Anogenital Findings in Pediatric Sexual Abuse. Module 3

Transcription

1 Anogenital Findings in Pediatric Sexual Abuse Module 3

2 Accreditation Wright State University (WSU) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. WSU designated this activity for a maximum of 1.0 AMA PRA Category 1 Credit. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

3 Disclosure All individuals in a position to influence to content of the educational material must disclose to learners any relevant financial relationships. Having an interest or affiliation with a corporate organization does not necessarily prevent the speaker from participating in the proposed CME activity. It is the policy of the CME Committee to resolve any conflicts of interest prior to the presentation. Speaker: The Speaker has indicated that there is nothing to disclose. The following faculty/planning committee members have no financial arrangement or affiliation with a commercial entity: Lori Vavul-Roediger, MD Kathi Makoroff, MD

4 Source of Images and Selected Content All clinical images are from: Visual Diagnosis of Child Abuse 3 rd Edition, American Academy of Pediatrics Visual Diagnosis of Child Abuse 4 th Edition, American Academy of Pediatrics Images used with permission.

5 Objectives Understand that the majority of anogenital examinations are normal in cases of pediatric sexual abuse Accurately identify and document anogenital findings that result from both abusive and non-abusive injury Recognize physical findings outside of the anogenital exam often associated with sexual abuse Understand the significance of sexually transmitted infections in relation to sexual abuse 5

6 Introduction Even in cases where sexual abuse/ contact is proven legally, the majority of pediatric patients will have a normal anogenital exam Medical providers must recognize, correctly interpret and document anogenital exam findings Medical providers who conduct pediatric sexual abuse exams are responsible to provide accurate diagnostic impressions and to help interpret the significance of findings when speaking with other health care and child protective services workers It is recommended to complete Modules 1 and 2 prior to this Module 6

7 Interpretation of Exam Findings Classification of anogenital findings serves to aide medical providers in accurately assessing physical findings The following guidelines are from Journal of Pediatric and Adolescent Gynecology (2015) as noted

8 I. Normal Variants J Pediatr Adolesc Gynecol 2015 O clock method These findings are found commonly in NON-abused children: Annular, crescentic or estrogenized hymenal tissue morphology Imperforate hymen: no opening in the hymenal tissue Microperforate hymen: one or more small openings in the hymen Septate hymen: hymen with one or more bands of hymenal tissue Hymenal tag or mound Any notch or cleft of the hymen (regardless of depth) ABOVE the 3 to 9 o clock locations Hymen that appears to be relatively narrow along the entire posterior rim (3-9 o clock) with smooth edge Superficial, shallow notch of hymen below the 3 to 9 o clock positions in the posterior hymenal rim

9 Hymen that appears to be relatively narrow along the entire posterior rim (3-9 o clock) with smooth edge Note how the hymen appears circumferentially narrow The posterior rim of the hymen is smooth Normal variant

10 Superficial, shallow notch of hymen below the 3 to 9 o clock positions in the posterior hymenal rim Shallow notch (arrow) of hymen at the 7-o clock position Hymenal mounds (asterisks) at the 6- and 8-o clock positions could give a false appearance of a notch Use of different examination techniques verified persistence of shallow notch in this patient Notches and hymenal margin irregularities are common normal variants in the anterior half of the hymen, above the 9- and 3-o clock positions Important to know some posterior hymenal notches (below 3-9 o clock) may be normal variants While some hymenal notches may, in fact, be related to prior abuse, such cannot be used as definitive evidence that vaginal penetration has occurred. In the posterior hymen, a shallow hymenal notch is very different from a complete transection. A complete transection does support prior penetrating injury. anterior rim posterior rim * *

11 I. Normal Variants (continued) J Pediatr Adolesc Gynecol 2015 Vestibular band: tissue noted in periurethral region Intravaginal ridge or column Diastasis ani: smooth anal tissue Perianal skin tag(s) Dilation of the urethral orifice Hyperpigmentation of genital or anal tissues in children with darker skin tones

12 II. Findings Caused by Trauma and/or Sexual Contact J Pediatr Adolesc Gynecol 2015 These findings may be the result of sexually abusive or non-abusive trauma. Detailed medical history and exam are required to discern origin. The findings noted support a disclosure of sexual abuse, and are highly suggestive of abuse even in the absence of a disclosure, unless a timely and plausible description of accidental injury is provided. Acute laceration or bruise to labia, penis, scrotum, perianal region or perineum Bruising, petechiae or abrasions on the hymen Acute laceration/ transection of the hymen, partial or complete Vaginal laceration Perianal laceration with exposure of tissue below the dermis Healed hymenal transection/ complete hymen cleft: a defect in the posterior hymen between 4 o clock and 8 o clock that extends to the base of the hymen with no hymenal tissue discernable at this location 12

