o Surgical: caused by an incision or excision
o Traumatic: caused by an injury (mechanical, thermal, or chemical)
o Chronic:caused by an underlying pathophysiology, such as pressure sores, or venous leg ulcers, over time

Exact biologic process that takes place in orderly sequence
* An exudate containing blood, lymph, and fibrin begins clotting and loosely binds the cut edges together
* Blood supply to the area is increased, and the basic process of inflammation is set in motion
* Leukocytes increase in number to fight bacteria in the wound area and by phagocytosis help to remove damaged tissues
* The served tissue is quickly glued together by strands of fibrin and a thin layer of clotted blood, forming a scab

Wound Healing
* Plasma seeps to the surface to form a dry protective crust
* This seal helps to prevent fluid loss and bacterial invasion
* During the first few days of wound healing, the seal has little tensile (The resistance of a material to a force tending to tear it apart) strength
* After 3-4 days , connective tissue cells (fibroblasts)rapidly proliferate and give strength to the wound by producing collagen, a tough fibrous protein responsible for the structural integrity of the skin
* At the same time small blood vessels regenerate and build new blood channels, granulation tissue (fibrous connective tissue)includes blood vessels and lymphatics that proliferate from the base of the woind
* Rapidly growing and multiple epithelial cells begin to restore the epithelial continuity of the skin
* At this stage the wound appears healed, healing is not complete until the granulation tissue organizes into scar tissue
* By the ninth or tenth day, the wound is moderately well healed and then becomes progressively stronger
* The whole process of repair takes 2 weeks or more depending on factors such as physical condition of the patient, size and location of the wound, and stresses put on the incisional area
* During this time the scar (cicatrix)strengthens as the connective tissue shrinks
* The amount of tissue loss, the existence of contamination or infection and damage to tissue are all factors that determine the type of wound healing that will occur
* Process of healing takes place in one of three ways
o Healing by primary (first) intention
o Healinh by secondary infection (granulation)
o Healing by delayed primary closure (third intention)

Healing by primary (first) intention
* Edges of an incised wound in a healthy person are promptly and accurately approximated
* Contmination is held to a minimum by impeccable (without fault or error) aseptic technique
* Trauma to the wound is minimal
* After suturing , no dead space is left to become site of infection
* Drainage is minimal

Healing by secondary intention (granulation)
* When surgical wounds are characterized by tissue loss with inability to approximate wound edges, healing occurs through secondary intention
* This type of wound is left open and allowed to heal from the inside towaed the outer surface
* In infected wound this process allows the proper cleansing and dressing of the wound as healthy tissue builds up from the inside
* The area of tissue loss gradually fills with granulation tissue (fibroblasts and capillaries)
* Scar tissue is extensive because of the size of the tissue gap that must be closed. Contraction of surrounding tissue also takes place
* Consequently this healing process takes longer than primary intention healing

Healing by delayed primary closure (third intention)
* This healing process takes place when approximation of wound edges is delyed by 3-5 days or more after injury or surgery
* The condition contribute to a decision for a dalyed closure are:
o 1. Removal of an inflamed organ
o 2. Heavy contamination of wound

Factors influencing wound healing
* The patient´s nutritional status and overall recuperative (To return to health or strength; recover) power
* Especially significant is an adequate supply of protein, which is necessary for the growth of new tissues, the regulation of the osmotic pressure of blood and other body fluids and the formation of prothrombin, enzymes, hormones and antibodies
* Vit C which aids connective tissue production and strong scar formation
* Scrupulous aseptic technique must be used to prevent any wound infection-the most common cause of delayed wound healing
* Theories abound as to the genesis of wound infection. Cross – contamination from operating room, post anesthesia care unit and unit personel is believed to be a primary source
* Aseptic principles and maintenance of operating room environmental conditions are significant factors
* Length of time that the wound is open in the operating room has also been mentioned
* The pat own endogenous flora
* Rough handling of tissue causes trauma that cal lead to bleeding and other conditions conducive to the infection
* Other factors pat age, stress level, presxisting condition as diabete, anemia, malnutriion, cancer , obesity, advanced age, cardiovascular, respiratory impairments. Overall physiacal and psychological condition

