Article

Female genital mutilation and female genital schistosomiasis-bourouwel, the worm: Traditional belief or medical explanation for a cruel practice?

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... Whereas the abnormalities of the urinary bladder and the distal ureter are characteristic, upper urinary tract obstruction is nonspecific and may be observed in other conditions [7][8][9][10][11]. The disease was known in Egypt since antiquity [12]. Diagnosis and its clinical consequences have again become a research focus in the nineties of the last century [13][14][15][16][17][18][19] and are being investigated further until today [14]. ...
... Whereas schistosomiasis is a wellknown risk factor for squameous bladder cancer, it is still not known whether or not schistosomiasis also constitutes a risk factor of cervical cancer [21,22]. It has been speculated that female genital mutilation was practiced to treat symptoms of female genital schistosomiasis [12]. Schistosomiasis may contribute to the development of vesicovaginal fistula [23]. ...
Article
Urogenital Schistosomiasis Presenting Genital and Urinary Tract Lesions and Abdominal Discomfort in a Sterile Angolan Woman Background: Schistosomiasis or bilharziasis is a parasitic disease caused by blood fluks of the genus Schistosoma. Schistosoma haematobium has been found in the Middle East, India, Portugal and Africa and it is responsible by urogenital schistosomiasis, pathology with strong economic and health repercussions in the endemic countries. The repercussions of schistosome infection in the health of an Angolan woman are presented and the effects of urogenital schistosomiasis in the human fertility are discussed. Methods: A woman who came to the hospital for gynaecologic consultation because of primary sterility. She presented micturition problems, abdominal discomfort and back pain. Biopsies of the bladder and uterus epithelium showed Schistosoma haematobium ova. The patient was subdued to parasitological, ultrasonographical and cystoscopical examinations and treatment of the schistosomiasis associated to drug to prevent bacterial super-infection. Results: Ultrasonography showed hypertrophy and irregularity of the bladder wall. Hystologic analysis showed S. haematobium eggs in the uterus epithelium and bladder. Cystocopy revealed sandy patches and ulceration at the ureteric meatus. Conclusions: This was the first documented description of female genital schistosomiasis in Angola. Considering that S. haematobium is endemic in Angola, it is expected that a lot of similar cases of urogenital schistosomiasis are occurring in Angola. Then, preventive actions and early treatment of schistosomiasis should be implemented in endemic areas.
Article
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Weltweit gibt es wahrscheinlich 130–150 Mio. Frauen, die von weiblicher Genitalbeschneidung (,,female genital cutting“, FGC/ “female genital mutilation“, FGM) betroffen sind. Auch in Deutschland muss bei Patientinnen aus Ländern, in denen diese grausame Praxis weiterhin besteht, damit gerechnet werden (etwa 30.000 Frauen derzeit). Eine gute Gesprächsführung unter Beachtung soziokultureller Hintergründe und mit Kenntnissen über weibliche Genitalbeschneidung kann der Patientin neue Möglichkeiten wie operative Korrekturen eröffnen. Gerade in der Geburtshilfe muss mit Patientinnen, bei denen eine Infibulation erfolgte, eine Strategie vereinbart werden – eine Defibulation ist auf jeden Fall notwendig. Es gibt Studien mit widersprüchlichen Aussagen zu Komplikationen nach FGM unter der Geburt. Unklar bleibt, ob die schlechteren Ergebnisse nach FGM an der Beschneidung oder am niedrigeren sozioökonomischem Status liegen. Zumindest ist ein Zusammenhang zwischen verlängerter Austreibungsperiode und narbigen Veränderungen nach FGM möglich. Daher könnten Komplikationen ihren Ursprung haben. Eine gute Kenntnis des Themas und eine klare eigene Haltung sollten selbstverständliche Voraussetzungen sein für eine Tätigkeit in Ländern, in denen FGM praktiziert wird.
