Management of painful clitoral neuroma after female genital mutilation/cutting

Our results in this small retrospective study showed that traumatic clitoral neuromas were common findings associated with FGM/C scarring. All women who underwent clitoral reconstruction at our clinic presented with at least a neuroma of the clitoris in the peri-clitoral scar tissue that was removed during surgery, although the neuroma was not always associated with pain or sexual symptoms. Four out of seven women experienced neuropathic clitoral pain.

Pain after nerve injury is called neuropathic pain and is defined by the International Association for the Study of Pain as “pain directly resulting from a lesion or disease affecting the somatosensory system” [9]. Neuropathic pain can persist long after an injury has healed. As our patients experienced, it can include allodynia (pain induced by innocuous stimuli such as touch) and hyperalgesia (severe pain induced by painful stimuli) and it is often described as burning, needling, or electrical-type sensations [10]. Therefore, painful neuromas can severely impact quality of life and cause functional impairment and psychological distress [11]. The psychosexual well-being and daily life of the four women who suffered from clitoral pain were greatly affected. Providers who care for women with FGM/C should consider a diagnosis of clitoral neuroma in patients with neuropathic clitoral pain, even when a palpable or visible painful mass is not visible. Comprehensive multidisciplinary care should include counseling, psychosexual therapy, and surgical treatment.

In our study, women who presented with pain symptoms were treated by surgical excision to remove the clinically visible or invisible neuroma. Clitoral reconstruction envisages excision of the fibrosis surrounding the clitoris, as shown in Fig. 2 [8]. This method allows for the removal of an eventually painful neuroma. To date, clitoral reconstructive surgery has been studied in a mixed population of symptomatic and asymptomatic women [9]. Further studies should separately assess the outcome of clitoral reconstruction in women who suffer from clitoral pain and should perform histology on the excised fibrotic tissue. These results could help to provide a better understanding of the best candidates for this surgical technique, as well as to evaluate its outcomes in terms of efficacy of pain reduction, improved sexual function, and post-operative complications. No evidence exists regarding the risks of clitoral neuromas following clitoral reconstructive surgery. Previous studies have recommended performing the technique close to the pubic symphysis during sectioning of the suspensory ligament of the clitoris before recreating a neo-glans. This avoids damaging the dorsal neurovascular pedicle of the clitoris [12, 13]. Indeed, one study focused on the course of the dorsal nerve of the clitoris (DNC) in six adult female cadavers, showing that the distance of the DNC from the midpoint of the pubic symphysis ranges between 1.6 and 4.8 cm, and no nerves exist at the 12-o’clock position. The DNC is a sensory nerve that divides into two cords at 1 o’clock and 11 o’clock along the body of the clitoris, terminating at a mean distance of 1 cm short of the tip of the glans [14], without reaching the tip of the intact clitoris [14‐16].

Chronic clitoral pain greatly impacts relationships, as well as daily and psychosexual experiences, and in our experience, can also recall memories and sensations from the past FGM/C experience. An appropriate psychosexual follow-up should always accompany the surgery to allow better screening and care for additional past traumatic life events (e.g., forced marriage, war, rape) that are often found in migrant and vulnerable populations [17, 18]. The immediate post-operative analgesia should be adequate [17], and surgical and psychosexual follow-ups should be part of the normal routine. Multidisciplinary care includes health education and sex therapy, which allows practitioners to meet the needs of many women without performing clitoral surgery. Our data are similar to previous findings showing that after psychosexual care, only a few women still ask for clitoral reconstruction [17].

One of the limitations of our study was the small sample size, which does not allow for generalization of the results. We also retrospectively reviewed the medical files, but did not use validated scales to assess sexual function. However, the gynecologist who attends, operates, and performs the follow-up examinations on all the women at the clinic reviewed the medical files. Additionally, although validated scales were not used, the medical files were documented with detailed information on sexual function (e.g., body image, gender identity, sexual pleasure, lubrication, pain, and orgasm) independently collected by the surgeon and sex therapist. Further research could focus on the validation and development of questionnaires and scales to assess sexual function among women with FGM/C, to be used also among those subject that undergo surgery.

Our findings are novel and important. First, they improve the available scarce evidence on effective treatments for clitoral pain after FGM/C. Second, they provide input for further studies on clitoral reconstruction outcomes among women suffering from clitoral pain. Our study explains for the first time why clitoral reconstruction can improve clitoral pain symptoms after FGM/C from a pathophysiological point of view. We can conclude that post-traumatic clitoral neuroma is a consequence of FGM/C, and is most likely due to cutting of the dorsal nerve of the clitoris. Nerve resection can cause chronic or sexual clitoral pain or be asymptomatic. Previous work has shown that neuromas of other anatomical sites are symptomatic in 3–5% of cases [19]. The pathophysiological mechanisms of neuroma-associated pain remain poorly understood, and several theories have been proposed, such as fibrous stroma modification, mechanical irritation, or persistent stimulation [20]. Surgical excision has been reported to be a more successful treatment than pharmacological management [19]. In our sample, surgical excision, which was part of a comprehensive multidisciplinary treatment paradigm, provided an effective treatment for clitoral pain due to a post-traumatic neuroma.

Finally, these results provide additional scientific evidence for the possible complications due to FGM/C, increasing the arguments for preventing this practice in future generations.