Download Conditions mistaken for abuse

Anogenital and microbiologic findings
in sexually abused children.
Arne K. Myhre
Department of pediatrics / RVTS – M
St. Olav’s University Hospital
Norwegian University of Science and Technology
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Prevalence figures CSA world wide
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Sexually abusive acts - The spectrum
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Genital exposure
Observation of a child
Kissing
Fondling
Masturbation
Fellatio
Cunnilingus
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Penile penetration of vagina and/or
anus
Digital penetration of vagina and/or
anus
Vulvar coitus
Pornography
Multidisciplinary assessment
• Medical examination
Part of the puzzle
- History
- General examination
- Colposcopic examination
- Different tests (forensics,
microbiology)
General
History examination
Colposcopic Other tests
examination
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Genital colposcopic examination
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Child well prepared and relaxed
Supine position for prepubertal girls
Stirrups in adolescent girls
Never use of force!!
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Labial separation
Illustrations borrowed from prof. Joyce Adams,
University of California, San Diego
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Labial traction
Supplementary techniques: When
something looks wrong
Floating method
Knee – chest position
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Other methods
Cotton swab
Foley catheter
Aim: Improve visualisation of posterior hymen
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Anal examination
Examine in left lateral position
Separation of buttocks for 30 seconds
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Sexual transmitted infection (STI)
An infection that can be acquired and transmitted
trough sexual activity.
Specific for children: identification of an STI can have,
in addition to medical implications, serious legal
and child protection implications.
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As a consequence….
• We have to consider the possibility of other form of transmission
Vertical transmission
“Innocent” heteroinoculation
Autoinoculation
Possibility of transmission from objects (fomite transmission)
• To be aware of false positive tests, use tests with high specificity,
and confirmation tests
• Positive predictive value: the proportion of patients with positive
tests who are correctly diagnosed – is dependent on prevalence
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Hammerschlag, M.R. Sexual assault and abuse of children. Clinical Infectious Diseases
2011; 53(S3): 103-9.
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Anogenital warts and HPV
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Anogenital warts detected in abused (1 – 4%) and non-abused (4/305, 1,3%)
children
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HPV detected in abused (5 - 30%) and non-abused (1 - 2%) children
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Of children with AGW, few – 80% sexually transmitted
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Different modes of transmission and long latency period:
Sexual
Non-sexual:
- Vertically during pregnancy or birth (pooled transmission risk 6,5% in
meta-analysis)
- Horizontally: Auto- or heteroinnoculation
- Fomite
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Herpes simplex
• Epidemiology: few studies done, but HSV seems to be rare in abused
children.
• Transmission: few studies
Avaliable evidence is to weak to allow an estimate of the likelihood of
sexual transmission
Sexual transmission has been reported more commonly in children over
5 years of age where genital lesions alone occur and where type 2
herpes simplex virus is isolated
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Criteria for testing
CDC 2010
• Symptoms and signs of an STI
(discharge, pain, genital itching, odor,
urinary symptoms, genital ulcers or
lesions).
• A suspected assailant is known to have
an STI or to be at high risk for STI.
• A sibling or another child or adult in the
household or the child’s immediate
environment has an STI.
• The patient or parents requests testing
• Evidence of genital, oral or anal
penetration or ejaculation is present
BASHH 2010
• Disclosure of penetrative sexual
abuse
• Physical signs of penetrative
sexual abuse
• Consensual sexual activity
• Genitourinary symptoms, e.g.
vaginal discharge
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Timing of testing
• Baseline testing of secretions, urine and blood
• Two weeks after last contact if early baseline
• Serology at 3 and 6 months after contact
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Sites to be sampled
Orifices involved in the act of abuse, can involve:
Genital: vagina, cervix (adolescents), urethra, meatus or introitus
Anal: anal canal and/or rectum
Oral: pharynx
Abuse of a particular orifice may not be disclosed, even when abuse
elsewhere has been established.
When disclosure of abuse – consider sampling all sites.
Should also avoid causing pain in the child
When abuse is suspected, case – by – case decision based on
symptoms, signs and probability of abuse.
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Prepubertal girls: Hymenal surface is painful, use
introital swab or trans-hymenal swab.
Apply one drop of water on swab
Borrowed from dr. Joyce Adams
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Anal swabs
Even if proctoscope is
recommended, normally taken
from the anal canal after
separation of buttocks
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Test methods
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N. Gonorrhoeae:
Culture is method of choice (used
from all sites)
NAAT: from urine and vagina can
be used, positive test confirmed
with culture
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Chlamydia trachomatis:
Culture is rarely avaliable.
NAAT’s are mainly used (genital
sites and urine)
Different NAAT for confirmation.
Not approved for extragenital sites.
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Test methods
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Tricomonas vaginalis:
Culture and / or wet mount.
