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Child sexual abuse - Suspected Child Abuse
See also in: Anogenital
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Child sexual abuse - Suspected Child Abuse

See also in: Anogenital
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Contributors: Mary Spencer MD, Noah Craft MD, PhD, Ann Lenane MD, Amy Swerdlin MD, Manasi Kadam Ladrigan MD, Carol Berkowitz MD
Other Resources UpToDate PubMed

Synopsis

More than 88,000 children were confirmed victims of sexual abuse in the United States in 2002. Of the 3 million cases of child abuse investigated each year, about 20% are reported as sexual abuse.

In the majority of children with legal confirmation of sexual abuse, the genital examination of the abused child is normal. In one study, only 4% of all children referred for medical evaluation of sexual abuse had abnormal examinations at the time of evaluation. This study showed that even among children who reported vaginal or anal penetration, the rate of abnormal examination findings was only about 5%. Physical findings are often absent even when the perpetrator admits to penetration of the child's genitalia. Thus, it is not appropriate to interpret a normal genital examination as evidence that sexually abusive contact did not take place.

When physical signs are present, they are often nonspecific and range from erythema and ecchymosis to ulcerations.

All girls suspected of possible sexual abuse should undergo evaluation of the labia majora, labia minora, introitus, and hymen for erythema, ecchymoses, lesions, abrasions, or tears. There may also be urethral injury as well.

Although less common than in girls, sexual abuse in boys is still a major but under recognized problem. In boys, the external genitalia must be evaluated for erythema, ecchymosis, abrasions, lacerations, and bite patterns. The urethral meatus may also have lacerations, erythema, and discharge.

Circumferential injuries to the shaft or glans penis in boys is suggestive of abuse. Penile and anal secretions should be cultured for sexually transmitted diseases, and anal secretions should be examined for semen if penetration is suspected.

Codes

ICD10CM:
T76.22XA – Child sexual abuse, suspected, initial encounter

SNOMEDCT:
95922009 – Child sexual abuse

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

A variety of dermatologic conditions cause ulcers, erythema, friability, and even bleeding of the perineum and should be considered when sexual abuse is suspected. The differential diagnosis is extensive and includes lichen sclerosus, nonspecific vulvovaginitis, seborrheic dermatitis, atopic dermatitis, contact dermatitis, scabies, perianal streptococcal infection, pinworm infection, lichen simplex chronicus, lichen planus, psoriasis, hemangiomas, bullous pemphigoid, Behçet's disease, and urethral prolapse.

Findings (Boys and Girls)
Perineal Area

Findings (Girls Only)
  • Excoriation, bleeding, vascular lesions: nonspecific vulvovaginitis, group A streptococcal vaginitis, lichen sclerosus, lichen simplex chronicus, lichen planus, atopic dermatitis, hemangiomas, vaginal retained foreign objects
  • Increased vascularity of the hymen and vestibule: local irritants, normal nonestrogenized state
  • Scarring: linea vestibularis (10% of newborns), female circumcision
  • Labial adhesion: irritation or rubbing
  • Vaginal and urethral findings: sarcoma botryoides (form of embryonal rhabdomyosarcoma resembling a bunch of grapes protruding from the vagina), caruncle (erythematous, vascular, papillary growth in urinary meatus of females), ureterocele, urethral prolapse
Findings (Boys Only)
  • Penile trauma: hair tourniquet, zipper entrapment injury, straddle injury
  • Penile or scrotal erythema: irritants, infection, trauma

Best Tests

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Management Pearls

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Therapy

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References

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Last Updated: 12/14/2018
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Child sexual abuse - Suspected Child Abuse
See also in: Anogenital
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Child sexual abuse : Abrasion, Anxiety, Erythema, Female genital, Fine skin fissures, Genital edema, Male genital, Personality changes, Ecchymosis
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