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Genitourinary problems.
With respect to the genitourinary sequelae of FGM/C, reported years and sometimes decades following the procedure, we identified 17 comparative studies.21 , 27 , 29–33 , 37 , 43 , 45 , 46 , 54 , 55 , 57 , 60 , 64 , 65 In total, the studies included 38 390 women. The most frequently measured outcomes were genital tissue damage, vaginal discharge and itching, urological complications and infections. Many sequelae were examined in only one or a few studies and/or they were relatively rare events, such as keloids and abscesses. Analyses were thus often unable to establish whether there were statistically significant differences between the groups being compared and the CIs were wide. As a result, there was insufficient information available from the studies to assess difference in risk relative to FGM/C exposure. The results were inconclusive with respect to: scarring, keloids, abscesses, fistulae, damaged tissue (perineum, anal sphincter), disfigurement, vaginal obstruction and cysts.
According to four cross-sectional studies (n=3657), there was a trend for a greater risk of vaginal discharge and itching with FGM/C (adjusted ORs (AOR) from 0.94 to 2.81).33 , 54 , 57 , 60 Urological long-term complications were reported in four comparative studies (n=3611), none of which could establish a statistically significant difference, either in unadjusted analyses (RRs from 0.85 to 1.78) or in adjusted analyses (AORs from 0.80 to 1.29), between women with FGM/C and women with no FGM/C.27 , 33 , 54 , 60 However, results from two studies of moderate to high methodological study quality indicated a trend for a greater risk of burning or painful urination with FGM/C (RR=2.56, 95% CI 0.80 to 8.22; RR=1.66, 95% CI 0.96 to 2.85).33 , 60 Menstrual problems were reported in five studies (n=6564).30 , 31 , 33 , 54 , 64 They showed a trend towards a greater risk of menstrual problems with FGM/C: dysmenorrhoea (RR=1.44, 95% CI 1.11 to 1.86), difficulty in menstruation (RR=1.02, 95% CI 0.06 to 16.28), menstrual problems (RR=0.77, 95% CI 0.61 to 0.97), irregular menses (RR=2.56, 95% CI 1.48 to 3.45) and difficulty in passing menstrual blood (RR=1.75, 95% CI 0.78 to 3.93).
Ten comparative studies (n=28 940) reported results concerning long-term genitourinary infections.21 , 29 , 30 , 37 , 43 , 46 , 54 , 55 , 64 , 65 Owing to few studies and the low number of events, the findings were inconclusive for the following outcomes: chronic pelvic infections, reproductive tract infections, genital infections and vaginitis. However, in adjusted analyses, two studies of low to moderate methodological quality found a statistically higher risk of reproductive tract infections (AOR=1.54, 95% CI 1.08 to 2.21) and genital infections (AOR=1.72, 95% CI 1.02 to 2.92) with FGM/C.37 , 43 Meta-analyses showed a greater risk of urinary tract infections (RR=3.01, 95% CI 1.42 to 6.38; GRADE: very low; figure 3)21 , 29 , 30 , 64 , 65 and bacterial vaginosis (AOR=1.68, 95% CI 1.28 to 2.22; GRADE: very low) with FGM/C (figure 4).46 , 54.
Painful sexual intercourse.
Dyspareunia (painful sexual intercourse) was reported in six studies (n=6204).31 , 33 , 54 , 58 , 60 , 64 The meta-analysis, presented in figure 3, showed an increased risk of dyspareunia with FGM/C (RR=1.53, 95% CI 1.20 to 1.97; GRADE: very low). Correspondingly, results from two nationally representative studies from Eritrea (n=12 540) indicated a ‘dose–response’ relationship, with a lower risk of problems during sexual relations with FGM/C types I–II relative to type III (RR=0.19, 95% CI 0.16 to 0.24; RR=0.44, 95% CI 0.27 to 0.72).34 , 35.
HIV and sexually transmitted infections.
HIV and sexually transmitted infections (STIs) were clinically examined in one case–control study and 10 cross-sectional studies (n=12 912).26 , 32 , 39 , 44 , 46 , 52 , 54 , 55 , 62 , 63 , 71 The case–control study could not establish a difference between FGM/C and no FGM/C regarding STIs (AOR=1.13, 95% CI 0.73 to 1.77).32 Similarly, the meta-analysis of cross-sectional studies failed to establish a difference (RR=1.07, 95% CI 0.75 to 1.53; GRADE: very low; figure 3).54 , 55 , 71 As shown in figure 4, also the meta-analysis for HIV, based on four studies which presented adjusted data, failed to establish a difference relative to FGM/C (AOR=0.95, 95% CI=0.54 to 1.67; GRADE: very low).44 , 46 , 62 , 71.
Twelve studies presented data on infertility (n=36 473).20 , 23 , 40 , 41 , 46 , 47 , 48 , 50 , 54 , 64 Two case–control studies of high methodological quality examined whether FGM/C was a predictor for infertility. The case–control study from Sudan could not establish an association between infertility and FGM/C (AOR=1.77, 95% CI 0.52 to 7.10).20 Similarly, the case–control study from Egypt could not establish a difference between FGM/C type II and type I with respect to tubal factor infertility (AOR=1.9, 95% CI 0.8 to 4.2).40 The available evidence did not allow us to conclude whether women were more likely to be infertile if they were cut by a traditional than a medical circumciser (AOR=2.1, 95% CI 0.8 to 5.7).40 Ten cross-sectional studies examined infertility in women with and without FGM/C. The association between FGM/C and infertility varied, both in unadjusted analyses (effect estimates ranged from 0.34 to 3.67) and adjusted analyses (AORs from 0.99 to 2.76). Specifically, the results of the two clinical studies of moderate to high methodological quality did not establish a greater risk with FGM/C (OR=1.3, 95% CI 0.7, 2.7; OR=1.05, 95% CI 0.65 to 1.67. Of eight adjusted estimates, two reached significance. These are not shown here because the CIs were not provided in the publications).46 , 54.

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