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Herpes simplex virus:
NAAT
Culture
Type specific serology for HSV1
and HSV2 (repeat after 3 weeks)
HSV2 serology not reliable for
children < 14
Motile trichomonads seen in a wet
mount
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Test methods
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Anogenital warts and human
papillomavirus:
AGW is mainly a clinical diagnosis
HPV typing of biopsies or from
swabs is controversial
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UK National guidelines
-2010.
www.bashh.org
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UK National guidelines
- 2010.
www.bashh.org
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UK National guidelines
- 2010.
www.bashh.org
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Classification according to abuse
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Approach to interpretation of colposcopic
findings (JA 2011)
1. Findings documented in newborns or commonly seen in nonabused children
Normal variants
Findings commonly caused by other medical conditions
Conditions mistaken for abuse
2. Indeterminate findings: Insufficient or conflicting data from research studies, or
no expert consensus
3. Findings diagnostic of trauma and/or sexual contact
Acute trauma
Residual (healing) injuries
Injuries indicative of blunt force penetrating trauma (or from
abdominal/pelvic compression injury if such history is given)
Presence of infection confirms mucosal contact with infected and
infective bodily secretions; contact most likely to have been sexual in
nature
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Findings diagnostic of trauma
and/or sexual contact
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Acute trauma to external genital/anal
tissues
Acute lacerations or extensive bruising of labia, penis, scrotum,
perianal tissues or perineum.
Fresh laceration of posterior fourchette
May be from unwitnessed accidental trauma or from physical or
sexual abuse
Girl, trampoline accident
Borrowed from JA
Boy, sexual abuse
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Boy, sexual abuse
From anal study
Residual (healing) injuries
Perianal scar (may be due to other
medical conditions as Crohn’s disease,
accidental injuries or previous medical
procedures.
Scare of posterior fourchette or fossa
(pale area in the midline may also be due
to linea vestibularis or labial adhesions)
Illustrations borrowed from J. Adams
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Injuries indicative of blunt force penetrating trauma (or
from abdominal/pelvic compression injury if such
history is given)
Bruising of
the hymen
Laceration (tear, partial
or complete) of the
hymen
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Perianal laceration extending
deep to the external anal sphincter
(not to be confused with partial
failure of midline fusion)
Borrowed from J. Adams
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Hymenal transection (healed): An area between 4 o’clock and
8 o’clock on the rim of the hymen, where it appears to have been
torn through, to or nearly to the base, so there appears to be
virtually no hymenal tissue remaining at that location.
This finding has also been referred to as a “complete cleft” in
sexually active adolescents or young adult women.
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Missing segment of hymenal tissue. Area in the posterior (inferior)
half of the hymen, wider than a transection, with an absence of
hymenal tissue extending to the base of the hymen, which is
confirmed using additional positions or methods
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STI
Presence of infection confirms mucosal
contact with infected and infective bodily
secretions; contact most likely to have
been sexual in nature.
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• Positive confirmed culture for gonorrhea, from genital area, anus or
throat, in a child outside the neonatal period
• Confirmed diagnosis of syphilis, if perinatal transmission is ruled out
• Trichomonas vaginalis in a child older that one year of age, with
organisms identified by culture or, in vaginal secretions, by wet mount
examination
• Positive culture from genital or anal tissues for chlamydia, if child is
older than 3 years at time of diagnosis and if specimen was tested
using cell culture or comparable method approved by CDC
• Positive serology for HIV if perinatal transmission, transmission from
blood products, and needle contaminations have been ruled out.
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Indeterminate findings: Insufficient or
conflicting data from research studies, or no
expert consensus
These findings may support a child’s clear disclosure
of sexual abuse, if one is given, but should be
interpreted with caution if the child gives no disclosure.
Report to CPS may be indicated in some cases.
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Deep notches or clefts in the posterior/inferior rim of hymen,
that extend through more than 50% of the width of the
hymen.
Deep notches or complete clefts in the hymen at the 3 o’clock or
nine o’clock location in adolescent girls
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Marked, immediate anal dilatation to an AP diameter of 2 cm or
more, in the absence of other predisposing factors such as chronic
constipation, sedation, anesthesia, and neuromuscular conditions
Total anal dilatation in LLP and KCP.
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Genital or anal condyloma accuminata in a child, in the absence of
other indicators of abuse. Lesions appearing for the first time in a
child older than 5 – 8 years may be more suspicious for sexual
transmission
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Herpes type 1 or 2 in the genital or anal area in a child with on
other indicators of sexual abuse. Isolated genital lesions caused
by HSV – 2 in a child older than 4 – 5 years may be more
suspicious for sexual transmission
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Findings documented in newborns or
commonly seen in nonabused children
Normal variants
Findings commonly caused by other medical
conditions
Conditions mistaken for abuse
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Conclusion
• Prevalence of medical findings
Non acute examinations 5 – 10 %
Acute examinations 20 – 50 % (depending on age)
• Follow up studies document rapid and complete healing after
anogenital trauma.
