The medical evaluation of sexual abuse, while predominantly relying upon history, needs to include a thorough and specialized genital and anal examination. Examiners require a detailed understanding of physical findings that might be suggestive or even diagnostic of genital trauma or sexually transmitted infections. In addition, health professionals examining possible victims of sexual abuse must have a thorough knowledge of those medical conditions that can cause genital and/or anal findings that might be confused with abusive trauma or sexually transmitted infections. As the evidence base relating to the interpretation of genital and anal findings has grown, there has been a concurrent recognition of those medical conditions that can be confused with findings from abusive trauma. It is therefore critical that the examiner has up-to-date information on such clinical entities.
“Mimics” range from the relatively common finding of erythema to uncommon presentations such as genital ulcerations. In this chapter we review several of the more common conditions including those that are associated with inflammatory changes, other medical mimics, and non-sexual genital trauma.
Irritants and Dermatitis
Vaginitis, vulvitis, and vulvovaginitis are nonspecific signs with a multitude of causes ( Figure 12-1 ). Dermatitis is the most common vulvar condition in children and most often the result of atopy or irritants in nondiapered children. The onset of symptoms related to vulvar atopic dermatitis can be after the child is toilet trained. Children often present with vulvar itching and the labia majora are dry, erythematous, and can be lichenified. The labia minora can be involved. Desquamation of the labia minora can lead to staining of the underwear, which is often interpreted as vaginal discharge. Treatment includes emollients and 1% hydrocortisone cream.
A significant cause of genital discharge, pain, irritation, and redness in toilet trained children appears to be poor hygiene habits, which lead to an irritant contact dermatitis. In fact, improved hygiene techniques are often curative in children without a history of trauma and with examination findings suggestive of poor hygiene habits. Wiping the vulvo-perianal area from back to front has been implicated as a risk factor. Soaps, bubble baths, and shampoo can also lead to irritant contact dermatitis, as can prolonged wearing of wet swimming suits and shaving or plucking of pubic hair. , Allergic vulvar dermatitis is a rare finding in young children but has been reported as the result of the dyes, rubber chemicals, or glues in diapers. , Pinworms can be found in more than 30% of children presenting for medical care because of signs or symptoms of vulvovaginitis. Candida can be seen in diapered children, but it is rarely a cause of vulvovaginitis in nondiapered children before puberty. ,
Diaper dermatitis is the most common dermatological condition in diapered children. Though there are clear overlaps and a distinction is somewhat artificial, diaper dermatitis can be divided into primary and secondary types. Secondary diaper dermatitis is defined as an eruption that occurs in the diaper area with a defined cause. Causes of secondary diaper dermatitis include malaria rubra (the result of blockage of the eccrine ducts), seborrheic dermatitis, and allergic contact dermatitis and a variety of other infectious agents.
Primary diaper dermatitis is ill defined and is primarily noninfectious and nonallergic. The cause is multifactorial and the most important factors are moisture, friction, urine, feces, and sometimes microorganisms. Persistent moisture and fecal enzymes disrupt skin integrity and cause the skin to be more susceptible to injury. The clinical presentation of primary diaper dermatitis can be varied, but often includes erythema and mild scaling of the gluteal cleft, buttocks, thighs, and lower abdomen ( Figure 12-2 ). There may be maceration in the skin folds and areas rubbed by the diaper are often most severely affected. First line treatment of primary diaper dermatitis is elimination of the irritants. This includes daily baths, frequent diaper changes, and barrier creams such as zinc oxide. Second line treatment includes 1% hydrocortisone cream, antifungal cream, and mupirocin ointment.
Children who have chronic incontinence of feces or urine can develop Jacquet erosive diaper dermatitis of the genital or perianal skin ( Figure 12-3 ), “characterized by 2-5 mm well-demarcated papules and nodules with central umbilication or punched-out ulcers.” , There have been other reports linking chronic incontinence of feces or urine to pseudoverrucous papules and nodules mimicking condyloma acuminatum ( Figure 12-4 ).
Though more likely mistaken for physical rather than sexual abuse, severe dermatitis resembling a scald burns have been reported in children who have ingested senna-containing laxatives. The exact pathogenic mechanism is unclear but appears to be related to irritant effects of the senna ( Figure 12-5 ).
Labial Adhesions
Labial adhesions are often noted as an incidental finding ( Figure 12-6 ). Less frequently they are discovered in the course of evaluation of genital complaints such as discomfort, dysuria, or recurrent vulvar or vaginal infections. They can also present with blood in the underwear if adhesions are lysed through the course of play or through minor genital trauma ( Figure 12-7 ). The vestibule is sometimes obscured and patients present with a thin avascular line in the midline. The fusion can appear thin and filmy or dense and fibrous.