Article
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Background: Urogenital schistosomiasis, caused by infection with Schistosoma haematobium, is widespread and causes substantial morbidity on the African continent. The infection has been suggested as an unrecognized risk factor for incident HIV infection. Current guidelines recommend preventive chemotherapy, using praziquantel as a public health tool, to avert morbidity due to schistosomiasis. In individuals of reproductive age, urogenital schistosomiasis remains highly prevalent and, likely, underdiagnosed. This comprehensive literature review was undertaken to examine the evidence for a cause-effect relationship between urogenital schistosomiasis and HIV/AIDS. The review aims to support discussions of urogenital schistosomiasis as a neglected yet urgent public health challenge. Methodology/principal findings: We conducted a systematic search of the literature including online databases, clinical guidelines, and current medical textbooks. We describe plausible local and systemic mechanisms by which Schistosoma haematobium infection could increase the risk of HIV acquisition in both women and men. We also detail the effects of S. haematobium infection on the progression and transmissibility of HIV in co-infected individuals. We briefly summarize available evidence on the immunomodulatory effects of chronic schistosomiasis and the implications this might have for populations at high risk of both schistosomiasis and HIV. Conclusions/significance: Studies support the hypothesis that urogenital schistosomiasis in women and men constitutes a significant risk factor for HIV acquisition due both to local genital tract and global immunological effects. In those who become HIV-infected, schistosomal co-infection may accelerate HIV disease progression and facilitate viral transmission to sexual partners. Establishing effective prevention strategies using praziquantel, including better definition of treatment age, duration, and frequency of treatment for urogenital schistosomiasis, is an important public health priority. Our findings call attention to this pressing yet neglected public health issue and the potential added benefit of scaling up coverage of schistosomal treatment for populations in whom HIV infection is prevalent.
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To determine the prevalence of female genital schistosomiasis in riparian communities in the Volta basin of Ghana, The study was a cross-sectional study conducted among women 15-49 years in the Volta Basin. Urinary schistosomiasis prevalence was determined using microscopy. A structured questionnaire was also administered to collect information on the demography, obstetric history and reproductive health experiences. Cervical punch biopsy was collected from women who consented to be screened for FGS. Descriptive statistics was used to determine frequency of occurrence, chi squared and logistic regression to identify associated variables Urinary schistosomiasis prevalence among the women was 24.8% while 10.6% of them diagnosed with FGS. More FGS diagnosed women (57.7%, p value =0.04%) were observed to report copious discharge, vaginal itch (80.8%, p=0.042) and lower abdominal pain (66.7%, p= 0.041) compared to FGS negative women. The predominant abnormal observation of the lower genital tract made was erythematous cervix (18.8%). The study confirms the reproductive health symptoms associated with FGS and recommends awareness creation on FGS among women in endemic communities to facilitate early treatment.
Article
Presentation pruritus vulvae with nodular lesions.Diagnostic pointers foreign travel, cosinophilia, urine microscopy, punch biopsy.Diagnosis vulval sehistosomal granulomas.Outcome responded to praziquantel.
Article
A synoptic inventory developed by us (Feldmeier and Krantz, 1993) was used for systematically reviewing existing data as to how and to what degree gender- and sex-related factors influence the validity of the diagnosis of schistosomiasis in women. Diagnostic sectors comprising survey methodology, parasitological methods, immunodiagnosis, detection of pathology and diagnosis of schistosomiasis in the female genital tract have thus been scrutinized. In this way we have identified important gaps in the scientific knowledge of diagnosis of an important parasitic infection. Socio-cultural and gender-related determinants have never been studied systematically, and it is mostly by circumstantial evidence that we can point out potential biases, sometimes for sex but more often for gender, in much of the published material concerning diagnostic categories suitable for schistosomiasis. These errors in diagnostic procedures and the ensuing lack of validity deserve attention from the fields of biomedicine and social science, preferably in a collaborative effort.
Article
In this paper we summarise the parasitological, clinical and epidemiological characteristics of female genital schistosomiasis (FGS), a frequent manifestation of the infection with Schistosoma haematobium. Means to diagnose and treat lesions in the lower and upper genital tract are discussed. Based on clinical findings and available pathophysiological as well as immunological data it is conceivable that FGS of the cervix and vagina not only facilitates the infection with agents of sexually transmitted diseases, but presumably also alters the natural history of such infections. Two infectious agents are of particular concern: the Human Immunodeficiency Virus and the oncogenic Human Papilloma Viruses. Possible interactions and their consequences are discussed and research areas which should be addressed are outlined.
