Technique for Peri-Clitoral Cyst Excision Following Female Genital Mutilation/Cutting

Objectives: To describe a technique for removal of a peri-clitoral epidermal inclusion cyst in a patient with a history of FGM/C with emphasis on preservation of sexual function and maximizing cosmetic outcomes.


Methods: This is a video case report of a surgical patient at an academic center.

Clinical Relevance: Female genital mutilation and cutting (FGM/C) is defined by the World Health Organization as any procedure removing external female genitalia for non-medical reasons and has been condemned by numerous human rights organizations worldwide. Women who have undergone FGM/C face a myriad of immediate and delayed urogenital complications including urinary complaints, pelvic pain, and sexual dysfunction. A rare delayed complication is the development of inclusion cysts at the site of the prior procedure. While removal of inclusion cysts is not routinely recommended, excision can be considered for symptomatic patients who desire surgical management. Various methods have been described for surgical cyst excision while minimizing disruption of the dorsal nerve of the clitoris, including lateral skin incisions to spare the midline epithelium and intraoperative sensory mapping to guide incision placement. While published methods describe avoiding the anatomical course of the nerve as elucidated in prior cadaveric dissection studies, there is minimal reporting of pre- and postoperative sexual function for patients undergoing peri-clitoral cyst removal. For patients who have undergone FGM/C, preoperative assessment of sexual function and mapping of existing sensation is vital to avoid further neurological damage and sexual dysfunction.
We describe the case of a 32-year-old female with a history of FGM/C presenting with a 6 cm symptomatic peri-clitoral cyst. She was able to achieve orgasm with manual stimulation. Given the size of the cyst, patient highly desired surgical removal. Magnetic resonance imaging (MRI) confirmed the presence of a 6 cm labial cyst with proteinaceous fluid and a single non-enhancing septum. To guide incision placement, preoperative in-office sensory mapping was performed to delineate areas of intact sensation and demarcate areas along the cyst that are required for orgasm. Options for management were discussed with the patient who ultimately decided on surgical excision of the cyst with preservation of overlying epithelium. She underwent an uncomplicated excision which was performed with a left lateral skin incision to avoid areas noted to have intact sensation and/or contributing to ability to orgasm. Following excision of the cyst, the redundant epithelium was reconstructed to resemble normal labia minora. Final pathology revealed an epidermal inclusion cyst. In the postoperative period following recovery, patient reported maintenance of orgasm ability and satisfaction with cosmesis. In this video, we discuss techniques for preoperative sensory mapping, excision of a large peri-clitoral cyst, and maximizing cosmesis while preserving sexual function in a patient with history of FGM/C.