Perianal findings in prepubertal children selected for nonabuse: A descriptive study

doi:10.1016/0145-2134(89)90005-7

Child Abuse & Neglect

Volume 13, Issue 2, 1989, Pages 179-193

https://doi.org/10.1016/0145-2134(89)90005-7 Get rights and content

Abstract

The results of the perianal portion of a project designed to collect normative data of the anogenital anatomy from a representative sample of prepubertal children is presented. A total of 318 children were examined by three physicians from a child sexual abuse evaluation program. After screening for the onset of puberty and the possibility of undetected abuse, 267 subjects remained. The sample included 161 girls and 106 boys ranging in age from 2 months to 11 years. The perianal findings that were encountered with the greatest frequency included erythema (41%), increased pigmentation (30%), and venous engorgement (52%) after two minutes in the knee-chest position. Wedge-shaped smooth areas in the midline, with or without depressions, were found both anterior and posterior to the anus in 26% of the children. Anal skin tags/folds were discovered anterior to the anus in 11 %. In 49% of the children there was some dilatation of the anus which opened and closed intermittently in 62%. Flattening of the anal verge and rugae occurred during dilatation by the midpoint of the examination in 44% and 34%, respectively. Perianal findings that were found infrequently in all subgroups included skin tags/folds (0%) and scars (1%) outside the midline, anal dilatation greater than 20 mm without the presence of stool in the rectal ampulla (1.2%), irregularity of the anal orifice after complete dilatation (3%), and prominence of the anal verge (3%). No abrasions, hematomas, fissures, or hemorrhoids were encountered. Less commonly detected findings within specific subgroups included perianal erythema in girls (32%) as compared to boys (57%), pigmentation in the lighter skinned white children (22%) when compared to black (53%) and Hispanic (58%) children, and venous congestion at the beginning of the examination (7%) when compared to the same findings after four minutes in the knee-chest position (73%). There were no perianal skin tags/folds found in the boys. The relatively high incidence of perianal soft tissue changes that were found in this study, when compared to the frequency of similar observations in children suspected of having been sexually abused, reemphasizes the caution medical examiners must exercise in rendering an opinion as to the significance of medical findings.

Résumé

On a mis sur pied un projet ayant pour but de récolter des valeurs normatives de l'anatomie ano-génitale chez une cohorte d'enfants pré-pubères. 318 enfants ont été examinés par 3 médecins appartenant à un programme en rapport avec les sévices sexuels. Après avoir filtré les enfants pubères et dépisté la possibilité de sévices non reconnus, il est resté 267 sujets dont 161 filles et 106 garçons, âgés de 2 mois à 11 ans. Les trouvailles péri-anales comprenaient un érythème (41%), une pigmentation augmentée (30%), un engorgement veineux après 2 minutes dans la position génupectorale (52%), des régions lisses sur la ligne médiane de la verge et la région dorsale de l'anus (21%), des dépressions et des petites cavités médianes, soit antérieures ou postérieures au niveau anal (18%) et des petites parties pédiculées de peau situées sur la ligne médiane (11%). Chez 49% des sujets, on a trouvé une dilatation anale, une ouverture-fermeture intermittente des sphincters anaux dans le 62% des cas, un aplatissement du bord anal et des plis du sphincter anal, ceci au milieu de l'examen, chez respectivement 44 et 34% des enfants dont l'anus se dilatait. Des trouvailles non fréquentes dans tous les sous-groupes incluaient des pédicules de peau (0%) et des cicatrices (1%) en dehors de la ligne médiane, une dilatation plus grande que 20 mm sans la présence de selles dans l'ampoule rectale (1.2%). une irrégularité de l'orifice anal pendant la dilatation (3%) et une saillie du rebord anal (3%). On n'a pas trouvé de fissure anale. Parmi les trouvailles moins fréquentes à l'intérieur d'un sous-groupe: 32% des filles présentaient un érythème péri-anal contre 57% chez les garçons, la pigmentation chez les enfants à peau claire (22%) comparée à celle des noires (53%) et des hispaniques (58%); la congestion veineuse au début de l'examen (7%) et les pédicules anaux chez les garçons (0%). Cette incidence relativement fréquente de lésions des tissus mous péri-anaux, tels que rencontrées dans cette étude, a été comparée à la fréquence d'observation similaire chez les enfants qui étaient soupçonnés d'avoir été victimes de sévices sexuels. Elle a renforcé la notion que les examinateurs médicaux doivent exercer la plus grande prudence lorsqu'ils formulent un jugement quant à la signification des trouvailles physiques décrites cidessus.