Article
Background: Epidemiologic studies have shown that the association of genital human papillomavirus (HPV) with cervical cancer is strong, independent of other risk factors, and consistent in several countries. There are more than 20 different cancer-associated HPV types, but little is known about their geographic variation. Purpose: Our aim was to determine whether the association between HPV infection and cervical cancer is consistent worldwide and to investigate geographic variation in the distribution of HPV types. Methods: More than 1000 specimens from sequential patients with invasive cervical cancer were collected and stored frozen at 32 hospitals in 22 countries. Slides from all patients were submitted for central histologic review to confirm the diagnosis and to assess histologic characteristics. We used polymerase chain reaction-based assays capable of detecting more than 25 different HPV types. A generalized linear Poisson model was fitted to the data on viral type and geographic region to assess geographic heterogeneity. Results: HPV DNA was detected in 93% of the tumors, with no significant variation in HPV positivity among countries. HPV 16 was present in 50% of the specimens, HPV 18 in 14%, HPV 45 in 8%, and HPV 31 in 5%. HPV 16 was the predominant type in all countries except Indonesia, where HPV 18 was more common. There was significant geographic variation in the prevalence of some less common virus types. A clustering of HPV 45 was apparent in western Africa, while HPV 39 and HPV 59 were almost entirely confined to Central and South America. In squamous cell tumors, HPV 16 predominated (51% of such specimens), but HPV 18 predominated in adenocarcinomas (56% of such tumors) and adenosquamous tumors (39% of such tumors). Conclusions: Our results confirm the role of genital HPVs, which are transmitted sexually, as the central etiologic factor in cervical cancer worldwide. They also suggest that most genital HPVs are associated with cancer, at least occasionally. Implication: The demonstration that more than 20 different genital HPV types are associated with cervical cancer has important implications for cervical cancer-prevention strategies that include the development of vaccines targeted to genital HPVs.
Article
Ninety-six cases of extraurinary schistosomiasis due to Schistosoma haematobium were encountered in a retrospective histopathological study of cases encountered over a period of 12 years in Southern Iraq. Seventy-six cases involved three main systems, namely the female genital system (29 cases), male genital system (15 cases) and the lower intestinal tract (32 cases). In the remaining 20 cases unusual sites such as lymph nodes, skin, liver and lungs were affected. In none of these cases did the clinician initially consider schistosomiasis to be the cause of the patient's illness prior to the histological diagnosis.
Article
The social implications of the practice of female circumcision in Egypt are examined in this paper. Female circumcision is defined as the partial or complete removal of the external female genitalia, varying from removal of the prepuce of the clitoris only to the full excision of the clitoris, the labia minora, and the labia majora. Most Egyptian women are circumcised in the first or second degrees. The practice probably originated in Pharaonic Egypt, in which it was invested with mythological significance. Islamic tradition has reinforced the practice because of the belief that it attenuates sexual desire in women. The legal status is ambiguous. Current research shows that women, especially among lower socioeconomic groups, often do not understand the danger of the operation, which mothers usually cause to be performed on their daughters between the ages of 6 and 10, before the girl reaches puberty. Interviews conducted by the author in a pilot study in 1979 suggest that even in the absence of social and economic change, many uneducated women, given information, will question the validity of female circumcision. This questioning, and the uneducated woman's rejection of the practice, are based on new and emerging values such as respect for modern concepts of health and an enhanced definition of women's identity and roles. Moreover, in most cases, the memory of the operation is sufficiently traumatic so that mere questioning by a trusted service-provider or a friend would receive a positive response. The paper concludes with detailed responses of 4 women interviewed in the pilot study.
