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The examination of the genitalia of the infant and child — normal and abnormal
The examination of the genitalia of the infant and child- normal and abnormal
C. J. Hobbs, J. M. Wynne
Until the late 1980s examination of the genitalia was considered to be part of a complete medical examination. a In practice, although newborn infants of either sex were examined subsequent examination of girls was often cursory, whereas boys were repeatedly checked for undescended testes. An unfortunate consequence of the child sex abuse debate has been for some to consider the full medical examination undesirable. Whilst the repeated examination of children must always be justified, there are situations where it is certainly in the child's best interest to be seen and have, for example, a sexually transmitted infection diagnosed and treated. For the paediatrician current practice would be that all newborns should be carefully examined and older children as clinically indicated. Daytime wetting or vaginal discharge would be two such indications. Further examinations may be necessary to further assess physical signs: has there been healing or have the signs evolved? Resolution of signs is to be expected after trauma, new signs are expected in the case of a disorder such as lichen sclerosis. Consent for examination is always required, from the carer with parental responsibility or from an older child who is 'Gillick' competent. Consent must be informed but is equally valid whether oral or written. Once the Family Court is involved with a child, permission is needed from the court before an examination is performed. The Court may also specify the extent of any examination; this may put the paediatrician in a difficult position in terms of his clinical responsibility to the childY
Practically the 'restriction' of clinical examination has resulted in problems in training and paediatricians may feel uneasy about their competence. Doctors should take the opportunity to examine children under supervision and will find the physical signs become familiar as normal and abnormal become evident. Post-graduate courses are available to paediatricians who wish to improve their clinical skills. 6 Bamford 7 suggested that there were six main reasons why a child who might have been sexually abused should be physically examined: • to detect traumatic or infective conditions which may require treatment. • to evaluate the nature of any abuse • to provide forensic evidence • to reassure the child who may feel serious damage has been done • to start the process of recovery • as the sibling of an index child And to this list should be added 'young abusers' as perpetrators of abuse are frequently victims too (25% of abusers in a Leeds clinic were teenaged or younger) and the younger the abuser the greater the risk that they too have been sexually abused. Wherever children are examined there should be appropriate facilities3 and the manner of the examination is important. Children need time and unless the child is able to relax the examination is likely to be incomplete. Sedation or general anaesthetic is rarely needed - - unless there has been severe trauma and surgical intervention is needed, as in the rape of a young child. Microbiological facilities are required,
C J Hobbs, J M Wynne, Consultant C o m m u n i t y Paediatricians, Belmont House, 3/5 Belmont Grove, Leeds LS2 9NR Correspondence and requests for offprints to JMW.
Current Paediatrics (1995)5, 236242 © 1995PearsonProfessionalLtd
236
EXAMINATIONOF GENITALIA 237
and forensic specimens are taken in certain circumstances) A colposcope is useful in providing a good light source, magnification and the opportunity to take photographs unobtrusively. Photographs are useful in peer review but also in obviating the need for further examinations, the 'second opinion' may see the slides and the clinical records rather than the child. The physical examination is only part of the paediatric assessment and any opinion should be given in the light of the history and laboratory investigations. If the child has been sexually abused the medical opinion is part of the wider jigsaw which includes the police and social work investigation and assessment. 3
• burns or scalds • damage to the urethral meatus due to insertion of foreign body A urethral discharge is rare in prepubertal boys and suggests a STD. Genital (and/or anal) warts are the most commonly seen STD in CSA clinics. The differential diagnosis of genital injury in boys includes accidental injury, but a detailed history is needed, zips may cause problems but rarely toilet seats or bicycle handle-bars. Torsion of the testes, hydrocoele, testicular tumour or orchitis have not proved problematic in terms of diagnosis. Skin disorders could theoretically imitate trauma to the genitalia.
The examination
A paediatric examination is not complete without a full physical examination to include an opinion on the child's growth, development and behaviour during the examination. The association of physical abuse and sexual assault is well recognised and any bruises, lacerations etc should be recorded. This paper does not describe the examination of the anus or the physical signs associated with anal abuse? A recent paper 6 recorded perianal findings in young children without a history of sexual assault. Penetrative abuse of boys and girls (particularly young girls) is commonly oral abuse which usually leaves no physical signs or anal abuse, where in young children signs are seen in a majority. 7 It should be remembered that healing may be very rapid and if sexual abuse (CSA) is thought likely an examination at the beginning of the investigation is more likely to reveal abnormality than an examination delayed for weeks or months. Forensic tests 8 may be useful although only early (less than 72 h) after the last sexual assault in young children. The association of sexually transmitted disease and sexual abuse is well established, and again appropriate investigations should be instigated)
The genital examination of boys Recognition of inflicted trauma to the penis and scrotum is increasing. The boy's demeanour during the examination should be noted - - was he angry, passive appropriately embarrassed or calm and cooperative? Did he have a sustained erection or start to masturbate? Why was he so sexually excitable?