The true incidence of labial adhesions is unknown. Many girls with adhesions remain asymptomatic and never require medical intervention. The pediatric gynecologic literature reports an incidence of 0.6 to 3.0% in prepubertal girls; however, the sexual abuse literature focused on collecting normative values reports a much higher incidence. McCann reported an incidence of 38.9% but many of these adhesions were 2 mm or less. Berenson reported agglutination significant enough to obscure visualization of the hymen in 5% of girls less than 7 years old and partial agglutination in another 17%.
The cause of labial adhesions remains unclear but is thought to be related to conditions that cause local irritation combined with the low estrogen level of childhood. Some suggest that the thin skin covering the labia is easily denuded as a result of local irritation which leads to the labia adhering in the midline. As re-epithelialization occurs on both sides the labial remain fused. The fact that labial adhesions are rarely seen during childbearing years supports a protective role for estrogen. The exact role of estrogen however is unclear and some authors argue that estrogen may not be a factor at all. Female circumcision can mimic labial adhesions ( Figure 12-8 ).
Treatment of labial adhesions is controversial and longitudinal studies are lacking. Many advocate for no treatment in children with asymptomatic adhesions. Most adhesions resolve without treatment and virtually all resolve with the onset of puberty. Adhesions that result in discomfort, dysuria, recurrent vulvar or vaginal infections, or urinary retention might require intervention. If adhesions obscure the hymen in a suspected sexual abuse victim, a history suggestive of hymenal injury should guide the decision to treat, given the low overall incidence of hymenal findings in sexually abused children. Estrogen cream is usually considered first line treatment but side effects such as local skin pigmentation and breast budding can occur. Estrogen cream should be used sparingly for a short period of time in prepubertal child. One study suggested a success rate with estrogen use of only about fifty percent. Betamethasone 0.05% cream might also be an effective treatment, either as first line therapy or for patients that have failed previous therapy. Mechanical separation can be effective. This can be done in the office very gently with or without local anesthetic using an examining finger, swab or probe. Dense adhesions causing symptoms might require surgical intervention Estrogen cream following mechanical separation helps prevent recurrence.
Crohn Disease
Crohn disease or regional enteritis is a chronic inflammatory bowel disease (IBD). Unlike ulcerative colitis, which presents as mucosal inflammation of only the colon, Crohn is characterized by transmural “skip lesions” that can occur anywhere in the gastrointestinal tract from the mouth to the anus. Such anal lesions have caused concern for abuse in clinical reports ( Figure 12-9 ). , In addition to GI tract findings, several reports have described so-called “metastatic Crohn” with cutaneous and genital manifestations. Crohn vulvitis was first described by Parks in 1965. A careful family history is important as approximately 20% of patients have an affected relative. Additionally, a complete history and physical evaluation will reveal characteristic findings, including poor growth, diarrhea, abdominal pain, and enteric blood loss. The accurate diagnosis of Crohn disease can be critically important to a young patient.
Genital/Anal Infections
There are a variety of bacteria that can cause significant genital or anal inflammation in children. In a study looking primarily at Gardnerella vaginalis in nonabused preschool children, Myhre and colleagues cultured a wide variety of common pathogenic and nonpathogenic bacteria from the youngsters. Isolates included Streptococcus pyogenes, Staphylococcus aureus, Streptococcus pneumonia , Escherichia coli , and Hemophilus influenzae . Among those isolates, Streptococcus pyogenes and Hemophilus influenzae were commonly associated with inflammatory findings. Streptococcus pyogenes, Staphylococcus aureus, and Hemophilus influenzae are well documented causes of vulvar and perianal infection. Though trained examiners rarely confuse such infections with abusive trauma, the child’s caregivers and perhaps some less experienced examiners might attribute clinical findings of vulvovaginitis to trauma ( Figure 12-10 ). In addition to the often-needed reassurance, identification and treatment are crucial as well. There is evidence, for example, that the reactive arthritis associated with group A streptococcal pharyngitis can also occur in association with genital infections. There are reports of methicillin-resistant Staphylococcus aureus (MRSA) vulvar infections in women, and scrotal ulceration in men. A complete medical evaluation of these infections necessarily includes bacterial and viral cultures.
Finally, with respect to infectious mimics, warty growths such as verruca vulgaris and molluscum contagiosum can certainly be confused with human papillomavirus (HPV) infections and thus raise concern for the possibility of sexual contact ( Figure 12-11 ). Because of the absence of clarity with respect to the transmission of HPV, these findings should be treated quite conservatively when there is no history for sexual contact. Verruca and molluscum are generally self-limiting infections.