Absence of signs of injuries does not exclude sexual abuse, even
abuse with vaginal or anal penetration
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Controversies regarding transmission
Transmission through “bath water, wash clothes and toilet seats“
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Dayan, L. Transmission of Neisseria gonorrhoea from a toilet seat. Sex
Transm Infect 2004; 80: 327
Goodyear-Smith, F. What is the evidence for non-sexual transmission of
gonorrhoea in children after the neonatal period? A systematic review. J
Forens Legal Med 2007; 14: 489-502.
Bergeron C, Ferenczy A, Richart R. Underwear: contamination by human
papillomaviruses. Am J Obstet Gynecol 1990; 162: 25-9
There are reports of fomite transmission, but very rare. Must be decided
on a case to case basis, and in most cases it will be found very unlikely
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Diagnostic interpretation of a “normal
examination”
• It does not mean ”nothing happened” – Most perpetrators do not
intend to physically harm the child while engaging in sexual acts and
thus most examinations do not have acute or chronic residual.
• Rather than describing an examination without findings as “normal” a
more accurate and informative conclusion is.. “the physical
examination does not demonstrate any acute or chronic residual to the
contact nor would be anticipated to in light of the history provided.”
Martin Finkel, DO, FAAP
Professor of Pediatrics
CARES Institute
University of Medicine & Dentistry of New Jersey
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Findings commonly caused by other
medical conditions
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Erythema (redness) of the
vestibule, penis, scrotum or
perianal tissues (may be due to
irritants, infection or trauma)
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Increased vascularity (dilatation of
existing blood vessels) of vestibule
and hymen (may be due to local
irritants, or normal pattern in the
non estrogenizeid state)
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Labial adhesions:
Fusion of the surfaces of the vestibular wall, normally due to some form of irritation.
Common in girls wearing diapters, and also associated with skin diseases and rubbing.
Girl with extensive labial
adhesions
Same girl after treatment with oestrogen
cream
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Vaginal discharge:
This is a rare finding in prepubertal girls.
It has infectious and noninfectious causes, cultures must be taken
to confirm if it is caused by sexually transmitted organisms or other
infections.
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Friabillity of the porterior fourchette
or commisure:
A superficial break in the
skin seen when traction of the labia is
applied.
(may be due to irritation,
infection, or skin diseases)
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Anal fissures:
usually due to constipation, perianal irritation
Child with Crohn’s disease
Small fissure in a child
with a history of SA
Chronic fissure in
a constipated
child
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Multiple fissures in a child with
Crohn’s disease
Venous congenstion or venous pooling in
the perianal area (usually due to positioning
of the child, also seen with constipation)
Elevated head and crying
Laying flat and quiet
Two year old girl examined in supine KC position (Pictures borrowed from dr. Kari Ormstad)
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Conditions mistaken for abuse
Urethral prolaps
Vulvar ulcers (may be caused
by many types of viral infections
and other conditions)
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Lichen sclerosus et atroficus
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Failure of midline fusion
Rectal prolaps (often caused by
infection)
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External anal dilatation
Total anal dilatation to less than 2 cm (anterior
- posterior dimension), with or without stool visible
External anal dilatation
Total anal dilatation with stool
Prone knee – chest position
Supine position
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Marked erythema, inflamation and fissuring of the perianal
or vulvar tissues due to infection with group A beta hemolytic
strepptococci
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References
• Adams J.A. Medical evaluation of suspected child sexual abuse: 2011
update. J Child Sex Abuse 2011; 20: 588 – 605
• Royal College of Paediatrics and Child Health. The physical signs of
child sexual abuse. An evidence-based review and guidance for best
practice. London: Royal College of Paediatrics and Child Health; 2008
• Stoltenborgh M, et al. A global perspective on child sexual abuse:
meta-analysis of prevalence around the word. Child Maltreat 2011;16:
79 – 101
• McCann J, et al. Healing of nonhymenal genital injuries in prepubertal
and adolescent girls: a descriptive study. Pediatrics 2007; 120: 100011
• McCann J, et al. Healing of hymenal injuries in prepubertal and
adolescent girls: a descriptive study. Pediatrics 2007; 119:e1094–106
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References
• United Kingdom National Guideline on the management of sexually
transmitted infections and related conditions in children and young
people – 2010
• CDC MMWR. Sexually transmitted diseases treatment guidelines,
2010
• Hammerschlag, M.R. Sexual assault and abuse of children. CID 2011;
53 (S3): 103-9
• Reading R, Rannan-Eliya Y. Evidence for sexual transmission of
genital herpes in children. Arch Dis Child 2007; 92: 608-13
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References
• Jayasinghe Y, Garland SM. Genital warts in children: what do they
mean? Arch Dis Child 2006; 91: 696-700.
• Unger, E.R. et al. Anogenital human papillomavirus in sexually
abused and non-abused children: a multicenter study. Pediatrics
2011; 128: e658
• Hammerschlag MR, Guillen CD. Medical and legal implications of
testing for sexually transmitted infections in children. Clin Microbiol
Rev 2010; 23: 493-506
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