The injuries seen include: • bruising including petechial haemorrhages - there may be associated swelling in sucking injury • torn frenulum in forced retraction of the foreskin • incised wound to the penis, usually proximal and dorsal but may be circumferential • red, linear, circumferential mark - - due to ligature
The genital examination of pre-pubertal girls: The examination of the genitalia is better left to the end of the exam by which time most girls will have gained some confidence in the examiner. In younger girls the gender of the doctor is less important than the manner of the exam, but as puberty approaches some girls would prefer a woman doctor to see them. Table I Normal genital findings in the prepubertal girl
1. Hymenpresent 2. Configurationof hymenchangeswith age variantsare annular, crescentic,sleeve,septate,fimbriated 3. Freemargin of hymenthin with fine vesselsvisible 4. Hymenalopening < 4 mm. horizontally 4. Minorbump in hymenin associationwith vaginalridge 4. Absenceof posterior notchesin hymen,anteriornotches infrequent 5. No hymenaltransectionsor attenuation 6. Minordegreesof labialfusion are commonin infancy 7. Non-specificerythemaand discharge Girls are usually examined in the supine, froglegged position, with the upper half of the child covered. In the US the knee-chest position is used to give a better view of the posterior hymen. This is an undignified position for the child but is worth considering if there is difficulty in the interpretation of signs. The girls's demeanour during the exam should be noted, was she angry, passive, flirtatious, frightened, appropriately embarrassed, calm and cooperative? Inspection precedes labial separation, and labial traction may be necessary if the hymenal opening remains closed. The mode of examination should be recorded, as the significance of some signs depends on the method used. 9 If the child is pre-pubertal or has any early signs of puberty, this should be recorded. On inspection there may be redenning, bruises, burns or lacerations of the external genitalia. Look for warts, vesicles and any vaginal discharge. The labia majora may be flattened, wrinkled, the perineum may be thickened, scarred or pigmented. Record any signs of skin disorder, lichen sclerosis or eczema. Does the hymenal opening gape open?
238 CURRENT PAEDIATRICS
Describe any labial fusion (site, length, thickness).
Labial separation is achieved gently to reveal the urethra, hymen and perihymenal tissues. Describe the urethral opening (normal, gaping, reddened, prolapsed). Describe any reddening, laceration, bruising (difficult to recognise) of the perihymenal tissues, any scarring (seen as whitened, thickened, irregular areas with distorted vascular pattern). Is the posterior fourchette friable, scarred? Are there perihymenal support bands? The hymen is described with attention to the configuration, free margin, reddening, oedema and vascular pattern. The size of the hymenal opening horizontally is measured, usually with a tape-measure held adjacent to the child. Glass rods give a more accurate measurement, as long as care is taken not to stretch the opening, but are not routinely used as practitioners are concerned to make the examination as atraumatic to the child as possible. The anterior-posterior diameter is also measured as is the posterior rim of the hymen. This latter measurement is often difficult to make because of uncertainty as to where the hymen ends. In pre-pubertal girls a vaginal examination is rarely required.
Interpretation of genital findings There have been many papers written over the last few years attempting to describe what is 'normal' and 'abnormal' with regard to the pre-pubertal girl's genitalia. There is a consensus on some important points: • all newborns have a hymen, unless there are associated multiple genito-urinary anomalies, l° • the effect of maternal oestrogen causes the infant hymen to be thicker and redundant when compared with an older child where the hymen is thin, has a fine free edge and the vascular pattern is visible. As puberty advances the hymen again becomes thicker and redundant with overlapping folds as the effect of the oestrogen is seen. • the most commonly seen configuration of the hymen at birth is annular, that is, it surrounds the vaginal orifice 360 degrees. • fimbriated, sleeve, and septate hymens are also seen in the newborn (1/72 was recorded as crescentic). 11 • by the age of 3 years 50% of girls have a crescentic hymen ie. an absence of hymen below the urethra. 11 • notches in the hymen between 5-7 o'clock were not seen in the same study, and anterior notches were seen uncommonly at 3 years. (in around 5%). Minor notches may be seen as a result of an indentation on a fimbriated hymen which alters with age.
• asymmetry of the anterior aspect of the hymen i.e. a notch at 10 o'clock is likely to be significant as are deep notches at any site as they are thought to represent, healed incomplete, transections of the hymen. • transections of the hymen are not seen in the non - - abused child. • attenuation (loss of hymenal tissue) is highly correlated with abuse? It is thought that the hymen is 'rubbed away' to the point it can not recover. • the hymen is 'elastic' and following penetration with stretching may be widened and gape i.e. is open before the labia are separated (the opening is usually closed at the beginning of the exam in the non-abused child). Over time, usually weeks, if the child is not re-abused the hymenal opening will again decrease in size. Unless attenuation is the cause of the wide opening (this implies previous, probably repeated, abuse). • labial fusion is due to loss of the upper squamous epithelial layer of the labial mucosa with the formation of a conective tissue bridge. Any trauma may cause this and labial fusion (or, agglutination) is most common in infants with a history of nappy rash. Labial fusion when seen particularly in children out of nappies, which is long, thickened and irregular sometimes with distortion of the vascular pattern is worrying. Is the trauma that caused the fusion rough fingering or intra crural intercourse? • the size of the hymenal opening depends upon the age of the child, the onset of puberty, the examination technique (position, use of traction), and whether the child is able to relax. Table 2 The signs associated with genital abuse
1. 2. 3. 4. 5.