Article
Female genital schistosomiasis has been neglected as a disease entity during a period when considerable progress has been achieved for schistosomiasis as such. The pathophysiology and immunology are imperfectly understood, appropriate diagnostic tools are not at hand, therapeutic rationales do not exist, the natural history is not well known and women's perception of their illness has never been studied. Based on the findings of a systematic analysis, made by an inventory of research needs on women and tropical diseases, it has been possible to highlight individual and public health hazards of female genital schistosomiasis, such as the disease being a possible cofactor for te spread of the human immunodeficiency virus. This paper gives an example of how a gender perspective on a well-known parasitic disease can bring new challenges to the research community and the public health sector.
Article
To determine the presence of human papillomaviruses (HPVs) in cervical cancer among patients in Tanzania and to ascertain their prevalence in cases associated with schistosomiasis. In situ hybridization was applied to 31 carcinomas of the uterine cervix including 10 in which schistosomiasis co-occurred. Twenty-six cases in this series also exhibited koilocytic dysplasia. Twenty-six out of 31 cases revealed a specific hybridization for HPVs with varying density and distribution. A slightly higher labeling of HPV-16 than -18 was demonstrated. All schistosomiasis-associated cancers encoded the papillomaviruses. The 31 patients were predominantly young adults, a fact that reflects sexual activity at a very young age in the ethnic communities of Africa. These findings shed new light on the presumed etiologic implication of schistosomiasis in the genesis of cervical cancer. In the absence of HPV, schistosomiasis is not the oncogenic causative agent for carcinoma of the uterine cervix.
Article
Epidemiologic studies have shown that the association of genital human papillomavirus (HPV) with cervical cancer is strong, independent of other risk factors, and consistent in several countries. There are more than 20 different cancer-associated HPV types, but little is known about their geographic variation. Our aim was to determine whether the association between HPV infection and cervical cancer is consistent worldwide and to investigate geographic variation in the distribution of HPV types. More than 1000 specimens from sequential patients with invasive cervical cancer were collected and stored frozen at 32 hospitals in 22 countries. Slides from all patients were submitted for central histologic review to confirm the diagnosis and to assess histologic characteristics. We used polymerase chain reaction-based assays capable of detecting more than 25 different HPV types. A generalized linear Poisson model was fitted to the data on viral type and geographic region to assess geographic heterogeneity. HPV DNA was detected in 93% of the tumors, with no significant variation in HPV positivity among countries. HPV 16 was present in 50% of the specimens, HPV 18 in 14%, HPV 45 in 8%, and HPV 31 in 5%. HPV 16 was the predominant type in all countries except Indonesia, where HPV 18 was more common. There was significant geographic variation in the prevalence of some less common virus types. A clustering of HPV 45 was apparent in western Africa, while HPV 39 and HPV 59 were almost entirely confined to Central and South America. In squamous cell tumors, HPV 16 predominated (51% of such specimens), but HPV 18 predominated in adenocarcinomas (56% of such tumors) and adenosquamous tumors (39% of such tumors). Our results confirm the role of genital HPVs, which are transmitted sexually, as the central etiologic factor in cervical cancer worldwide. They also suggest that most genital HPVs are associated with cancer, at least occasionally. The demonstration that more than 20 different genital HPV types are associated with cervical cancer has important implications for cervical cancer-prevention strategies that include the development of vaccines targeted to genital HPVs.
