Bilateral hydronephrosis secondary to female circumcision (Images)

A 45-year-old woman visiting from the Arabian Peninsula was reviewed in the hospital with lower back pain. She was conservatively dressed, overweight, and thought to have mechanical back pain and vitamin D deficiency. Serum 25 hydroxy vitamin D3 concentration was low at 4?ng/ml (10?pmol/ml); however, she was also noted to have a markedly elevated serum urea at 32?mmol/l (89.6?mg/dl) and creatinine at 456??mol/l (5.6?mg/dl). She denied any urinary symptoms or kidney problems. However, imaging revealed bilateral hydronephrosis post urethral stricture (Figure 1). She subsequently confirmed on further direct questioning that she had suffered difficulty passing urine, having to strain for many years, and that she had been circumcised as a young girl.