Anal Abuse MATLA A BANA 2011

Transcription

1 Anal Abuse Clinical Forensic Medicine MATLA A BANA 2011

2 Marcus X This is the horrific story of Marcus X who fell prey to the lusts of his bachelor uncle This lecture is a tribute to the woes of a child who did not ask to be abused The psychological damages done were far worse than the physical trauma

3 Marcus X 5 Years old

4 Family Structure Grandma Grandpa Mother Father Uncle Bachelor Marcus

5 Marcus Presented with: ALARM BELLS: Sexual Play other children Encircling genitals in magazines Recalls the taste of semen Uncle put his tottie in my mouth Refused to visit farm he was fond of Examined Referred to a Clinical Psychologist

6 06:00 03:00 09:00 12:00 01:00 NOTES: Marcus (5 years) was seen approximately 5 months after alleged sodomy The position of examination was KNEE-CHEST He had a definite scar PERI-ANAL in the 01:00 position No dilatation could be demonstrated Note the fecal soiling in the midline

7 Outline Introduction Anatomy Approach to the anus Normal versus Abnormal Fissures; Dilatation; Cupping; Funneling Tire sign Adams Classification

8 Introduction IMPORTANCE: CORRECT EXAMINATION PROCEDURE CORRECT INTERPRETATION OF FINDINGS 1987: CLEVELAND (ENG) 125 CHILDREN REMOVED ON BASIS OF REFLEX ANAL DILATATION - ALL THESE CHILDREN WERE PLACED BACK TRAGIC EVENT

9 ANAL ANATOMY ANAL ANATOMY THE ESSENTIALS

10 C R O S S S E C T I O N

11 Anal Sphincters

12 Anatomy And Physiology TWO SPHINCTERS: A. INTERNAL - Smooth Muscle Involuntary B. EXTERNAL - Pelvic Floor Voluntary

13 Anal Reflexes: A. CUTANO-ANAL REFLEX External sphincters contracts when the skin of the buttocks is touched. Under voluntary control it can relax to prevent pain or injury B. RECTO-ANAL REFLEX Internal sphincter relaxes when rectum is distended. The external sphincter can override this process NEVER EXAMINE THE ANUS WHEN STOOLS FILL THE RECTUM

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15 Anal Mucosa Rectal mucosa Pecten Anal Verge

16 ANAL EXAMINATION ANAL EXAMINATION AN APPROACH

17 How to examine the anus: SUPINE KNEE CHEST POSITION LEFT LATERAL POSITION PRONE KNEE CHEST POSITION Gently part the buttocks. Examine for signs of abuse. Anal verge as well as the rugae should be inspected. Internal examination is rarely necessary unless a PR bleeding is observed.

18 Approach to the anus Supine knee- chest Prone knee-chest

19 Supine knee-chest

20 Prone Knee Chest

21 The Anus What can go wrong with the anus: During and after Abuse? During and after Normal Processes? During and after Pathological Processes? Congenital abnormalities

22 Abuse Related - Acute Tears peri-anal Ecchymoses - bruising Abrasions Redness Swelling

23 Abuse Related - Chronic Scar Tissue formation Hypertrophy of peri-anal skin Infections Gonorrhoea & Lues Warts [C Accuminata] Dilatation spontaneous Cupping or Funnelling

24 Normal Processes Constipation Related: Fissure formation Midline Tears 12:00 & 06:00 Tag formation [Sentinel Piles]

25 Pathological Chron s Disease: Peri-anal scars Diarrhoea Mucoid stools Family history > 15 years

26 Fusion defects Congenital

27 Its Normal to be Abnormal McCann Non Abused Children: Erythema [Redness] - 40,5% Pigmentation [Darkening]- 29,5% Venous Congestion - 7% - 52% - 73% Smooth midline areas - 26% (06:00 & 12:00) Anal tags - Midline = Normal Sphincter Dilatation [See next page]

28 Sphincter Dilatation Dilatation occurred in 49% of children and mean diameter was 10mm ( 1mm - 25mm) In 91% of children examined the maximums were less than 20mm and the mean diameter 5,7mm 30% before 30 seconds 55% before 2 minutes 5% After 5 minutes 38% stayed open and 68% opened intermittently

29 Controversial issues Hobbs survey (1989) children: Reckon ERYTHEMA, FISSURES, VENOUS CONGESTION is positive for abuse. Anal DILATATION seen in only 4%

30 Controversial issues Various Studies on reflex anal dilatation: Ellis-Fraser and Wright in ,5% of Abuses Stanton and Sunderland % of non-abused Priestly % of all children Agnerrson, Evans et al % with constipation Claydon % of severe constip. Anal dilatation is more common in abuse, but fits abused and nonabused

