Genital examination technique and findings in sexually abused children

1. Genital examination technique and findings in sexually abused children Ciara Earley VFPMS VFPMS Seminar Monday June 2nd 2014

2. Before you begin.... • Timing of the examination,< 72 hours in acute cases • Location • The purpose of the examination • The genital examination as a part of a complete medical examination • Not just “hymenologists!” • Consent NB (Gillick competent, court order, parental)

3. And then... • Equipment: Adequate light and privacy • Colposcopy recommended if available • Magnification and illumination, enables Peer Review • Can be awkward and technically difficult in younger children • Who else needs to be present ?

4. Normal Female anatomy

5. The examination • Comfortable position and clothing • The hymen as a clock face • Position of patient • Supine frog leg • Prone knee-chest • Left lateral • Supine knee chest

6. Labial traction technique

8. Handy hints • Don’t forget that the prepubertal hymen is sensitive • Relaxation enables a better view of the hymen • Elevation of the pelvis may help visualisation • Reposition • Extra pair of hands! • Moistened swab in adolescents • May need a repeat examination in certain cases

9. Normal Female Anatomy • Several changes from neonatal period to adolescence • Oestrogen effects may remain for the first year or two • Pre-pubertal: Less oestrogen effect, thin atrophic tissues, • Labia majora flat appearance, labia minora thin,

10. Pubertal changes • Influence of Oestrogen returns • Thickened hymenal tissue with more elastic and fibre content • Fimbriated appearance • Thicker tissues less vulnerable to damage and infection

11. Hymenal membrane • “The most insignificant anatomical structure of the female without an analog in the male has assumed a social importance at variance with its almost neutral physiologic value or its potential influence upon health” Wile Is The Psychology of the hymen . J NervMentDis .1937 (Feb):143-156

12. Hymenal Variations • Vary with age • Newborn hymens annular or fimbriated • Hymenal configuration changed in 65% • 68% of hymenal tags present at birth disappeared, 9 tags formed Berenson, A, A longitudinal study of hymenalmorphology in the first 3 years of life, Pediatrics 1995; 95: 490-496

13. Hymenal variations contd • Cresenteric configuration more common as children aged • The number of mounds and intravaginal ridges increased as the children aged • No deep notches or transections observed in those who did not have a history of sexual abuse • A decrease in the amount of tissue in the posterior hymen was noted but some tissue always present Berenson, AB, Grady, JJ, A longitudinal study of hymenal development from 3 to 9 years of age, Journal of Pediatrics, 2002; 140: 600-607

14. Hymenal variations contd • Notches/cleft: an angular V shaped indentation on the edge of the hymenal membrane which does not extend right through to the vaginal wall. Common at 3 and 9 o clock positions. • Bumps : Localised rounded areas of tissue can be seen anywhere on the hymen Berenson A.B. Normal anogenital anatomy. Child Abuse and Neglect 1998;22(6) 589-96

15. Hymenal Variations contd • Tags : Flaps or appendages extending more than 1mm from the rim. Common in the newborn • Hymenal Ridges : External ridges may be seen at 12 and 6 oclock. Most easily observed at birth . 86% of newborns in one study. Usually tend to resolve Berenson et al Appearance of the hymen in newborns Pediatrics ,87,458-465

16. Other genital variants • Linea vestibularis : Pale midline avascular streaks of the posterior vestibule • Median Raphe: More obvious in males also present in females • Failure of midline fusion: The defect can extend from the fossanavicularis to the anus. The tissue at the base of the defect is pale and avascular with smooth borders. • Periurethral bands

17. Examination findings (Female) • Normal • Non specific: Erythema • Concerning findings include: • Bruising or abrasions of the genitalia • Decreased amount or absent tissue in the posterior aspect • Injury or scarring of the posterior fourchette/fossanavicularis or hymen • Complete transection of the hymen • Deep hymenal cleft 3-9 oclock

18. Examination findings • Case control study “Most hymenal measurements lack sensitivity or specificity to be used to confirm previous penetration” • Berenson A.B. et al Use of hymenal measurements in the diagnosis of previous penetration Pediatrics2002;109(2) p 228-235 • Berenson et al A case control study of anatomic changes resulting from sexual abuseAmJObstet Gynecol2000;182:820-34 • Vaginal discharge more common in abused children • A hymenaltransection,perforation, or deep notch was observed in 4 children all of whom were abused • Kellog N et al Genital Anatomy in Pregnant Adolescents: “Normal” doesn’t mean “Nothing Happened”Pediatrics 2004;113e67-e69 • Only 2/36 had definitive findings of penetration

19. Male genital examination • Inspection of urethral meatus, foreskin and penis • Scrotum and testes

20. Anal examination • Left lateral or supine knee chest • Lateral buttock separation technique not recommended (post Cleveland inquiry

21. Anal examination findings • Several Non specific findings • McCann et al 318 children selected for non abuse • Erythema 41% • Increased pigmentation 30% • Venous engorgement 52% (after 2 minutes knee chest position) • “Smooth areas” 26% (always on midline) • Anal tags 11% • McCann et al Perianal findings in prepubertal children selected for non abuse :a descriptive study.Child Abuse and Neglect1989;13(2)179-93

22. Anal dilatation • McCann study 49% of children ( AP diameter <0.1cm-2.5cm , mean 1.0cm) • Small % (1.2%) > 20mm without the presence of stool • Hobbs and Wynne “ Dilatation over 0.5cm does not in our experience occur in normal children” McCann et al Perianal findings in prepubertalchilren selected for non abuse :a descriptive study.Child Abuse and Neglect1989;13(2)179-93 Hobbs C.J. & Wynne J.M. Sexual abuse of boys and girls: The importance of anal examination.Child abuse and Neglect 13 (2) : 195-210 1989

23. Anal dilatation contd • Cleveland inquiry : 125 children diagnosed as sexually abused over a 5 month period. • Several other causes of anal dilatation • Chronic constipation • Crohn’s disease • Neurological disorders • During anaesthesia Summary of the Cleveland Inquiry BMJ ;297: July 1988 : p190-191

24. Concerning findings • Anal lacerations (may need further surgical intervention/ EUA) • Anal tags outside the midline (not noted in McCann’s study) • Important to correlate clinical findings and relevant history and medical history

25. Resources • Berenson and McCann studies • Gall J et al Current Practice in Forensic Medicine” chapter on “The paediatric hymen” • Child Abuse and Neglect, diagnosis, treatment and evidence Carole Jenny. Chapter 10 &11 • Child Abuse, Medical Diagnosis and management 3rd edition Reece & Christian

26. Summary • The genital examination is only a part of the overall evaluation of sexual abuse in children • Preparation is important • A detailed knowledge of normal anatomy and variants is required • Most examinations are normal