13 III. Diagnostic of Sexual Contact J Pediatr Adolesc Gynecol 2015 The following two conditions are diagnostic of sexual contact: Pregnancy Semen identified from forensic specimen(s) taken directly from child s body

14 Acute Trauma to the External Anogenital Region

15 Genital bruising Bilateral labial bruising May result from blunt impact trauma, crush injury or suction /bite History helps to discern if this is the result of abusive trauma

16 Labial laceration May result from direct trauma to the tissues or from traction on the tissues, separating them from one another

17 Laceration of fossa navicularis Note an acute laceration from the fossa navicularis extending into the posterior fourchette May be seen in blunt force trauma Child disclosed digital-vaginal penetration

18 Perineal Laceration Acute laceration of the perineal region Patient disclosed penile-vaginal penetration Normal genital exam Only positive finding is laceration of the perineum Verifies need to complete a detailed external anogenital exam

19 Periurethral trauma Periurethral bruising noted with no injury to the hymen Result of blunt trauma Child reported attempted penetration with an object

20 Penile Trauma Genital bruising may be the result of: 1) non-abusive trauma 2) sexual abuse (suction, biting, or excessive traction) 3) forms of physical abuse

21 Penile Bruising Toilet accidents are often the origin of genital trauma This image demonstrates bruising of the glans penis in a toddler resulting from forceful pinching inflicted due to child s urinary incontinence

22 Acute penile and scrotal injury Penile bruising and scrotal laceration from being struck with an object

23 Perianal Abrasion Superficial layers of the anal epidermis are involved Image shows abrasions from 11-1 o clock positions on the anus Child reported her privates were touched

24 Acute Perianal Injury: Anal Laceration Acute, deep lacerations noted at the 4 o clock and 6 o clock positions on the anal margin Findings are consistent with penetrating anal trauma May be result of finger(s), penis or object penetration

25 Acute Perianal Injury Diffuse perianal bruising Anal lacerations noted at 12 o clock and 5 o clock (arrows) Child reported penile-anal penetration

26 Hymenal Bruising Note the erythematous bruising from approximately 6-9 oclock on the hymen with petechial bruises in the periurethral tissue Note LACK of injury to labial structures (which would be seen more commonly in straddle type of injury) Young child with no known history of trauma Highly suspect for inflicted trauma

27 Hymenal Bruising Adolescent female with bruising of the hymen from 2 oclock to 10 oclock Patient disclosed digital-vaginal penetration

28 Acute Hymenal Transection Complete transection at 5 o clock on the hymen (arrow) Associated bruising at 6-8 o clock on hymen Result of penetrating trauma Injuries appear relatively acute Cannot precisely date or time

29 Hymenal and Vaginal Trauma Large laceration from 4-6 o clock on hymen with complete interruption Laceration extends into the posterior vaginal wall Requires surgical exploration and repair under anesthesia Hymen laceration Vaginal laceration

30 Healed Trauma to the External Anogenital Region

31 Healed Trauma Suspected healed hymenal transection at 5 o clock Limited view More upward labial traction and examination in supine and prone knee-chest positions is indicated See next slide A suspected abnormality (positive exam) should be confirmed with second technique Prone knee chest-prepubertal female Use of cotton swab-pubertal female

32 Confirmation of healed hymenal transection in two positions in pre-pubertal female Supine frog leg More labial traction used Prone knee chest Confirms persistence of abnormality at 5 o clock in the posterior hymenal rim

33 Healed Transection Annular, estrogenized hymen Healed hymenal transection noted at 6 o clock Emphasizes need for careful exam using swab to examine a pubertal female s estrogenized hymen to identify possible abnormality Cannot precisely date or time other than to note is healed Result of penetrating trauma May be from object, finger, penis Patient s history is needed to verify etiology

34 Considerations A normal anogenital examination is the typical finding in the vast majority of cases of child / adolescent sexual abuse. Medical literature supports that approximately 95% of girls who have been sexually abused have no evidence of anogenital injury at time of examination. Finding an abnormal anogenital exam is even less likely for boys who have been sexually abused. Medical providers must be aware of and able to explain such to caregivers, investigators, attorneys, and juries, and to older patients themselves. A history of penetrating sexual abuse should not lead a medical provider to assume abnormality will or must be found on anogenital exam.

