It is seen that as the severity of FGM/C increases, the incidence of symptomatic POP (group 3) increases. Development of symptomatic POP (group 3) in patients with type 3 FGM/C was approximately 17 times higher than in patients without FGM/C, when group 1 was taken as reference. In the multivariable analysis, it was observed that type 3 FGM/C caused symptomatic POP approximately 2.4 times more than type 2 FGM/C. Our study revealed that FGM/C had a significant relation with symptomatic POP.
Severe FGM/C (especially type 3), which is performed at an early age before the development of the genital organs, disrupts the mechanical structure and dynamism of the endopelvic fascia and causes anatomical defects, also frequent and chronic infections play an important role in the formation of POP. In addition, factors that impaired the support of the pelvic endopelvic fascia such as delivery (operative vaginal delivery), malnutrition and menopause are known to cause POP. Therefore, it is a logical approach to consider the association between FGM/C, which practices at the juvenile period (most often FGM/C is performed in the 2–8 age range) traumatically to the genital area and causes psychological effects, and POP in the African population.
United Nations, World Health Organization, Amnesty International, and various world states try to end the practice which they call "genital mutilation", and which is extremely harmful to the health of the woman and her future children. They react to the impairment of the female genital anatomy as a result of any type of FGM/C and even the distinction between female and male circumcision, and they want both practices to be prevented (1, 2, 6).
Thanks to the recent effective measures of all these international organizations, practicing severe FGM/C types such as type 2 and 3 have been reduced by the awareness of the societies especially the new generation young women of the harms of this practice. It is not surprising that the type 3 FGM/C patients in our study were older and had more symptomatic POP. Especially in these groups where younger age FGM/C ratios are low, simpler excision methods such as type 1 are used and pelvic anatomy is exposed to less trauma, POP, and related complications are seen lower.
Female genital mutilation/cutting (FGM/C) is still commonly practiced and associated with serious health problems in women's life. The prevalence of FGM/C vary across and within countries. In a prospective study in 2006 by WHO, including 28 obstetric centers of 6 African countries and 28393 women, the prevalence of FGM/C was reported 82% in Sudan (16). In our study, the prevalence of FGM/C was found to be 87.2%, consistent with recent studies that reported prevalence of FGM/C in Sudan was 89% (7), 87.9% (15) and 80.2% in another study (20). Considering the FGM/C Types, we found Type 3 FGM/C to be the most common, consistent with the studies conducted in Sudan (16, 21, 22). Regarding ethnicity and changing mentality, in some communities Type 1 FGM/C is practiced most frequently (3, 13, 23). Advanced invasive procedure carries out severe complications, so type 3 is the most associated type with complications.
This presented study was done in a FGM prevalent country, Sudan, and was designed specifically to investigate the relation between different types of FGM and pelvic floor dysfunction. The median age of participants was 49 years (min:30-max:91) in the study and higher than other studies on FGM/C (3, 16), as it is a study conducted among women with pelvic floor disorders. If we consider the types according to age in our study, we realized that the new generation prefers the less complicated Type of FGM/C due to awareness of the practice. 50% of the no FGM/C group and 77.8% of the Type 1 FGM/C group were women under the age of 40. Women aged 70 and over had Type 3 FGM/C most frequently (84.6%). Older age was associated with both increased FGM/C rates (24, 25) and more complicated types of FGM/C (Type 2, 3). The reason is that almost all women in the past had to embrace female circumcision, and it was difficult or impossible to come across a woman who had not practiced. However, FGM/C had declined among youth, possibly due to human rights and legal protection, and even due to imposed prison sentences, FGM is now performed in secrecy in some communities or none at all.
Our study demonstrated that FGM/C was more prevalent among women living in rural areas in accordance with the literature (7, 26). As shown in many studies we found that non-employed and non-educated women were more likely to have undergone FGM/C and the significance of women's education to eradicate the practice of FGM/C is obvious (3, 7, 14, 27, 28). FGM/C practice rates decreased after the introduction of national training programs, and the availability of guidelines for FGM/C management for healthcare professionals and the general population.