Lacerationof hymen* Attenuation of hymen* Enlargedhymenalopening Distorted or asymmetrichymenalopening Notch in hymen, especiallyposterior but also asymmetrical anterior notches 6. Irregular,thickenedor rolled edge to hymen,may be associated with bumps 7. Moundedscar at posterior fourchette 8. Labialfusion 9. Dilated urethral opening 10. Erythema, oedema, abrasions, lacerations, bruising of genitalia 11. Vaginalforeignbody 12. Sexuallytransmitted disease 13. Other signs of abuse: physical,emotional,neglect, growth disorder 14. The child's demeanourduring the exam.
The 'normal' range is wide but a review 12 stated that a hymenal opening of >4 m m is associated with CSA, but a wide hymenal opening whilst supportive of a diagnosis of abuse is not diagnostic of abuse. As
EXAMINATION OF GENITALIA 239
with other physical signs it must be put into the context of the child's story and any other physical signs. • a minor irregularity of the hymenal margin may be associated with longitudinal vaginal ridge but definite bumps in the hymen may be related to previous trauma ie. a tear which has healed. Similarly a rolled, thickened free edge to the hymen in a child over 3 years is cause for concern. • secondary obliteration of the hymenal opening may follow trauma. • masturbation is universal; if it is 'excessive' i.e. the child masturbates so frequently as to interfere with usual activities a reason should be found for this behaviour. There may be some redenning around the clitoris but actual injury amounts to self - mutilation which is associated with abuse, as is obsessive masturbation. • vaginal foreign bodies are strongly associated with C S A . 13
• healing is rapid and often is complete, scarring is rare. • normal variants include a septate hymen, a 'white streak' across the posterior fourchette, vascular anomalies (which may look like bruises), a midline avascular area at the posterior fourchette. • the differential diagnosis of genital abuse 14 includes skin disorders of which lichen sclerosis is the most common, accidental injury, congenital haemangioma and infections e.g. threadworms, streptococcal infection, prolapsed urethra.
Accidental injury • straddle injury is the most common. • penetrative injury to the labia occurs but not accidental penetration of the hymen. • forced abduction of the legs, as in the splits, has not been described except anecdotally to damage the hymen; there is one case report of rape which caused midline tearing. Accidental trauma to the posterior fourchette is rare and CSA should be considered. • use of tampons in pubertal girls causes slight stretching. • the child gives a history of a sudden, painful injury with immediate bleeding. • in straddle injury the injury is anterior, may be asymmetrical, and affects the mons pubis, clitoris, and the anterior part of the labia majora and minora. There may be marked swelling and bruising and occasionally laceration.
• accidental penetrative injury to the labia occurs in young girls, out of nappies, falling astride toys. There may be minor bruising, and a short laceration, which may bleed profusely but does not usually require suturing. • a seat-belt injury has been reported in the differential diagnosis of accidental trauma but the history must fit, i.e. the impact must cause the belt to slip and straddle the child's genitalia to cause damage. • female genital mutilation is illegal in the U K but widely practised worldwide. • masturbation and vaginal foreign bodies - - as above.
Urinary tract infection • a history of recurrent dysuria, and possible discharge is common in girls who have been sexually abused. • proven urinary tract infections are uncommon i.e. a poor marker of CSA.
The diagnosis of CSA 15 • depends upon the history. • the physical signs - - which depend on the type of abuse, the age of the child, when the abuse occurred, the frequency of the abuse, the presence and type of infection (non - - specific or STD). • other non - - accidental injury. • forensic tests to demonstrate semen, blood, saliva etc. (usually negative in young children where the abuse is usually ongoing and intrafamilial). • the social services and police investigation. Table 3 The differential diagnosis of abnormal genital findings 1. 2. 3. 4. 5. 6.
Accidental injury e.g. straddle injury Inflicted injury e.g. sexual assault, female genital mutilation Skin disease e.g. lichen sclerosis et atrophicus Vulvitis e.g. threadworms, bubble-bath, poor hygiene, trauma Vulvo-vaginitis e.g. non-specific (as 4.), STD Congenital lesions e.g. haemangioma, midline white streak posterior fonrchette 7. Aquired lesions e.g. urethral prolapse, polyp 8. Scarring implies previous trauma
Summary of the examination of the genitalia of the pre-pubertal child • all newborns are currently examined and major congenital abnormality is likely to be recognised. • the genitalia of girls are only subsequently inspected if there is a specific indication e.g. daytime wetting, 'soreness', possible abuse.
240
CURRENT PAEDIATRICS
• the examination of the genitalia is part of a complete paediatric assessment. • consent, from the carer with parental responsibility is needed before any examination verbal consent is valid. • the genital examination begins with inspection, palpation of the testes, and possibly retraction of the foreskin in boys. Likewise in girls inspection is followed by separation of the labia and if the hymenal opening can not be visualised, labial traction. Vaginal examination is not part of a usual examination. The method of the examination should be recorded. • microbiological swabs should be collected appropriately if STD are to be diagnosed.