Terms

* Keloid
* Proud flesh
* Gangrene
* Adhesions
* Dehiscence
* Evisceration

Wound Classification
* Clean wound
* Clean contaminated wound
* Contaminated wound
* Dirty or infected wound

Dressing
Wound Healing, Dressing, and Drains.ppt

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Management of Keloids

Management of Keloids
By: Thad Riley
Advisor: Bill Grimes


What is a Keloid?
* Non-cancerous fibrous proliferations that occur in the dermis after trauma or injury to the skin
* Keloids grow beyond the boundaries of the original wound site (vs. hypertrophic scar)
* Etiological factors that determine how a scar becomes a keloid remain unknown

Who and Why?
* Individuals with darker-pigmented skin or who freckle are more predisposed
* Seen largely in Africans, African-Americans, Hispanics, and Asians
* Can be a familial/genetic predisposition
* Can be due to immunological causes
* Bottom line… No one knows!

How? (Pathophysiology)
* A result of an overactive inflammatory response and fibroblast proliferation
* A result of an abnormal collagen deposition in healing skin wounds
* Skin wound tension is a contributing factor in keloid formation
* Individuals with an inflammatory or infectious element are at a predisposition for keloids

Where?
* Anterior Chest
* Mandibular angle
* Shoulder
* Earlobes
* Upper Arms & Upper Back
* Posterior Neck
* Lateral Neck

So…What’s the Problem?

The Problem
* PROBLEM is with the TREATMENT OPTIONS
* The pathophysiology of these scars is so poorly understood that it is basically unknown
* Surgery is the only approved treatment
* A successful surgical protocol for removal of these types of scars is greatly lacking
* Surgical treatments available today only provide temporary relief
* Often grow back and do so in an aggressive manner

Possible Solutions
* Surgical excision alone
* Post-surgical treatment agents:
o Mitomycin C solution
o The dietary compound quercetin
o Imiquimod 5% topical cream
o Intralesional corticosteroid injection
o Topical silicone gel sheets

How they work…
* Mitomycin C solution (MC)
o An anti-neoplastic agent
o Has anti-proliferative effects on fibroblasts, stopping keloid formation
o MC effectively blocks angiogenesis during the healing process of the wound, thus inhibiting keloid development
o MC is widely available and relatively cheap
* The dietary compound quercetin
o most common sources: apples, onions, red wine, and ginkgo biloba.
o has strong anticancer, antioxidant, antiviral, anti-inflammatory, and antimicrobial characteristics
o Inhibit keloid fibroblast proliferation, collagen production, and contraction of keloid derived fibroblasts
* Imiquimod 5% topical cream
o Induces apoptosis in keloidal tissue
* Intralesional corticosteroid injection
o Inhibit fibroblast growth and break down collagen deposition
o postoperative steroid injection is the most common form of keloid treatment
o corticosteroids commonly used include hydrocortisone and dexamethasone.
* Topical silicone gel sheets
o Impermeable to water, reduces hemostasis and therefore, decreases the hyperemia and fibrosis often associated with keloids
o have been used for more than twenty years to help reduce the size of scarring
o efficacy and safety of the silicone gel sheets is well established.

And the Winner is…
* Imiquimod 5% topical cream
Analysis
* 13 keloids from 12 patients were surgically removed
* All keloids were present for at least 1 year and free of any treatment for the past 2 months
* A thin layer of imiquimod 5% cream was applied topically each night for 8 weeks
* 4 week asessments
* At 24 weeks, no keloids had recurred

Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids (Berman and Kaufman, 2002 )
* 2 cases of irritation and superficial erosion were reported; resolved with cessation of the cream
* At the 24 week assessment, RECURRENCE RATES of keloids treated with imiquimod 5% cream were LOWER than any previously reported in the literature
* Study did not control for the effects of vehicle application or other potential variables
* Further comparative studies with longer follow-up periods are needed
* Additional studies needed to determine dosing frequency and duration

Pilot study of the effect of postoperative imiquimod 5% cream on the recurrence rate of excised keloids (Berman and Kaufman, 2002 )

Conclusion
* To develop a successful treatment plan for the keloid, two things have to be done:
o 1. Further research to better understand the causes behind keloid formation
o 2. Establish a standard surgical protocol
* In short, the topic of keloids is greatly under-exposed.

References

Management of Keloids.ppt

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