Female Genital Schistosomiasis (FGS) in a Nonendemic Setting: Retrospective Case-Notes Review of Schistosoma haematobium-Positive FGS Cases at the Hospital for Tropical Diseases, London, With a Pragmatic Clinical Pathway for Nonendemic Settings

Hannah Rafferty; Clare E Warrell; Spencer Polley; Rashmita Bodhani; Laura E Nabarro; Gauri Godbole; Amaya L Bustinduy; Eyrun F Kjetland; Michael H Hsieh; Peter L Chiodini

doi:10.1093/ofid/ofaf180

Female Genital Schistosomiasis (FGS) in a Nonendemic Setting: Retrospective Case-Notes Review of Schistosoma haematobium-Positive FGS Cases at the Hospital for Tropical Diseases, London, With a Pragmatic Clinical Pathway for Nonendemic Settings

Open Forum Infect Dis. 2025 Mar 24;12(5):ofaf180. doi: 10.1093/ofid/ofaf180. eCollection 2025 May.

Authors

Hannah Rafferty¹, Clare E Warrell^{1

2

3}, Spencer Polley¹, Rashmita Bodhani¹, Laura E Nabarro¹, Gauri Godbole¹, Amaya L Bustinduy², Eyrun F Kjetland^{4

5}, Michael H Hsieh⁶, Peter L Chiodini^{1

7}

Affiliations

¹ Hospital for Tropical Diseases, London, UK.
² Clinical Research Department, London School of Hygiene and Tropical Medicine, London, UK.
³ Rare and Imported Pathogens Laboratory, Porton Down, UK.
⁴ Departments of Infectious Diseases and Global Health, Oslo University Hospital, Oslo, Norway.
⁵ Discipline of Public Health, Nelson Mandela School of Medicine, University of KwaZulu-Natal, Durban, South Africa.
⁶ Department of Urology, School of Medicine and Health Sciences, The George Washington University, Washington DC, USA.
⁷ Malaria Reference Laboratory, London School of Hygiene and Tropical Medicine, London, UK.

Abstract

Background: Female genital schistosomiasis (FGS), the genital manifestation of S. haematobium infection in women, results in protean gynecological symptoms and longer-term complications. FGS affects an estimated 75% of women with S. haematobium, totaling 56 million women, mainly in Sub-Saharan Africa. With increasing migration, FGS will be encountered more frequently in nonendemic settings. Despite this, evaluation of FGS diagnosis and management and guidelines for these settings are lacking.

Methods: A retrospective case-notes review was undertaken of patients presenting to the Hospital for Tropical Diseases, London, from 1998 to 2018 with S. haematobium ova in terminal urine or on biopsy. Descriptive and outcome variables were collected. Specific FGS variables included documented gynecological symptoms and referrals to sexual health and gynecology specialists. Results informed a clinical pathway aiding diagnosis and management of FGS.

Results: Overall, 186 patients with S. haematobium ova in terminal urine or biopsy were included, 62 (33.3%) of whom were women. Four women had documented gynecological symptoms (4/62, 6.5%). Two symptomatic women were referred to gynecology (2/4, 50%), and 2 were lost to follow-up (2/4, 50%). Gynecological symptoms were not documented for many women, despite proven S. haematobium infection.

Conclusions: Given that 75% of women with S. haematobium infection may have FGS, there is a gap in diagnosis in this nonendemic setting. We developed a clinical pathway to improve diagnosis and management of FGS, including inquiry about gynecological symptoms, followed by targeted referrals to gynecology, sexual health, and urological imaging. By formalizing a pathway, we aim to improve FGS care in this nonendemic setting.

Keywords: Schistosoma haematobium; clinical pathway; female genital schistosomiasis; imported infection; nonendemic.