11. Berenson A B. A longitudinal study of hymenal morphology in the first three years of life. Pediatrics 1995; 95: 490-496. 12. Heger A, Emmans S. Introital diameter as the criterion for sexual abuse. Pediatrics 1990; 85:222 223. 13. Herman-Giddens M E. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc 1994; 148: 195-200. 14. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma AJDC 1990; 144 (12): 1319-1322. 15. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse and Neglect 1993; 17:91-110.
Further reading Meadow R. ABC of Child Abuse, London: British Medical Journal, 1989. Hobbs C J, Hanks H G I, Wynne J M. Child abuse and neglect: a clinicians handbook. London: Churchill Livingstone, 1993. The Royal College of Physicians. The physical signs of sexual abuse in childhood. London: A Report of the Royal College of Physicians, 1991.
• all doctors working with children should take the opportunity to examine the genitalia fully, so as to recognise the range of normal. • if an inexperienced doctor unexpectedly finds physical signs which may indicate CSA, it is necessary to discuss the findings with a more senior doctor and probably to re-examine the child before initiating child protection procedures. • child protection medicals should be performed by adequately trained childrens' doctors who have access to peer-review, and, increasingly use colposcopes to examine and record findings. • there is an increasing literature on the range of normal - - abnormal, the changes seen with age, newborn-pre-schooler, pre-pubertal-puberty, and the healing which occurs after trauma (learned only by follow up clinics).
References 1. Meadow S R. Editorial. Staying cool in child abuse. BMJ 1987; 295: 345. 2. Department of Health 1991. An introductory guide for NHS; the Children Act. HMSO, 1989. 3. Hobbs C J, Hanks H G I, Wynne J M. The management of child abuse Child Abuse and Neglect Churchill Livingstone, 1993 pp 246-248. 4. Post-graduate course for Paediatricians (Consultant, SCMO, S.R.) interested in Child Abuse. Tutors: C. J. Hobbs & J. M. Wynne. Further information: Mrs. C. Myers Community Paediatrics, St. James (University) Hospital, Beckett St., Leeds. 9. 5. Bamford F, Roberts R. Child sexual abuse. In Meadow R (ed.) ABC of Child Abuse British Medical Journal, London. 6. Berenson A B, Somma-Garcia PA-C. Perianal findings in infants 18 months of age or younger. Pediatrics 1993: 838-840. 7. Hobbs C J, Wynne J M. Buggery in childhood - a common syndrome of child abuse Lancet 1986; ii: 792-796. 8. Royal College of Physicians. Physical signs of sexual abuse in children. A report of the Royal College of Physicians, London, 1991. 9. Hobbs C J, Wynne J M. The evaluation of child sexual abuse. In: Child Abuse. Hobbs C J Wynne, eds. J M Balliere's Clinical Paediatrics 1993; 1 (1). 10. Jenny C, Kuhns M, Arakawa E Hymens in newborn female children. Pediatrics 1987; 80:399400
Fig. 1--Male aged 3 years. Contact burn to scrotum, petechiae on dorsum of penis.
Fig. ~ - M a l e aged 4 years. Circumferential incised wound to proximal penis requiring suturing.
EXAMINATION OF GENITALIA 241
b,a ma oro
Urethra Hymen Vestibule Post.fourchette /
/
[ [ ~
a tor ,
(l ~ \~' \ Labia minora !~,~Opening ~.~,~_~ ) --in hymen ~ - j -)~., Anus
Fig. 3~Prepubertal girl, to show normal anatomy.
Fig. ~ H i g h magnification colposcope picture of an annular hymen, female 6 years, to show thin, free edge to hymen and fine, vascular pattern.
Fig. 4~Female, 18 months, note thick, fleshy hymen, hymenal opening visible as slit.
Fig. 7--Female, 4 years, normal, but septate hymen.
Fig. 5--F~male, 5 years, normal, annular hymen.
Fig. 8~Female, 7 years, extensive labial fusion. Child had a severe hearing loss and had been sexually abused by her teenaged brother. Any trauma, infection or abuse may lead to fusion of the labia.
242 CURRENT PAEDIATRICS
Fig. 9--Female, 6 years, recent sexual assault, bruising and bleeding at friable tissue at the posterior fourchette. Note the widely gaping hymenal opening. There is attenuation of the hymen laterally, this child has almost certainly been previously abused.
Fig. 10~Female, aged 6 years, uniform vulvitis, gaping urethra, deep notch at 6 o'clock this is a healed, posterior tear in the
hymen.
Fig. ll--Female, aged 7 years, previous history of CSA, presented with painful, vesicular rash and vulvovaginitis, Herpes Simplex Type 1. Note the swollen hymen and discharge.
Fig. 12~-Female, aged 6 years, Lichen Sclerosis.
