You need to specifically ask about female ritual genital surgery and actually need to examine the patient to know what a urine dipstick will tell you about urinary tract infection in this population. Patients themselves often do not know about normal female anatomy and cannot tell you with any accuracy what did or did not happen in their ritual genital surgery. About three-fourths of Somali females over 12 years of age have had a more radical surgical procedure which leaves them with a single introital opening about 1 – 2 cm in diameter at the posterior fourchette. The clitoris, labia minora, and part of the labia majora have been removed. There is a central surgical scar and flap of skin obscuring the urethral opening and upper half of the introitus. If the procedure was done by a lay person in the country side, the central scar is often irregular and there may be more than one opening in the scar tissue. The altered anatomy means that urine and vaginal secretions are completely mixed together and a “clean catch urine” cannot be reliably obtained. You can often visualize the urethra by doing labial traction in an upward direction and with nursing assistance a catheter specimen might be obtained in a parous woman. It is not at all easy to accomplish in a nulliparous teen or woman.
Most young nulliparous women and many older women are very modest about having an examination and will not allow a male physician to do the exam. They will often allow an exam if the provider is female and they recieve a clear explanation of why they need the exam. It helps to explain that there isn’t one medicine that will treat infections in both the urine and vagina (usually some anatomy discussion is necessary), and that treating for a urine infection unnecessarily may only cause a vaginal infection. If a patient refuses an exam, do a dipstick urine. If a UTI is present it should show both positive LE and nitrate. Treat for 3 days, and have them come back for a review of symptoms, an examination if possible, and repeat urine dipstick at the end of the treatment. Clean catch urine cultures are a waste of time and money.
The cause of vaginitis is difficult to diagnose in nulliparous teens and adults because of the limited examination. Young women are very concerned about having swabs inserted into the vagina and usually will not allow this to be done if they are not sexually active. Inspection of the genitalia and looking at the character of the discharge may help. Empiric treatment with sitz baths and a single oral dose of fluconazole, with a follow-up visit is often the only management option.
References
Miller, L. Female Circumcision. In Sciarra JJ. ed. Gynecology and Obstetrics. Philadelphia, PA: JB Lippencott; 1997:1-7.