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Genital examination technique and findings in sexually abused children

Genital examination technique and findings in sexually abused children. Ciara Earley VFPMS VFPMS Seminar Monday June 2 nd 2014 . Before you begin. Timing of the examination,< 72 hours in acute cases Location The purpose of the examination

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Genital examination technique and findings in sexually abused children

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  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

  7. 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

  8. 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,

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

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

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

  20. 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

  21. 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

  22. 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

  23. 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

  24. 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

  25. 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

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