C. J. Hobbs, J. M. Wynne
Until the late 1980s examination of the genitalia was considered to be part of a complete medical examination. a In practice, although newborn infants of either sex were examined subsequent examination of girls was often cursory, whereas boys were repeatedly checked for undescended testes. An unfortunate consequence of the child sex abuse debate has been for some to consider the full medical examination undesirable. Whilst the repeated examination of children must always be justified, there are situations where it is certainly in the child's best interest to be seen and have, for example, a sexually transmitted infection diagnosed and treated. For the paediatrician current practice would be that all newborns should be carefully examined and older children as clinically indicated. Daytime wetting or vaginal discharge would be two such indications. Further examinations may be necessary to further assess physical signs: has there been healing or have the signs evolved? Resolution of signs is to be expected after trauma, new signs are expected in the case of a disorder such as lichen sclerosis. Consent for examination is always required, from the carer with parental responsibility or from an older child who is 'Gillick' competent. Consent must be informed but is equally valid whether oral or written. Once the Family Court is involved with a child, permission is needed from the court before an examination is performed. The Court may also specify the extent of any examination; this may put the paediatrician in a difficult position in terms of his clinical responsibility to the childY
Practically the 'restriction' of clinical examination has resulted in problems in training and paediatricians may feel uneasy about their competence. Doctors should take the opportunity to examine children under supervision and will find the physical signs become familiar as normal and abnormal become evident. Post-graduate courses are available to paediatricians who wish to improve their clinical skills. 6 Bamford 7 suggested that there were six main reasons why a child who might have been sexually abused should be physically examined: • to detect traumatic or infective conditions which may require treatment. • to evaluate the nature of any abuse • to provide forensic evidence • to reassure the child who may feel serious damage has been done • to start the process of recovery • as the sibling of an index child And to this list should be added 'young abusers' as perpetrators of abuse are frequently victims too (25% of abusers in a Leeds clinic were teenaged or younger) and the younger the abuser the greater the risk that they too have been sexually abused. Wherever children are examined there should be appropriate facilities3 and the manner of the examination is important. Children need time and unless the child is able to relax the examination is likely to be incomplete. Sedation or general anaesthetic is rarely needed - - unless there has been severe trauma and surgical intervention is needed, as in the rape of a young child. Microbiological facilities are required,
C J Hobbs, J M Wynne, Consultant C o m m u n i t y Paediatricians, Belmont House, 3/5 Belmont Grove, Leeds LS2 9NR Correspondence and requests for offprints to JMW.
Current Paediatrics (1995)5, 236242 © 1995PearsonProfessionalLtd
236
EXAMINATIONOF GENITALIA 237
and forensic specimens are taken in certain circumstances) A colposcope is useful in providing a good light source, magnification and the opportunity to take photographs unobtrusively. Photographs are useful in peer review but also in obviating the need for further examinations, the 'second opinion' may see the slides and the clinical records rather than the child. The physical examination is only part of the paediatric assessment and any opinion should be given in the light of the history and laboratory investigations. If the child has been sexually abused the medical opinion is part of the wider jigsaw which includes the police and social work investigation and assessment. 3
• burns or scalds • damage to the urethral meatus due to insertion of foreign body A urethral discharge is rare in prepubertal boys and suggests a STD. Genital (and/or anal) warts are the most commonly seen STD in CSA clinics. The differential diagnosis of genital injury in boys includes accidental injury, but a detailed history is needed, zips may cause problems but rarely toilet seats or bicycle handle-bars. Torsion of the testes, hydrocoele, testicular tumour or orchitis have not proved problematic in terms of diagnosis. Skin disorders could theoretically imitate trauma to the genitalia.
The examination
A paediatric examination is not complete without a full physical examination to include an opinion on the child's growth, development and behaviour during the examination. The association of physical abuse and sexual assault is well recognised and any bruises, lacerations etc should be recorded. This paper does not describe the examination of the anus or the physical signs associated with anal abuse? A recent paper 6 recorded perianal findings in young children without a history of sexual assault. Penetrative abuse of boys and girls (particularly young girls) is commonly oral abuse which usually leaves no physical signs or anal abuse, where in young children signs are seen in a majority. 7 It should be remembered that healing may be very rapid and if sexual abuse (CSA) is thought likely an examination at the beginning of the investigation is more likely to reveal abnormality than an examination delayed for weeks or months. Forensic tests 8 may be useful although only early (less than 72 h) after the last sexual assault in young children. The association of sexually transmitted disease and sexual abuse is well established, and again appropriate investigations should be instigated)
The genital examination of boys Recognition of inflicted trauma to the penis and scrotum is increasing. The boy's demeanour during the examination should be noted - - was he angry, passive appropriately embarrassed or calm and cooperative? Did he have a sustained erection or start to masturbate? Why was he so sexually excitable?
