Child sexual abuse occurs when a dominant, more powerful person involves a depending, developmentally immature child or adolescent in sexual activities for his or her own or others’ sexual stimulation or gratification. This includes child pornography and prostitution, and ranges from nontouching abuses to direct genital, anal, or oral-genital contact. About 1% of children experience some form of sexual abuse each year. Perpetrators are usually male (75% to 90%) and usually involve adults or minors known to the child. Abuse by family members or known acquaintances often involves multiple episodes over weeks to years, whereas abuse by strangers tend to be a single episode. Most cases are detected when the child discloses the abuse. Sexually abused children may present with a variety of general and/or nonspecific symptoms and signs (eg, sleep disturbances, abdominal pain, enuresis, encopresis, phobias). Physical findings are often absent even when the perpetrator admits to penetration of the child’s genitalia. Many types of abuse leave no physical evidence, and injuries to the mucosa heal quickly and thus leave no physical evidence in most cases.
Figure 4.1 ▪ Condylomata Acuminata (Genital Warts Due to Sexual Abuse).
Lesions are seen in the perianal area of this 3-year-old male child who was abused by his maternal uncle. Genital warts are soft, flesh-colored, elongated lesions that develop around mucocutaneous junctions and intertriginous areas (eg, perianally, mucosae of female genitalia). Condylomata acuminata must be differentiated from condylomata lata as both occur in the same areas. (Photo contributor: Binita R. Shah, MD.)
Obtain a history in those older than age 3 years, and avoid leading and suggestive questions or showing strong emotions such as disbelief or shock in the absence of the parent so that their influence or distraction are minimized. Maintain a “tell me more” or “and then what happened approach.” Explain the physical examination to the child before conducting it and avoid any additional emotional trauma. Examination should be immediate if the patient presents within 72 hours of the alleged sexual abuse, and must include checking for acute injury or bleeding, vaginal discharge, possible presence of sexually transmitted infections (STIs) and the possibility of pregnancy in adolescent girls who have reached menarche. If more than 72 hours have passed since the alleged abuse, the exam can be scheduled at the earliest time that is comfortable for the child, the investigative team, and the physician. Perform a thorough physical examination, including mental and emotional status with special attention to areas that are involved in sexual activity. The supine frog-leg position is most often employed and well tolerated by prepubertal girls. It is important also to view the hymen in a second position if a concerning physical finding is seen. The prone knee-chest position often allows better visualization of the hymen, the fossa navicularis, and the posterior fourchette. Do not perform speculum or digital examinations in a prepubertal child. A digital rectal examination is usually not necessary. Conduct universal screening of postpubertal patients for gonorrhea, Chlamydia, syphilis, HIV, or other STIs. In asymptomatic prepubertal patients, the yield of positive cultures is very low, and appropriate cultures and serologic tests are recommended when epidemiologically indicated or when history and/or physical findings suggest oral, genital, or rectal contact. Prophylaxis for STIs is not recommended for asymptomatic prepubertal children being evaluated for possible child sexual abuse. In contrast, adolescents should be encouraged to receive prophylaxis for STIs. Use a multidisciplinary approach involving local or regional child abuse consultants and a social worker. Once sexual abuse is identified, all siblings should be examined and close follow-up arranged within 1 to 2 weeks to detect new infections and to complete counseling and treatment for other STIs. Consider mental health assessment and treatment as necessary.
| STD Confirmed | Sexual Abuse | Suggested Action |
|---|---|---|
| Gonorrhea* | Diagnostic† | Report‡ |
| Syphilis* | Diagnostic | Report |
| HIV∥ | Diagnostic | Report |
| Chlamydia* | Diagnostic‡ | Report |
| Trichomoniasis | Highly suspicious | Report |
| Condylomata acuminata* | Suspicious | Report |
| Genital herpes | Suspicious | Report§ |
| Bacterial vaginosis | Inconclusive | Medical follow-up |
Figure 4.2 ▪ Condylomata Acuminata (Gental Warts) Due to Sexual Abuse.
(A, B) A cauliflower-like mass present for 1 year on the perineum of this 10-year-old girl is shown. She was repeatedly sexually abused by her stepfather since the age of 8. Condylomata start as pinhead papules that are pink, red, or skin colored. Lesions remain either solitary or develop into grapelike clusters and may coalesce in the rectal or perineal area to form a large cauliflower-like mass. (Photo contributor: Binita R. Shah, MD.)