Foreign Bodies
Vaginal foreign bodies have been reported in 4% to 10% of prepubertal girls who come in for evaluation of persistent vaginal discharge. , Vaginal bleeding and blood-stained, foul-smelling discharge are the primary symptoms mimicking sexually transmitted infections (STI) or trauma. The presence of blood is an important predictor and is found in at least 50% of children with a vaginal foreign body. A recurrent or persistent discharge despite changes in hygiene habits and antibiotic treatment can be a clue to the diagnosis. Many times a detailed history will reveal that the child recalls the insertion of the item. Retained toilet paper is common but any number of other objects are inserted. In some situations, foreign body insertion is associated with a history of sexual abuse. Symptoms usually resolve after the removal of the foreign body. Irrigation can be used but is unlikely to be effective unless the foreign body is in the distal vagina and can be visualized ( Figure 12-12 ). Radiographic imaging can be helpful but a negative study does not rule out a foreign body. Vaginoscopy with anesthesia is indicated if suspicion of a foreign body is high or if the patient has persistent bloody vaginal discharge. Vaginoscopy allows the identification of foreign bodies and other pathology, such as malignancies and fistulas. ,
Vascular Problems
Both vasculitides and vascular anomalies can raise concern for genital trauma. Apparent genital trauma, including acute scrotal hemorrhage and stenosing urethritis, have been described in association with Henoch-Schönlein purpura. , Levin and Selbst described a case in which a vulvar hemangioma was thought to be a traumatic finding. Penile lymphangioma associated with cellulitis has also been described and can appear to be of traumatic origin. While these conditions are most often confused with physical abuse, any time there is concern for inflicted genital trauma, the specter of sexual abuse is raised.
Neoplasia
Sarcomas, carcinomas, and germ cell tumors of the genitals have all been reported in childhood. Of these, the embryonal type of rhabdomyosarcoma, sarcoma botryoides, is far and away the most common. , It presents as a polypoid mass protruding from the vagina sometimes confused with urethral prolapse or human papillomavirus (HPV). Unexplained genital masses should, of course be referred for definitive diagnosis as soon as possible.
Anal Findings
Among parents and health professionals alike, the issue of fecal incontinence often raises concern for sexual abuse. There are some publications that describe an association of encopresis with sexual abuse. These studies, however, have methodological shortcomings and do not confirm that fecal incontinence is a reliable indicator of sexual abuse. In one study that examined fecal soiling as a predictor of sexual abuse, children with a history of sexual abuse were compared with children referred for psychiatric evaluation and a normative sample. While the sexually abused group did have significantly more incontinence than the normative sample, there was no significant difference compared with the group referred for psychiatric evaluation, indicating that soiling is not a reliable sign of sexual abuse.
Chronic constipation can be associated with marked anal dilatation on examination, and the dilatation should not be assumed to be a sign of sexual abuse. Anal dilatation can also be seen as a normal variant when stool is not present in the rectal vault. Anal fissures are a rare finding in the general pediatric population; however, they are seen in approximately 25% of children evaluated for constipation.
Perianal erythema is common and is not a specific sign of sexual abuse. Perianal venous congestion can resemble a perianal bruise but is a common finding, particularly when children are in a knee-chest position for an extended time ( Figure 12-13 ). Perianal skin tags are not an indicator of sexual abuse trauma and frequently are found in the midline.
Rectal prolapse is rare in children, but when it does occur, the child is usually brought urgently to medical attention and this might raise concern for rectal trauma and sexual abuse. It is most common before age 4 and the incidence is highest in the first year of life. It can involve only the mucosa or all layers of the rectum. The latter condition is referred to as procidentia. Parents often note a dark, red mass and excess mucus emerging from the anal verge, but note that the child does not appear to be in pain. Often the prolapse resolves by the time the child comes for medical attention. Because up to 23% of cystic fibrosis patients can have rectal prolapse, sweat chloride testing is indicated in any child with rectal prolapse. Recurrent prolapse can require surgical intervention.
Dilated hemorrhoid veins can be a source of rectal bleeding leading to the consideration of trauma. Hemorrhoids are rare in young children but more commonly effect teens and young adults. In children hemorrhoids are usually benign but the possibility of portal hypertension should be entertained. Treatment is often only symptomatic but any associated constipation or fecal impaction should be treated to avoid recurrence.
Urethral Prolapse
Prolapse of the urethral mucosa in girls is an uncommon condition. , The prolapse appears as a friable rosette of bright red or cyanotic tissue in the urethral area ( Figure 12-14 ). At times the prolapse is large enough to fill the vulvar introitus and obscure the hymen. The disorder occurs most commonly in prepubertal girls between the ages of 1 to 10 years. Usually there are no symptoms and the prolapse is visualized incidentally after bathing as a red-colored mass protruding from the labia. Bleeding from the genital area, which is generally minimal but commonly attributed to trauma, is often the first sign of urethral prolapse, and pain or tenderness are infrequent. Rarely there can be urinary retention. ,
Clinicians not experienced with urethral prolapse may mistake its presentation with that of sexual abuse, particularly when the presenting complaint is vaginal bleeding or the prolapse is hemorrhagic, thereby mimicking acute trauma to the hymen. In addition urethral prolapse can resemble human papillomavirus (HPV) infection of the urethral area ( Figure 12-15 ). Predisposing factors to this condition are thought to be perineal trauma, straining with constipation, diarrhea, or coughing. , Urethral prolapse is seen most commonly in African-American girls with some studies reporting as many as 89% to 100% of cases occurring in African-American girls.
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