The injuries seen include: • bruising including petechial haemorrhages - there may be associated swelling in sucking injury • torn frenulum in forced retraction of the foreskin • incised wound to the penis, usually proximal and dorsal but may be circumferential • red, linear, circumferential mark - - due to ligature
The genital examination of pre-pubertal girls: The examination of the genitalia is better left to the end of the exam by which time most girls will have gained some confidence in the examiner. In younger girls the gender of the doctor is less important than the manner of the exam, but as puberty approaches some girls would prefer a woman doctor to see them. Table I Normal genital findings in the prepubertal girl
1. Hymenpresent 2. Configurationof hymenchangeswith age variantsare annular, crescentic,sleeve,septate,fimbriated 3. Freemargin of hymenthin with fine vesselsvisible 4. Hymenalopening < 4 mm. horizontally 4. Minorbump in hymenin associationwith vaginalridge 4. Absenceof posterior notchesin hymen,anteriornotches infrequent 5. No hymenaltransectionsor attenuation 6. Minordegreesof labialfusion are commonin infancy 7. Non-specificerythemaand discharge Girls are usually examined in the supine, froglegged position, with the upper half of the child covered. In the US the knee-chest position is used to give a better view of the posterior hymen. This is an undignified position for the child but is worth considering if there is difficulty in the interpretation of signs. The girls's demeanour during the exam should be noted, was she angry, passive, flirtatious, frightened, appropriately embarrassed, calm and cooperative? Inspection precedes labial separation, and labial traction may be necessary if the hymenal opening remains closed. The mode of examination should be recorded, as the significance of some signs depends on the method used. 9 If the child is pre-pubertal or has any early signs of puberty, this should be recorded. On inspection there may be redenning, bruises, burns or lacerations of the external genitalia. Look for warts, vesicles and any vaginal discharge. The labia majora may be flattened, wrinkled, the perineum may be thickened, scarred or pigmented. Record any signs of skin disorder, lichen sclerosis or eczema. Does the hymenal opening gape open?
238 CURRENT PAEDIATRICS
Describe any labial fusion (site, length, thickness).
Labial separation is achieved gently to reveal the urethra, hymen and perihymenal tissues. Describe the urethral opening (normal, gaping, reddened, prolapsed). Describe any reddening, laceration, bruising (difficult to recognise) of the perihymenal tissues, any scarring (seen as whitened, thickened, irregular areas with distorted vascular pattern). Is the posterior fourchette friable, scarred? Are there perihymenal support bands? The hymen is described with attention to the configuration, free margin, reddening, oedema and vascular pattern. The size of the hymenal opening horizontally is measured, usually with a tape-measure held adjacent to the child. Glass rods give a more accurate measurement, as long as care is taken not to stretch the opening, but are not routinely used as practitioners are concerned to make the examination as atraumatic to the child as possible. The anterior-posterior diameter is also measured as is the posterior rim of the hymen. This latter measurement is often difficult to make because of uncertainty as to where the hymen ends. In pre-pubertal girls a vaginal examination is rarely required.
Interpretation of genital findings There have been many papers written over the last few years attempting to describe what is 'normal' and 'abnormal' with regard to the pre-pubertal girl's genitalia. There is a consensus on some important points: • all newborns have a hymen, unless there are associated multiple genito-urinary anomalies, l° • the effect of maternal oestrogen causes the infant hymen to be thicker and redundant when compared with an older child where the hymen is thin, has a fine free edge and the vascular pattern is visible. As puberty advances the hymen again becomes thicker and redundant with overlapping folds as the effect of the oestrogen is seen. • the most commonly seen configuration of the hymen at birth is annular, that is, it surrounds the vaginal orifice 360 degrees. • fimbriated, sleeve, and septate hymens are also seen in the newborn (1/72 was recorded as crescentic). 11 • by the age of 3 years 50% of girls have a crescentic hymen ie. an absence of hymen below the urethra. 11 • notches in the hymen between 5-7 o'clock were not seen in the same study, and anterior notches were seen uncommonly at 3 years. (in around 5%). Minor notches may be seen as a result of an indentation on a fimbriated hymen which alters with age.
• asymmetry of the anterior aspect of the hymen i.e. a notch at 10 o'clock is likely to be significant as are deep notches at any site as they are thought to represent, healed incomplete, transections of the hymen. • transections of the hymen are not seen in the non - - abused child. • attenuation (loss of hymenal tissue) is highly correlated with abuse? It is thought that the hymen is 'rubbed away' to the point it can not recover. • the hymen is 'elastic' and following penetration with stretching may be widened and gape i.e. is open before the labia are separated (the opening is usually closed at the beginning of the exam in the non-abused child). Over time, usually weeks, if the child is not re-abused the hymenal opening will again decrease in size. Unless attenuation is the cause of the wide opening (this implies previous, probably repeated, abuse). • labial fusion is due to loss of the upper squamous epithelial layer of the labial mucosa with the formation of a conective tissue bridge. Any trauma may cause this and labial fusion (or, agglutination) is most common in infants with a history of nappy rash. Labial fusion when seen particularly in children out of nappies, which is long, thickened and irregular sometimes with distortion of the vascular pattern is worrying. Is the trauma that caused the fusion rough fingering or intra crural intercourse? • the size of the hymenal opening depends upon the age of the child, the onset of puberty, the examination technique (position, use of traction), and whether the child is able to relax. Table 2 The signs associated with genital abuse
1. 2. 3. 4. 5.