Figure 4.3 ▪ Condyloma Lata Due to Sexual Abuse.
Flat-topped, round-oval nodular lesions and plaque (formed by papules that coalesce) with a wide base are seen around the anus and genitalia in a 6-year-old girl who was repeatedly abused by her stepfather. Unlike condylomata acuminata, these lesions are flat and not covered by digitate vegetations. (Reproduced with permission from Shah BR, Laude T: Atlas of Pediatric Clinical Diagnosis. WB Saunders, Philadelphia, 2000, p. 40.)
Figure 4.4 ▪ Genital Herpes Due to Sexual Abuse.
Extremely painful ulcerative lesions (HSV type 2 culture positive) were seen in an 8-year-old girl who was repeatedly abused by her uncle in the past 2 weeks. Genital herpes is uncommon in children. Lesions usually appear after an incubation period of 2 to 20 days after exposure. Except for perinatal transmission at birth, most HSV-2 genital infections are sexually transmitted. (Photo contributor: Binita R. Shah, MD.)
Figure 4.5 ▪ Gonococcal Conjunctivitis.
An 8-year-old girl with profuse mucopurulent discharge. Her eye, pharyngeal, and rectal cultures were positive for Neisseria gonorrhea. Investigation among the family members led to a 21-year-old uncle with gonococcal urethritis, and subsequently he confessed abusing this girl. (Reproduced with permission from Shah BR, Laude T: Atlas of Pediatric Clinical Diagnosis. WB Saunders, Philadelphia, 2000, p. 40.)
A normal physical examination does not exclude abuse; diagnostic findings are seen in 5% of victims.
Physical examination should not result in additional emotional trauma.
Vaginal, rather than cervical, samples are adequate for testing of STIs in prepubertal children.
Diagnosis is often made on the basis of the history; a child’s statement of abuse is often the most important evidence.
Presume sexual abuse until proven otherwise in a child presenting with STIs.
Figure 4.6 ▪ Injuries Due to Sexual Abuse.
(A) Fresh bleeding and blood clots at the introitus and a superficial laceration in the posterior fourchette were seen in this 4-year-old girl who was sexually abused by her uncle. (B) A hematoma at the introitus and fresh anal injuries with significant anal dilation were seen in this 4-month-old infant brought to the ED with cardiopulmonary arrest. These injuries occurred while infant was being cared by mother’s boyfriend. Posterior rib fractures, splenic rupture, and retroperitoneal hematoma were other injuries seen in this infant. (Photo contributor: Binita R. Shah, MD.)
Figure 4.7 ▪ Infantile Hemangioma Mimicking Sexual Abuse.
A 7-month-old infant with hemangioma with central erosions of the gluteal cleft with extension to the perineum. Evaluation of this midline hemangioma revealed a tethered cord and left-sided duplex ureter, thus fulfilling criteria for PELVIS syndrome. Because of perianal location and erosion, this can be mistakenly attributed to sexual abuse. (Photo contributor: Sharon A. Glick, MD.)
The authors acknowledge the special contributions of Binita R. Shah, MD, to prior edition.
Condyloma acuminata (genital warts) are skin-colored, fleshy lesions on mucocutaneous junctions and intertriginous areas, which can coalesce to large cauliflower-like lesions. Locations include perianal area, glans penis, scrotum, labia or posterior introitus, vagina, cervix, anus, urethra, mouth, nose, and eyes. Symptoms may include pruritus, burning, bleeding, and pain depending on location and size. Condyloma acuminate is caused by human papillomavirus (HPV), which is prevalent and insidious: >50% of sexually active people are infected and most infections are asymptomatic, unrecognized, or subclinical and self-limited. Transmission, occurs by sexual and nonsexual contact activity. Genital warts in children require careful consideration as about 50% are the result of sexual abuse. Nonsexual acquisition is usually seen in children <3 years old and may be suggested by warts on the hands (with autoinoculation patient transferring warts to mouth, genitals, anal area), a mother with hand warts, sexual play among children, absence of other signs of sexual abuse, and warts distant from the anus or introitus.
Figure 4.9 ▪ Condylomata Acuminata.
Condylomata lesions grouped into grapelike clusters in a sexually active adolescent girl. These can be pink, red, or skin colored, with a smooth or velvety surface and soft consistency. Lesions may coalesce in the perineal area to form a large cauliflower-like mass. (Photo contributor: Binita R. Shah, MD.)
