Sexual Abuse
Cindy W. Christian
INTRODUCTION
Child sexual abuse is defined as the involvement of children in sexual activities that they cannot understand, are not developmentally prepared for, cannot give informed consent to, and that violate societal taboos. “Sexual abuse” is a general term that includes a broad range of activities, including noncontact activities (e.g., pornography, either in its production or in its viewing; inappropriate observation of the child while dressing, toileting, or bathing; and perpetrator exhibitionism directed at the child) and contact activities. Sexual abuse frequently occurs over time as the perpetrator gains the trust of the child, and it can progress from noncontact to contact forms of abuse.
DIFFERENTIAL DIAGNOSIS LISTChild sexual abuse can have various presenting signs and symptoms. The following are physical signs associated with sexual abuse and the differential diagnosis for each.
Vaginal or Penile Discharge
Infectious Causes
Sexually transmitted infections (STIs)—Neisseria gonorrhoeae, Chlamydia trachomatis, Trichomonas vaginalis
Group A Streptococcus
Haemophilus influenzae
Staphylococcus aureus
Corynebacterium diphtheriae
Mycoplasma hominis
Gardnerella vaginalis
Shigella
Anatomic Causes
Ectopic ureter
Rectovaginal fistula
Draining pelvic abscess
Traumatic Causes
Foreign body
Chemical irritation (e.g., bubble bath)
Tight, nonporous clothing
Miscellaneous Causes
Nonspecific vulvovaginitis
Leukorrhea
Lipschutz ulcerations
Genital Bleeding
Infectious Causes
Urinary tract infection with gross hematuria
Vaginitis
Anatomic Causes
Vaginal polyp
Urethral prolapse
Vulvar hemangioma
Traumatic Causes
Straddle injuries (usually anterior lacerations)
Impaling (penetrating) injuries
Foreign body (e.g., toilet paper, small toys)
Dermatologic Causes
Lichen sclerosus et atrophicus (girls)
Balanitis xerotica obliterans (boys)
Endocrinologic Causes
Neonatal estrogen withdrawal
Precocious puberty
Neoplastic Causes
Sarcoma botryoides
Vaginal rhabdomyosarcoma
Estrogen-producing tumors
Genital Inflammation or Pruritus
Infectious Causes
Nonspecific vulvovaginitis
STIs—N. gonorrhoeae, C. trachomatis, T. vaginalis
Pinworms
Scabies
Vaginal candidiasis
Group A streptococcal perianal cellulitis
Traumatic Causes
Poor hygiene
Poorly ventilated or tight underwear
Chemical irritation
“Sandbox” vaginitis
Dermatologic Causes
Atopic dermatitis
Contact dermatitis
Seborrhea
Diaper dermatitis
Psoriasis
Lichen sclerosus et atrophicus (girls)
Balanitis xerotica obliterans (boys)
Systemic Causes
Urticaria
Crohn disease
Kawasaki syndrome
Stevens-Johnson syndrome
Bruising
Infectious Causes
Purpura fulminans
Disseminated intravascular coagulation
Traumatic Causes
Straddle injuries
Accidental penetrating injuries
Dermatologic Causes
Lichen sclerosus et atrophicus (girls)
Balanitis xerotica obliterans (boys)
Erythema multiforme
Mongolian spots
Vascular nevi
Hematologic Causes
Idiopathic thrombocytopenic purpura
Leukemia
Vitamin K deficiency
Coagulopathies
Disseminated intravascular coagulation
Metabolic Causes
Ehlers-Danlos syndrome
Osteogenesis imperfecta
Autoimmune Causes
Henoch-Schönlein purpura
Vasculitis
DIFFERENTIAL DIAGNOSIS DISCUSSION
A few diagnoses are commonly mistaken for sexual abuse and deserve comment.
Lichen Sclerosus et Atrophicus