35 Considerations Many reasons exist to explain why the majority of anogenital examinations are normal in pediatric sexual abuse, including: The time between last sexual contact/abuse and anogenital examination may be many days if not weeks or months later. Victims of sexual abuse often do not disclose their abuse immediately due to fear, threats or embarrassment. Excellent blood supply in the anogenital region allows rapid healing of trauma. The anogenital area is very elastic, allowing for stretching and distension without injury. Noted especially in anal tissue and estrogenized hymenal tissue

36 Considerations Some child victims experience vulvar coitus or gluteal coitus during which a perpetrator rubs a finger/object/penis between the labial skin folds or between the gluteal regions without actual penetration of the hymenal tissue or anal musculature These types of sex acts would not cause injury to the hymen or anus Perpetrators who sexually abuse children often desire ongoing sexual contact with their victims and may engage in sexual acts which are less likely to cause significant anogenital injury Perpetrators may use various lubricants to lessen likelihood of trauma Perpetrators may give a child victim medication or other substances to decrease child s ability to struggle or resist, thus potentially lessening risk of anogenital injury

37 Significance of a Normal Exam This image demonstrates an annular, estrogenized hymen which is normal in appearance This female adolescent is pregnant and reported repeated penile-vaginal penetration Due to the elastic and distensible nature of estrogenized hymenal tissue, penetration may occur with no abnormality resulting A normal exam does not rule out or confirm prior sexual abuse A normal exam may occur in cases of sexual abuse and in voluntary sexual contact

38 Resolution of Trauma Acute injury Bruising to hymen from 4-8 o clock 2 weeks post-abuse Complete resolution with normal exam The follow up exam demonstrates no evidence of abnormality despite clear trauma noted initially

39 Infections Transmitted by Sexual Contact* J Pediatr Adolesc Gynecol 2015 *The following are considered the result of sexual contact unless there is evidence of perinatal transmission or reasonably and independently documented extremely rare nonsexual transmission: Genital, rectal or pharyngeal Neisseria gonorrheae Syphilis Genital or rectal Chlamydia trachomatis Trichomonas vaginalis HIV-if transmission by blood transfusion ruled out

40 Important Reminders Sexually transmitted infection may be the first and sometimes only indication a child has been victimized Discharge may be scant or entirely absent Child may be asymptomatic with no complaints Highlights the need to test for STIs when there is a history of penetration and/or suspected exposure to STI despite a lack of physical findings

41 Neisseria gonorrheae Gram negative intracellular diplococcus Incubation period: 2-7 days Primary site of infection: male/female urethra, conjunctivae, rectum and pharynx, endocervix of adolescent females and the vaginal tract in pre-pubertal females Causes vaginitis (rather than cervicitis) in prepubertal females Swabs can be carefully obtained from the vagina or from urine (if using nucleic acid amplification test [NAAT]) in pre-pubertal girls As ascending infection in pre-pubertal children is rare, treatment may be delayed to ensure confirmatory testing is done In pre-pubertal children, an initial positive result requires confirmatory testing prior to treatment N. gonorrheae vaginitis in prepubertal female. Note normal hymenal exam and only small amount discharge noted in perineal skin region

42 Chlamydia trachomatis Obligate intracellular parasite Incubation period 7-14 days Serotypes D-K cause conjunctivitis, pneumonia, vaginitis, cervicitis, salphingitis and urethritis Infection outside of the neonatal period is generally considered diagnostic of sexual abuse In pre-pubertal children, confirmatory testing should always be obtained prior to treatment Often presents with minimal or no discharge at all (images) Important to test if a history of penetration and/or concern for exposure even in asymptomatic patients Image 1: Minimal discharge Image 2: No discharge, normal hymen Examples of C. trachomatis positive exams

43 Syphilis Systemic disease caused by spirochete Treponema pallidum Rarely seen in pediatric patients but must be aware of presentation Transmitted in utero or via direct contact with mucosal or skin lesions Treatment varies based on stage; repeat testing and close clinical follow up advised Multiple stages Primary-painless ulcer ( chancre ) occurs days post exposure. Heals spontaneously. May have atypical appearance in non-genital sites. Condylomata lata- grey/white raised lesions in axilla, genital/anal regions; intermediate stage Secondary-diffuse macular rash followed by papular, scaly rash on palm/soles; accompanied by alopecia, hepatitis, nephritis, arthritis, iritis, neurologic symptoms Tertiary-neurologic, cardiac, ophthalmologic symptoms with gummatous lesions

44 Trichomonas vaginalis Protozoal infection Incubation period of 4-28 days Prefers alkaline urogenital environment May persist up to 6 weeks in neonatal vaginal tract cause vaginitis T. vaginalis does not colonize mouth or GI tract Majority of patients are asymptomatic If symptoms are present, may be mild irritation to severe inflammation Pruritis Dysuria Genital discharge / vaginitis

45 Infections Transmitted by Sexual Contact Refer to Module 4 for information on testing and treatment of sexually transmitted infections

46 Infections Which May be Sexually or Non- Sexually Transmitted Infections that may be transmitted by sexual contact but are also passed by other modalities may cause confusion during evaluation Medical providers must be aware of the significance of such findings in relation to possible sexual abuse