Lacerationof hymen* Attenuation of hymen* Enlargedhymenalopening Distorted or asymmetrichymenalopening Notch in hymen, especiallyposterior but also asymmetrical anterior notches 6. Irregular,thickenedor rolled edge to hymen,may be associated with bumps 7. Moundedscar at posterior fourchette 8. Labialfusion 9. Dilated urethral opening 10. Erythema, oedema, abrasions, lacerations, bruising of genitalia 11. Vaginalforeignbody 12. Sexuallytransmitted disease 13. Other signs of abuse: physical,emotional,neglect, growth disorder 14. The child's demeanourduring the exam.
The 'normal' range is wide but a review 12 stated that a hymenal opening of >4 m m is associated with CSA, but a wide hymenal opening whilst supportive of a diagnosis of abuse is not diagnostic of abuse. As
EXAMINATION OF GENITALIA 239
with other physical signs it must be put into the context of the child's story and any other physical signs. • a minor irregularity of the hymenal margin may be associated with longitudinal vaginal ridge but definite bumps in the hymen may be related to previous trauma ie. a tear which has healed. Similarly a rolled, thickened free edge to the hymen in a child over 3 years is cause for concern. • secondary obliteration of the hymenal opening may follow trauma. • masturbation is universal; if it is 'excessive' i.e. the child masturbates so frequently as to interfere with usual activities a reason should be found for this behaviour. There may be some redenning around the clitoris but actual injury amounts to self - mutilation which is associated with abuse, as is obsessive masturbation. • vaginal foreign bodies are strongly associated with C S A . 13
• healing is rapid and often is complete, scarring is rare. • normal variants include a septate hymen, a 'white streak' across the posterior fourchette, vascular anomalies (which may look like bruises), a midline avascular area at the posterior fourchette. • the differential diagnosis of genital abuse 14 includes skin disorders of which lichen sclerosis is the most common, accidental injury, congenital haemangioma and infections e.g. threadworms, streptococcal infection, prolapsed urethra.
Accidental injury • straddle injury is the most common. • penetrative injury to the labia occurs but not accidental penetration of the hymen. • forced abduction of the legs, as in the splits, has not been described except anecdotally to damage the hymen; there is one case report of rape which caused midline tearing. Accidental trauma to the posterior fourchette is rare and CSA should be considered. • use of tampons in pubertal girls causes slight stretching. • the child gives a history of a sudden, painful injury with immediate bleeding. • in straddle injury the injury is anterior, may be asymmetrical, and affects the mons pubis, clitoris, and the anterior part of the labia majora and minora. There may be marked swelling and bruising and occasionally laceration.
• accidental penetrative injury to the labia occurs in young girls, out of nappies, falling astride toys. There may be minor bruising, and a short laceration, which may bleed profusely but does not usually require suturing. • a seat-belt injury has been reported in the differential diagnosis of accidental trauma but the history must fit, i.e. the impact must cause the belt to slip and straddle the child's genitalia to cause damage. • female genital mutilation is illegal in the U K but widely practised worldwide. • masturbation and vaginal foreign bodies - - as above.
Urinary tract infection • a history of recurrent dysuria, and possible discharge is common in girls who have been sexually abused. • proven urinary tract infections are uncommon i.e. a poor marker of CSA.
The diagnosis of CSA 15 • depends upon the history. • the physical signs - - which depend on the type of abuse, the age of the child, when the abuse occurred, the frequency of the abuse, the presence and type of infection (non - - specific or STD). • other non - - accidental injury. • forensic tests to demonstrate semen, blood, saliva etc. (usually negative in young children where the abuse is usually ongoing and intrafamilial). • the social services and police investigation. Table 3 The differential diagnosis of abnormal genital findings 1. 2. 3. 4. 5. 6.
Accidental injury e.g. straddle injury Inflicted injury e.g. sexual assault, female genital mutilation Skin disease e.g. lichen sclerosis et atrophicus Vulvitis e.g. threadworms, bubble-bath, poor hygiene, trauma Vulvo-vaginitis e.g. non-specific (as 4.), STD Congenital lesions e.g. haemangioma, midline white streak posterior fonrchette 7. Aquired lesions e.g. urethral prolapse, polyp 8. Scarring implies previous trauma
Summary of the examination of the genitalia of the pre-pubertal child • all newborns are currently examined and major congenital abnormality is likely to be recognised. • the genitalia of girls are only subsequently inspected if there is a specific indication e.g. daytime wetting, 'soreness', possible abuse.
240
CURRENT PAEDIATRICS
• the examination of the genitalia is part of a complete paediatric assessment. • consent, from the carer with parental responsibility is needed before any examination verbal consent is valid. • the genital examination begins with inspection, palpation of the testes, and possibly retraction of the foreskin in boys. Likewise in girls inspection is followed by separation of the labia and if the hymenal opening can not be visualised, labial traction. Vaginal examination is not part of a usual examination. The method of the examination should be recorded. • microbiological swabs should be collected appropriately if STD are to be diagnosed.