The relationship between FGM/C type and the occurrence of delivery-related problems was statistically significant in our study. In accordance with various studies, women with FGM/C Type 3 were significantly more likely to undergo cesarean section (C/S) with a rate 33.8%, followed by Type 2 (10.8%) and Type 1 did not increase the risk for C/S. Wuest et al reported higher risk for emergency C/S and deep vaginal tears in circumcised women, WHO reported significantly higher C/S and episiotomy rates among women with type 2 and 3 FGM/C and type 1 was ineffective on C/S rates (16, 29). Only a study declared that FGM/C had no risk for delivery except perineal tearing (30). Spontaneous vaginal delivery was most frequent with a range of 53.1% in no cutting group. Among assisted vaginal deliveried women, episiotomy with or without vacuum or forceps was highly prevalent in women with FGM/C than women without FGM/C. Episiotomy without vacuum or forceps was most common in FGM/C Type 1 group (62.2%), and episiotomy with vacuum or forceps was most common in FGM/C Type 3 group (13.1%). These findings were supported by Yassin et al with an episiotomy rate of 76.5% (21). FGM is usually performed in girls younger than 10 years old and even the least invasive type causes varying amounts of scar formation. The presence of this less elastic scar tissue causes varying degrees of perineal and vaginal tears during childbirth. Even, Birge et al. have presented a large epidermal inclusion cyst of the clitoris, an intensive scarring mass, in a woman with type 3 FGM/C, blocking urination and sexual functions due to genital anatomical disruption caused by repetitive episiotomies and deinfibulations (31). Complications of FGM/C are ranging from prolonged labor, assisted delivery, postpartum hemorrhage, difficulty in urination, urinary tract infections, hydronephrosis, kidney failure, urogenital fıstula to maternal and infant death. As a result, prolapse and related complications increase due to defects on the muscles and fascia of the genitalia and pelvic floor, after the deterioration of the genital anatomy and complicated deliveries. Sudan is still one of the highest prevalent country of maternal mortality (311/100000) in the world according to report of WHO in 2015 (32).
Although many studies have been conducted on sexual, physical and obstetric complications, and survey studies have been conducted on the difficulties and reasons of women mutilation experience and practice (3, 15) data about consequences of different types of FGM/C on urogynecological problems such as incontinence is scarce. In a few recent study evaluating urogynecological problems, FGM/C related lower urinary tract problems have been suggested as urgency, urinary retension and urinary incontinence (13, 33). Incontinence was mostly observed in type 3 FGM/C in our study, followed by type 2, and the most common type was mixt type incontinence. No cutting and type 1 FGM/C was unrelated with incontinence. Nerve damage and loss of strength-injury to the pelvic floor muscles play role of developing incontinence. Additionally, Birge et al reported that urogenital fıstula was highly associated with Type 2 and 3 FGM/C (34).
Although the prevalence of FGM/C in general population was 87.2%, we observed that this rate increased to 87% in women with POP. Regardless of the type, it is understood that FGM/C is significantly associated with POP and increases rate of POP. We revealed that type 3 FGM/C, which is the most invasive and hard procedure of FGM/C, is the most related type with pelvic organ prolapsus and related hydronephrosis and incontinence. FGM/C complications are based on damage to pelvic floor muscles and nerves. So to speak, FGM/C is a deliberated pelvic floor injury procedure. When FGM/C-related difficult deliveries and other risk factors of loss of pelvic floor support are added to this, pelvic floor dysfunction is inevitable. Weakness of the pelvic floor muscles due to neuropathic damage or mechanical muscular damage causes pelvic organ prolapse and / or dysfunction. This study is one of the pioneering studies investigating the effect of FGM/C types on pelvic floor disorders such as pelvic organ prolapse and incontinence. However, the relationship between POP and FGM/C decreases when counfounding variables are added to the model. This result proves that we should not ignore the fact that there are many factors affecting POP. But the thought of the relationship between FGM/C and POP would be logical. Hence, it will be more beneficial to conduct detailed research on this issue.