Oncogenic or high-risk HPV types (eg, HPV types 16 and 18) cause cervical cancers and other anogenital cancers. Persistent infection is the strongest risk factor for the development of precancers and cancers. HPV types 6 and 11 account for 90% of genital warts. Two HPV vaccines are licensed in the United States: a bivalent vaccine (Cervarix) containing HPV types 16 and 18 and a quadrivalent vaccine (Gardasil) containing HPV types 6, 11, 16, and 18. HPV DNA testing is not recommended as it does not alter clinical management. Differential diagnosis includes condylomata lata, pearly penile papules, and skin tags.
Untreated, visible warts can resolve on their own, remain unchanged, or increase in size or number. Treatment is aimed at relief of symptoms and many factors influence treatment selection, including size, number, anatomic site, morphology, patient preference, convenience, adverse effects, and provider experience. The response to therapy is influenced by the presence of immunosuppression and compliance with therapy. No treatment has been shown to be superior to any other and no single treatment is ideal for all patients or all warts. Patient-applied therapies and provider-administered therapies are available. Patient-applied treatment regimens for external genital warts include podofilox 0.5% solution or gel or imiquimod 5% cream or sinecatechins 15% ointment. Refer the patient to dermatology if diagnosis is uncertain, immunocompromised patient, warts are fixed, indurated, pigmented, ulcerated, or bleeding. Refer for provider-applied treatment regimens (eg, cryotherapy with liquid nitrogen, surgical removal, curettage, or electrosurgery).
Examination of sexual partners is not required; partners are usually infected at the time one person is diagnosed with HPV infection even in the absence of visible warts.
Exclude sexual abuse in children with genital warts.
Consult a specialist for management of intraanal warts as patients may also have warts on the rectal mucosa.
Laryngeal papillomatosis has been seen in infants born to mothers with HPV infection, delivered vaginally or by cesarean section.
Trichomonas vaginalis infection is almost always sexually transmitted with peak prevalence rates between ages of 16 to 35 years. The most common site of infection is the vagina, followed by periurethral glands and urethra. Patients present with pruritus, dysuria, dyspareunia, lower abdominal pain, vaginal discharge, postcoital bleeding, edema and excoriation of the external genitalia, bartholinitis, and urethritis.
Obtain vaginal secretions for microscopic detection of Trichomonas (specificity of 60%–70%). Tests like OSOM Trichomonas Rapid Test or AFFIRM VP III (nucleic acid probe test) performed on vaginal secretions have sensitivity of >83% and specificity >97%. Culture of Trichomonas is still the most sensitive and specific method of diagnosis. PCR assay for T vaginalis in vaginal or endocervical swabs, and in urine from both men and women is available (sensitivities ranging from 88% to 97%; specificity from 98% to 99%). T vaginalis has not been found to infect oral sites, and rectal prevalence appears low; therefore, oral and rectal testing is not recommended.
Treat patients with metronidazole (2 g orally in a single dose or 500 mg orally twice a day for 7 days) or Tinidazole (2.0 g orally in a single dose). Both of these regimens have high cure rates of about 95%. Intravaginal or topical metronidazole gel has not been shown to be effective and is not recommended. Certain strains of T vaginalis can have diminished susceptibility to metronidazole. If treatment failure occurs with single-dose metronidazole and reinfection is excluded, treat with metronidazole for a 7-day regimen or tinidazole. Treatment of all sex partners is advisable. Because of the high rate of reinfection among patients in whom trichomoniasis is diagnosed, refer the patient to the primary care physician for follow-up.
T vaginalis is one of the most common STDs in the United States.
Up to 25% to 50% of girls may be asymptomatic, whereas up to 90% of boys are symptomatic.
Symptomatic girls typically have diffuse, malodorous, yellow-green vaginal discharge with vulvar irritation.
Cervicitis is the most common signs of infection and “strawberry spots” may be seen.
Adverse pregnancy outcomes with trichomoniasis include premature rupture of membranes, preterm delivery, and low birth weight.
Figure 4.14 ▪ Trichomonas.
Saline wet mount demonstrating oval-bodied, flagellated trichomonads. They are similar in size to leukocytes and can be distinguished from them by their motility and presence of flagella. (Reproduced with permission from Hansfield HH: Atlas of Sexually Transmitted Diseases. McGraw-Hill, New York, 1992.)