47 Anogenital Warts Condyloma acuminatum is the result of infection with human papillomavirus (HPV) Incubation may be months to possibly few years Multiple modes of transmission vertical, sexual, autoinoculation, and skin-to-skin contact during routine care In older, verbal children, an investigation or assessment for possible sexual abuse is indicated when anogenital warts are discovered. In many cases, no specific disclosure of abuse is forthcoming, and the etiology of the warts may never be determined Diagnosis is usually based on clinical exam Biopsy with or without HPV typing does not help determine etiology and is not indicated unless the lesions are unusual in appearance and it is used to confirm clinical suspicion Resolves without treatment in several months If the lesions are causing pain / irritation, are severe or hindering urination or defecation, treatment may be indicated

48 Anogenital Warts In the absence of other indicators of sexual abuse, there is no expert consensus on the likelihood of anogenital warts resulting from sexual contact Of note, condylomatous lesions appearing for the first time in a child 5 years of age and older may be more likely to be the result of sexual contact 48

49 Anogenital Warts Evaluation Age-appropriate forensic interview Complete physical examination including anogenital regions Consider STI testing If indicated, refer to child protective services

50 Human Herpervirus (Herpes Simplex Virus) Causes PAINFUL lesions Incubation period of 2-14 days Human herpesviruses 1 and 2 may cause oral and/or genital lesions HSV type 1 is more often found in oral location HSV type 2 is more often found in anogenital regions HSV type 2 is more likely to result in a chronic, recurrent infection requiring suppressive therapy

51 Human Herpervirus (Herpes Simplex Virus) In the absence of other indicators of sexual abuse, there is no expert consensus on whether this infection is indicative of sexual transmission Many infected persons have minimal or no symptoms, but shed virus intermittently from the genital tract Vital to educate about asymptomatic spread of infection 51

52 Molluscum Contagiosum Highly contagious skin infection caused by DNA poxvirus Common in school-age children Incubation is 1-6 weeks Duration: ~2 months per papule Up to 3 years for overall infection Virus is spread from person to person by touching the infected skin, or from contact with infected fomites May be spread by sexual contact NOT diagnostic of sexual contact Child may autoinoculate anogenital area Diagnosis is by clinical exam May be mistaken for anogenital HPV warts 52

53 Bacterial vaginosis Polymicrobial infection Overgrowth of Gardnerella vaginalis, Mycoplasma hominis and /or anaerobic organisms Unknown incubation period Causes fishy genital odor due to elevation of vaginal ph Clue cells (epithelial cells studded with bacteria) sometimes noted on microscopic examination of vaginal epithelium Thin, yellow-gray vaginal discharge may be noted Over half of all persons infected are asymptomatic Associated with sexual contact may be seen in pediatric patients with no history of sexual contact /abuse Presence of BV raises concern, but does not prove, sexual contact/ abuse in pediatric patients

54 Additional Exam Findings in Sexual Abuse A thorough head to toe physical exam is mandatory in all cases of suspected maltreatment In cases of suspected sexual abuse/assault, a normal anogenital exam is often noted Documenting positive cutaneous findings can support a child s disclosure of abuse

55 Bite/Suction Injury Photo demonstrates multiple hickey marks which are the result of suction leading to bruising Patient disclosed being sexually assaulted at time of cutaneous trauma

56 Strangulation Subtle petechial bruises along patient s neck are the result of attempted strangulation Patient reported being held by perpetrator s hands around neck during incident of sexual abuse

57 Palatal Injury Careful exam of the oral cavity may reveal trauma resulting from abusive etiology Patient reported forceful penileoral contact Palatal bruising supports and is consistent with disclosure

58 Grab marks Thorough examination revealed multiple fingertip-sized bruises of lateral thigh Patient disclosed perpetrator held outer leg forcefully during sexual assault

59 Tagging, Branding and Tattooing Method for perpetrators to mark their territory Demonstrates ownership of child to others and to child victim Often noted in minor sex trafficking Tagging Signature using words or symbols Branding Use of hot implement or skin removal to mark child Tattoos Identifies child as property Whole-body cutaneous exam is required to assess for such findings Photodocumentation and detailed written description recommended Refer to following page for case examples

60 Tattoo Branding Tagging

61 Recommended Reading Adams JA, Kellogg ND, Farst KJ, Harper NS, Palusci VJ, Frasier LD, Levitt CJ, Shapiro RA, Moles RL, Starling SP, Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused, Journal of Pediatric and Adolescent Gynecology (2015), doi: /j.jpag Crawford-Jakubiak JE, Alderman EM, Leventhal J, Committee on Child Abuse and Neglect, Committee on Adolescence. Care of the Adolescent After an Acute Sexual Assault. Pediatrics February 2017.