31 Common Denominators Reflex anal dilatation: More in abuse More in constipation Associated with Crohn s More with sedating drugs (benzodiasepines)

32 Homosexuals Study amongst those active in anal intercourse: Tenesmus in 56% - most common complaint Resting anal pressure slightly reduced Squeeze pressure unchanged None had dilatation

33 Anal fissures [Constipation] versus Penetration injuries [Abuse]

34 Definition of a Fissure It is an elongated ulcer in the long axis of the lower anal canal

35 Location The position of anal fissures are in the 06:00 position and to a lesser extent in the 12:00 position In males the ratio is Anterior : Posterior 10% : 90% In females the distribution is 40% : 60%

36 Etiology Stools Force Direction = Backwards Explains the 06:00 Tears

37 Fissure Positions The constipation related fissures are situated between: Pectinate line and Muco-cutaneous junction Seldom if ever outside the anal ring Peri-anal tears are invariably the result of an external penetrative force

38 Fissures versus Peri-anal Tears Internal Sphincter External Sphincter 12:00 Peri-anal Pecten Fissures <Constipation> 06:00 Peri-anal Tears <External Force>

39 Acute Fissures Is a deep tear through the anal margin extending into the anal canal There is little inflammation induration or oedema of its edges Associated anal spasm and pain Retain stools vicious cycle

40 Fissures The McCann study - zero fissures Berenson (1993) - 89 children < 18 months 1 child with fissures 3 with anal tags CONSTIPATION can cause fissures - The appearance cannot indicate the causative mechanism. Small fissures are not consistent with abuse Deep fissures will heal with TAG formation

41 Chronic Fissures Has inflamed indurated margins The ulcer base is either: Scar tissue Internal sphincter muscle Is canoe shaped Has an anal tag [sentinel pile] inferior Piles are in the midline

42 Sentinel Pile Peri-anal skin tag

43 Notes: Tears in the 11:00 and 07:00 [None are midline tears] Both are in the peri-anal position Both are beyond the impact zone of constipated stools

44 NOTES: Multiple peri-anal tears highlighted with Toluidine Blue dye These are beyond the anal margin excluding constipation fissures ONLY AN EXTERNAL FORCE CAN BE RESPONSIBLE!!!

45 Abuse & the anus

46 The anus in abuse Frequency of anal involvement 40 83% 10 29% Penis 62% Repeated abuse 68%

47 Anal Verge

48 Anal Rugae

49 Pecten Line Pecten Line Pecten Anal Verge

50 Midline Fusion Defect

51 Peri-anal Tears Child had been gone for 24 hours was found without panties This was the clinical picture

52 Peri-anal Hypertrophy 1 Year old child with hypertrofied peri-anal skin The father confessed to sodomy

53 Anal fissures 2 yr old with history of chronic constipation. Exam shows & midline fissure & skin tag

54 Tear Scar

55 Peri-anal Abrasions

56 Peri-anal Redness

57 Anal Dilatation NORMAL FUNNELING External sphincter Column/Pecten Internal sphincter DILATATION

58 Cupping/Funneling External sphincter - dilated Column Dilated Internal sphincter - contracted

59 Tire Sign External sphincter (contracted/swollen) Column (Dilated) Internal sphincter (dilated)

60 06:00 02:00 10:00 NOTES: Tears are visible in 06:00; 10:00 and 02:00 positions Orientation picture was taken in the prone knee-chest position This was a DEFINITE case of forceful anal penetration The injuries are BORDERLINE and could be constipation related The anal ring was swollen tire sign

61 Adams Classification Category 1 [No indication of abuse] Perianal pigmentation Venous congestion perianal

62 Adams Classification Category 2 [Possible abuse] Erythema (redness) perianal Vesicular lesions (herpes) perianal Warts perianal Fissures Flattened anal folds Anal dilatation

63 Adams Classification Category 3: [Probable Abuse] Immediate large anal dilation š stools Acute abrasions, lacerations, bruising Peri-anal scar formation

64 Adams Classification Category 4 [Definite abuse] Perianal tears into the external sphincter Sperm or DNA confirmation Gonorrhoea; Syphilis

65 Back to Marcus X 5 Years old

66 06:00 03:00 09:00 12:00 01:00 NOTES: Marcus (5 years) was seen approximately 5 months after alleged sodomy The position of examination was PRONE KNEE-CHEST He had a definite scar PERI-ANAL in the 01:00 position

67 Outcome of Court Case Allegations that peri-anal scar could be: Result of Chron s Disease As result of a nail injury when mother inserted a suppository Accused found NOT GUILTY No doubt existed that Marcus was abused No scientific evidence that would connect the alleged perpetrator

68 Note Paedophiles do not rehabilitate Paedophiles always strike again The timed bomb is ticking

69 NO TIME