11. Berenson A B. A longitudinal study of hymenal morphology in the first three years of life. Pediatrics 1995; 95: 490-496. 12. Heger A, Emmans S. Introital diameter as the criterion for sexual abuse. Pediatrics 1990; 85:222 223. 13. Herman-Giddens M E. Vaginal foreign bodies and child sexual abuse. Arch Pediatr Adolesc 1994; 148: 195-200. 14. Bays J, Jenny C. Genital and anal conditions confused with child sexual abuse trauma AJDC 1990; 144 (12): 1319-1322. 15. Bays J, Chadwick D. Medical diagnosis of the sexually abused child. Child Abuse and Neglect 1993; 17:91-110.
Further reading Meadow R. ABC of Child Abuse, London: British Medical Journal, 1989. Hobbs C J, Hanks H G I, Wynne J M. Child abuse and neglect: a clinicians handbook. London: Churchill Livingstone, 1993. The Royal College of Physicians. The physical signs of sexual abuse in childhood. London: A Report of the Royal College of Physicians, 1991.
• all doctors working with children should take the opportunity to examine the genitalia fully, so as to recognise the range of normal. • if an inexperienced doctor unexpectedly finds physical signs which may indicate CSA, it is necessary to discuss the findings with a more senior doctor and probably to re-examine the child before initiating child protection procedures. • child protection medicals should be performed by adequately trained childrens' doctors who have access to peer-review, and, increasingly use colposcopes to examine and record findings. • there is an increasing literature on the range of normal - - abnormal, the changes seen with age, newborn-pre-schooler, pre-pubertal-puberty, and the healing which occurs after trauma (learned only by follow up clinics).
References 1. Meadow S R. Editorial. Staying cool in child abuse. BMJ 1987; 295: 345. 2. Department of Health 1991. An introductory guide for NHS; the Children Act. HMSO, 1989. 3. Hobbs C J, Hanks H G I, Wynne J M. The management of child abuse Child Abuse and Neglect Churchill Livingstone, 1993 pp 246-248. 4. Post-graduate course for Paediatricians (Consultant, SCMO, S.R.) interested in Child Abuse. Tutors: C. J. Hobbs & J. M. Wynne. Further information: Mrs. C. Myers Community Paediatrics, St. James (University) Hospital, Beckett St., Leeds. 9. 5. Bamford F, Roberts R. Child sexual abuse. In Meadow R (ed.) ABC of Child Abuse British Medical Journal, London. 6. Berenson A B, Somma-Garcia PA-C. Perianal findings in infants 18 months of age or younger. Pediatrics 1993: 838-840. 7. Hobbs C J, Wynne J M. Buggery in childhood - a common syndrome of child abuse Lancet 1986; ii: 792-796. 8. Royal College of Physicians. Physical signs of sexual abuse in children. A report of the Royal College of Physicians, London, 1991. 9. Hobbs C J, Wynne J M. The evaluation of child sexual abuse. In: Child Abuse. Hobbs C J Wynne, eds. J M Balliere's Clinical Paediatrics 1993; 1 (1). 10. Jenny C, Kuhns M, Arakawa E Hymens in newborn female children. Pediatrics 1987; 80:399400
Fig. 1--Male aged 3 years. Contact burn to scrotum, petechiae on dorsum of penis.
Fig. ~ - M a l e aged 4 years. Circumferential incised wound to proximal penis requiring suturing.
EXAMINATION OF GENITALIA 241
b,a ma oro
Urethra Hymen Vestibule Post.fourchette /
/
[ [ ~
a tor ,
(l ~ \~' \ Labia minora !~,~Opening ~.~,~_~ ) --in hymen ~ - j -)~., Anus
Fig. 3~Prepubertal girl, to show normal anatomy.
Fig. ~ H i g h magnification colposcope picture of an annular hymen, female 6 years, to show thin, free edge to hymen and fine, vascular pattern.
Fig. 4~Female, 18 months, note thick, fleshy hymen, hymenal opening visible as slit.
Fig. 7--Female, 4 years, normal, but septate hymen.
Fig. 5--F~male, 5 years, normal, annular hymen.
Fig. 8~Female, 7 years, extensive labial fusion. Child had a severe hearing loss and had been sexually abused by her teenaged brother. Any trauma, infection or abuse may lead to fusion of the labia.
242 CURRENT PAEDIATRICS
Fig. 9--Female, 6 years, recent sexual assault, bruising and bleeding at friable tissue at the posterior fourchette. Note the widely gaping hymenal opening. There is attenuation of the hymen laterally, this child has almost certainly been previously abused.
Fig. 10~Female, aged 6 years, uniform vulvitis, gaping urethra, deep notch at 6 o'clock this is a healed, posterior tear in the
hymen.
Fig. ll--Female, aged 7 years, previous history of CSA, presented with painful, vesicular rash and vulvovaginitis, Herpes Simplex Type 1. Note the swollen hymen and discharge.
Fig. 12~-Female, aged 6 years, Lichen Sclerosis.