Resumen

Se presentan los resultados de la parte perianal de un proyecto designado con el propósito de obtener datos normatives con respecto a la anatomía anogenital de una muestra representativa de niños prepuberales. Un total de 318 niños fueron examinados por tres médicos del Programa de Abuso Sexual. Después de eliminar a los niños puberales y a aquellos en que existía la posibilidad del abuso, quedaron 267 sujetos. La muestra incluyó 161 niñas y 106 niños de 2 meses a 11 años de edad. Hallazgos perianales frecuentes incluyeron la ericema (41%), el aumento de pigmentación (30%), la congestión venosa después de dos minutos en la posición rodillas-pecho (52%), areas lisas en la línea media en el borde (margen) y dorsal al ano (21%), hoyuelos o depresiones en la línea media o posterior o anterior al ano (18%), y cabos de piel anales localizados en la línea media (11%). La dilatación anal fué hallada en 49% de los sujetos, el abrirse y cerrarse intermitente de los esfinteres anales en el 62%, el aplanamiento del borde anal y los pliegues de piel anal ocurrieron a la mitad del examen en 44% y 34%, respectivamente, de los niños cuyos anos se dilataron. Hallazgos infrecuentes en todos los subgrupos incluyeron cabos de piel (0%) y cicatrices (1%) tuera de la línea media, dilatación anal major de 20 mm con ausencia de excremento en la ampolla rectal (1.2%), irregularidad del orificio anal durante la dilatación (3%), y prominencia del borde anal (3%). No se encontraron fisuras anales. Los hallazgos que ocurrieron menos frecuentemente dentro de un subgrupo fueron el ericema perianal en las niñas (32%) en oposición a la incidencia encontrada en los niños (57%), pigmentatión en los niños blancos (22%) en comparación con los niños hispanos (58%) y los niños negros (53%), congestión venosa al comienzo de la investigación (7%). y cabos anales en los niños (0%). La incidencia relativamente elevada de cambios en el tejido perianal blando que se encontró) en esta investigación, comparada con la frecuencia de observaciones similares en los niños sospechados de haber sido abusados sexualmente, recalca el cuidado que debe ser empleado por los médicos cuando emiten unjuicio con respecto al significado de sus hallazgos.

