Child sexual abuse - Suspected Child 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.
T76.22XA – Child sexual abuse, suspected, initial encounter
95922009 – Child sexual abuse
Findings (Boys and Girls)
- Inflammation or erythema: candidiasis, pinworm infection, cellulitis, contact dermatitis, atopic dermatitis, psoriasis, Kawasaki syndrome (perianal erythema commonly precedes the development of the diagnostic criteria for the disease)
- Ulcer or vesicular rash: syphilis, herpes simplex virus (HSV), varicella, Behçet's disease, bullous pemphigoid
- Bruising: blue-gray spot (Mongolian spot), trauma, hemolytic uremic syndrome, disseminated intravascular coagulation (DIC), immunoglobulin A vasculitis (formerly Henoch-Schönlein purpura)
- Erythema: encopresis, poor hygiene, pinworm infection, group A streptococcal or staphylococcal cellulitis, irritants, trauma
- Anal fissures: constipation, Crohn's disease, irritation
- Scarring: Crohn's disease, medical procedures, result of fissures; midline findings less suspicious for abuse
- Anogenital warts: condyloma acuminata (HPV), molluscum contagiosum, verruca vulgaris, acrochordon (skin tag)
- Rectal bleeding: hemorrhoids, Crohn's disease, polyps, rectal prolapse, rectal tumors, anal fissure from penetration
- Flattened anal folds: relaxation of anal sphincter, perianal edema from infection or trauma
- 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
- Penile trauma: hair tourniquet, zipper entrapment injury, straddle injury
- Penile or scrotal erythema: irritants, infection, trauma