Article
To assess the morbidity of S. haematobium infection in women of reproductive age (15-49 years) in the western part of Madagascar, the village of Betalatala with a prevalence of urinary schistosomiasis in women of 75.6% (95% confidence limit 69.3 to 81.9%) was compared with a neighbouring village with similar socio-economic characteristics and a prevalence of 5.0% (95% confidence limit 0 to 11.75%). The women were questioned in Malagasy about obstetrical history and urogynecological symptoms. They were examined gynaecologically, parasitologically and by ultrasonography. Important STDs were excluded by appropriate diagnostics. In Betalatala significantly more women reported a history of spontaneous abortion (P < 0.01), complaints of irregular menstruation (P < 0.001), pelvic pain (<0.05), vaginal discharge (P < 0.0001), dysuria (P < 0.05) and haematuria (P < 0.01) than in the control village. Biopsies were obtained from the cervix of 36 women with macroscopical lesions, and in 12 cases S. haematobium eggs were found by histological sectioning (33.3%). In the control village no eggs were detected in the histological sections of biopsies taken from 14 women. (P < 0.05). Infections with Candida albicans, Trichomonas vaginalis, Gardnerella vaginalis and Treponema pallidum were found in similar frequencies in both villages. In 9.8% of the women in Betalatala abnormalities of the upper reproductive tract were revealed by ultrasonography versus none in the women from the control village (P < 0.05). Echographic abnormalities of the urinary tract were present in 24% and 3% of the women in the study village and in the control village, respectively (P < 0.0001). These findings were accompanied by an elevated frequency of haematuria (55% versus 20%) and proteinuria (70.4% versus 25%) in the study population (P < 0.0001). Our study indicates that S. haematobium infection in women may not only cause symptoms in the urinary tract, but also frequently in the lower and upper reproductive tract.
Article
Schistosomiasis is the most frequently imported helminthic infection in The Netherlands. Patients with Schistosoma haematobium infections usually present with fever, hematuria, dysuria, or urinary frequency. The ectopic localizations in female genital schistosomiasis are frequently misdiagnosed or confounded with sexually transmitted diseases or genital tract cancers. This paper describes a patient who presented with vulvar hypertrophy as a symptom of acute female genital schistosomiasis. The aim of this paper is to draw attention to a neglected parasitic disease that in the future will be encountered in increasing numbers in Western Europe.
Article
Schistosoma haemtobium infection in travelers from endemic areas is usually asymptomatic, or presents with hematuria. Uncommon manifestations include neurological syndromes, genital dysaesthesias and watery or blood stained semen. This organism also causes disease within all structures of the female genital tract because of communications between pelvic venous complexes, and can occur long after return home. Schistosomiasis may not be suspected, resulting in delays in diagnosis and treatment. We present two cases which illustrate the diverse nature of this condition.
Article
Ancient texts and archaeological artifacts provide the starting point for a review of the surgical aspects of female genital mutilation (FGM) in ancient Egypt. Analysis of the ancient surgical procedure incorporates modern experience on the subject as well as ancient literary and cultural perspectives. Comparison of FGM with ancient Egyptian male circumcision and consideration of motivations for the practice contribute to our understanding of FGM. In particular, the documented association between male circumcision and generative ability suggests a novel comparison with a natural process in the female--the breaking of the hymen on first intromission--and ultimately a new hypothesis for the origin of ancient FGM.
Article
Despite growing public resistance to the practice of female genital cutting (FGC), documentation of its prevalence, social correlates or trends in practice are extremely limited, and most available data are based on self-reporting. In three antenatal and three family planning clinics in South-west Nigeria we studied the prevalence, social determinants, and validity of self-reporting for FGC among 1709 women. Women were interviewed on social and demographic history, and whether or not they had undergone FGC. Interviews were followed by clinical examination to affirm the occurrence and extent of circumcision. In total, 45.9% had undergone some form of cutting. Based on WHO classifications by type, 32.6% had Type I cuts, 11.5% Type II, and 1.9% Type III or IV. Self-reported FGC status was valid in 79% of women; 14% were unsure of their status, and 7% reported their status incorrectly. Women are more likely to be unsure of their status if they were not cut, or come from social groups with a lower prevalence of cutting. Ethnicity was the most significant social predictor of FGC, followed by age, religious affiliation and education. Prevalence of FGC was highest among the Bini and Urhobo, among those with the least education, and particularly high among adherents to Pentecostal churches; this was independent of related social factors. There is evidence of a steady and steep secular decline in the prevalence of FGC in this region over the past 25 years, with age-specific prevalence rates of 75.4% among women aged 45-49 years, 48.6% among 30-34-year olds, and 14.5% among girls aged 15-19. Despite wide disparities in FGC prevalence across ethnic, religious and educational groups, the secular decline is evident among all social subgroups.
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