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Anogenital Findings in 3569 Pediatric Examinations for Sexual Abuse/Assault
2018, Journal of Pediatric and Adolescent Gynecology
Accurate interpretation of anogenital examination findings in the context of suspected child and adolescent sexual abuse/assault is essential, because misinterpretation has significant child protection and criminal justice implications. A consensus approach to the interpretation of anogenital examination findings is widely used to support accurate diagnosis; however, a large-scale study using this standardized approach is lacking. The objectives of this study were to: (1) determine the proportion of anogenital examinations for sexual abuse concerns with findings diagnostic of trauma and/or sexual contact; (2) determine whether frequency of diagnostic findings varies according to age, gender, and timing of examination; and (3) characterize diagnostic findings.
Retrospective records of children aged 0-18 years evaluated for sexual abuse/assault were reviewed. Case details of 3569 patients were extracted and anogenital examination findings were reinterpreted using a published consensus approach.
Anogenital examination findings diagnostic of trauma and/or sexual contact were present in 173 of 3569 patients (4.8%). The prevalence of diagnostic findings was significantly higher in adolescents than in children younger than 12 years of age (13.9%, 114/823 vs 2.2%, 59/2657), in female vs male patients (5.7%, 164/2866 vs 1.5%, 9/614), and in examinations within 72 hours for children younger than 12 years (14.2%, 91/643 vs 4.5%, 45/997). Acute injuries were the most common type of diagnostic finding.
Diagnostic findings are present in a small proportion of children and adolescents examined for suspected sexual abuse/assault. It is essential that practitioners who interpret examination findings be adequately trained and familiar with the current consensus approach and are aware of case characteristics associated with higher likelihood of findings.
Updated Guidelines for the Medical Assessment and Care of Children Who May Have Been Sexually Abused
2016, Journal of Pediatric and Adolescent Gynecology
The medical evaluation is an important part of the clinical and legal process when child sexual abuse is suspected. Practitioners who examine children need to be up to date on current recommendations regarding when, how, and by whom these evaluations should be conducted, as well as how the medical findings should be interpreted. A previously published article on guidelines for medical care for sexually abused children has been widely used by physicians, nurses, and nurse practitioners to inform practice guidelines in this field. Since 2007, when the article was published, new research has suggested changes in some of the guidelines and in the table that lists medical and laboratory findings in children evaluated for suspected sexual abuse and suggests how these findings should be interpreted with respect to sexual abuse. A group of specialists in child abuse pediatrics met in person and via online communication from 2011 through 2014 to review published research as well as recommendations from the Centers for Disease Control and Prevention and the American Academy of Pediatrics and to reach consensus on if and how the guidelines and approach to interpretation table should be updated. The revisions are based, when possible, on data from well-designed, unbiased studies published in high-ranking, peer-reviewed, scientific journals that were reviewed and vetted by the authors. When such studies were not available, recommendations were based on expert consensus.
Children: Normal Anogenital Anatomy and Variants
2015, Encyclopedia of Forensic and Legal Medicine: Second Edition
Knowledge of normal anogenital anatomy and its congenital variants is critical for professionals performing forensic medical evaluations in cases of suspected child maltreatment. This chapter provides a review of relevant embryology as a foundation for the review of normal female and male external genital and anal anatomy, as well as common variants. It is essential that professionals know the spectrum of normal anatomy in order to recognize forensically important changes, while recognizing that the vast majority of anogenital exams performed for suspected child sexual abuse are normal and do not negate the history of consensual sex, sexual abuse, or assault.
Anal lesions presenting in a cohort of child gastroenterological examinations. Implications for sexual traumatic injuries
2015, Journal of Forensic and Legal Medicine
The purpose of this study was to describe the anal lesions found in children during a pediatric gastroenterology consultation when the reason for the complaint was related to a digestive disease. This prospective descriptive study included 100 children under 15 years of age over a 13-month period, consulting due to digestive symptoms.
The children were under 8 years old (90%) and 25% were under 3.1 years old. Constipation was the most frequent reason for consultation (69%). Fifty-one anal lesions were observed, of which 58.8% were anal fissures, 15.7% were skin tags and 5.8% were venous congestions related to straining. Anal fissures and skin tags were located at the median line, according to the clock-face method in supine position. No child had more than two anal lesions. No anal dilatation, sphincter hypotonia, anal scars, anal lacerations or bruises were found.
The two most common anal lesions were anal fissures and skin tags. These anal lesions were mainly observed at the median line and were due to constipation. No cases of multiple anal lesions were found in terms of common digestive diseases.
Reflex anal dilatation: An observational study on non-abused children
2014, Forensic Science International
Citation Excerpt :
These statements underline the persistent interest for the sign in the diagnosis of anal abuse in children [9]. Only few studies evaluating the prevalence of RAD in nonabused children have been carried out and presented relevant limitations such as the lack of a precise definition of a positive RAD, a small sample size, a limited age range of included children or the selection of patients presenting specific clinical conditions, like constipation or other favoring factors [10–16]. The aim of the present study was to evaluate the prevalence of RAD in a convenience sample of children with no suspicion of abuse admitted to a Pediatric Emergency Department (PED).
Reflex anal dilatation (RAD) is considered as a possible sign of anal abuse,however studies evaluating its prevalence in non-abused children are limited. The aim of this study was to evaluate the prevalence of RAD in a convenience sample of children with no suspicion of abuse admitted to a Pediatric Emergency Department (PED).
Prospective observational study including children admitted to the PED of Padova, Italy, between January and June 2011. Patients with no suspicion of abuse and for whom ano-genital examination was part of their medical evaluation were included. Children were excluded if in critical clinical conditions or if any suspicion of abuse arose during medical evaluation. Presence/absence of RAD and of factors favoring its appearance were recorded for each patient.
Two-hundred and thirty children (median age of 12 months, interquartile range 5–35 months) were finally included. A positive RAD was reported in 14 (6.1%, CI 95% 3.4–10). Only 3 patients (1.3%, CI 95% 0.3–3.7) showed a positive RAD in the absence of any predisposing factor.
RAD is an infrequent sign in non-abused children and it is particularly rare in the absence of any predisposing factor. Case-control studies are necessary to better clarify its diagnostic relevance.
Findings after Sexual Abuse – Children
2024, Forensic and Legal Medicine: Clinical and Pathological Aspects

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^☆: This project was supported in part by grants from the Medical Research Committee, Valley Medical Center and from the Office of Child Abuse Prevention (OCAP). State Department of Social Services, Sacramento, CA.

^☆☆: Preliminary data from this study was presented during the Health Science Response to Child Maltreatment Conference, San Diego, CA, January 21, 1988.

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Perianal findings in prepubertal children selected for nonabuse: A descriptive study☆,☆☆

Abstract

Résumé

Resumen

Adolescent Pediatric Gynecology

Lancet

Lancet

Child Abuse & Neglect

Nelson textbook of pediatrics

Sexual child abuse

BMDP statistical software

Sexual abuse of boys

American Journal of Diseases of Children

Genital findings in sexually abused, symptomatic, and asymptomatic girls

Pediatrics

Proctologic anatomy

Prepubertal female genitals: Examination for evidence of abuse

Pediatrics

Textbook of anatomy