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Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With Sexual Abuse, Accidental Injuries, or Genital Surgery in the Preadolescent Child

Astrid Heppenstall-Heger, MD^*, Gina McConnell, RN, Lynne Ticson, MD^*, Lisa Guerra, MD^*, Julie Lister, FNP and Toni Zaragoza, FNP

^* Department of Pediatrics, University of Southern California, Keck School of Medicine, Los Angeles, California
LAC+USC Medical Center, Center for the Vulnerable Child, Los Angeles, California

	ABSTRACT

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Objective. To study healing patterns of anogenital trauma in prepubescent children.

Methods. A prospective 10-year study was conducted of 94 children who had anogenital trauma and were followed to healing and documented using a colposcope with 35-mm camera attachment.

Results. The 13 boys and 81 girls were referred with injuries as a result of sexual assault or anogenital trauma. Hymenal injuries occurred in 37 cases; 2 transections healed after surgery, and 15 persisted unchanged. Partial tears, hymenal abrasions, or hematomas healed completely or with minor nonspecific changes. Of the 47 injuries to the posterior fourchette, 22 abrasions, hematomas, or tears healed completely; 12 tears healed with vascular changes; 2 developed labial fusions; 10 lacerations required surgery; and 6 scarred and 4 healed with vascular changes. Only 2 of 39 cases of perihymenal trauma healed with vascular changes. All 17 cases of labial trauma healed completely. Anal trauma healed completely in 29 of 31 with scarring occurring in only 2 cases that required surgery.

Conclusions. Anogenital trauma heals quickly, often without residua. Of the 94 cases, there were diagnostic anatomic changes in the 15 cases of hymenal transections (2 other cases healed completely with surgical reconstruction), 6 cases after surgical repair of posterior fourchette, and 2 cases of anal scarring after surgery.

Key Words: sexual abuse • child abuse • sexual assault • genital injuries • anogenital injuries • accidental genital injuries • healing of anogenital injuries

Abbreviations: CVC, Center for the Vulnerable Child • PF, posterior fourchette • FN, fossa navicularis

Sexual abuse is traumatic for the victim. Whether the abuse causes physical injuries or not, it triggers significant emotional sequelae that can last a lifetime. The diagnosis of sexual abuse triggers investigations and interventions by the social and legal systems with the potential for additional emotional trauma to the victim. Making an appropriate and accurate diagnosis is critical to the care and protection of the patient and to the outcomes of investigations and prosecutions. The presence of medical findings continues to be the most significant factor in any criminal investigation.¹ In the past 20 years of research in sexual abuse, the quality of medical evaluations and research has improved through the introduction of standardized terminology,² classification schemes,^3,4 and photographic documentation.^5,6

Early studies established the baseline for normal prepubescent genital anatomy and documented a range of nonspecific variations.^7–12 However, most research has reported only on anogenital findings in children who are referred for sexual abuse. These studies were published without control groups and had a wide range of anatomic variations reported as abnormal. With the introduction of standard terminology and photograph-documentation, research became more reliable and the rates of anatomic variations, reported as abnormal, dropped from >80%,^13,14 to 15% to 20%^1,15–17 and then to <5% in 2000.^18,19 Control studies that compared nonabused girls with those who were referred for abuse confirmed equal rates for nonspecific variations.¹⁹ Additional anatomic variants (hymenal narrowing, irregularities, or thickening) were recently documented in a group selected for nonabuse.¹²

There are 14 published cases on healing of anogenital trauma in children; however, only 8 were prepubertal.^20–23 Finkel²⁰ reported 1 prepubertal case with penetrating vaginal trauma that healed with a complete transection and 2 cases of anal lacerations that healed without residua. McCann and Voris²¹ reported 3 cases of vaginal trauma, 2 with transections and 1 with a partial tear. In each case, the injuries were between 3 and 9 o’clock. The transections persisted, and the hymen healed variously with irregularities or narrowing.²¹ They also reported 4 cases of perianal injuries.²² All healed completely, with 1 developing a skin tag at the injury site. Boos²³ reported 1 accidental hymenal injury with both a complete transection and a partial tear. The complete transection persisted, and the partial tear healed with an angular notch. Additional cases have been reported in textbook format.²⁴ This article was undertaken to clarify the significance of anatomic variations associated with healed trauma and to improve the process of evaluation and treatment of children with acute anogenital trauma.

	METHODS

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Between 1989 and 1999, the LAC+USC Medical Center, Center for the Vulnerable Child (CVC), evaluated 6320 preadolescent children including 109 children who were referred with acute anogenital trauma. The CVC, a university-affiliated, hospital-based child advocacy center, uses a multidisciplinary protocol and currently evaluates >2500 children each year for possible abuse, anogenital trauma, or genital complaints. The CVC is available for referrals 24 hours per day, 7 days per week, with children referred to the CVC by law enforcement, social services, emergency departments, and clinics throughout Los Angeles County.

Over the 10 years of this study, 3 pediatricians and 3 nurse practitioners examined the 109 prepubertal children with acute anogenital injuries. Of the 109, 94 children returned for reexamination until injuries had healed. Parents signed consents in compliance with Medical Center standards, with Institutional Review Board approval and according to the established protocols and procedures of the CVC. Parents and children were interviewed by trained social workers, nurses, or medical professionals using a standardized interview protocol developed in compliance with American Professional Society on the Abuse of Children²⁵ and State of California guidelines. Caregivers and patients were interviewed for history of acute injury, previous genital injuries, or suspected sexual abuse. A verbal consent was obtained from each child over the age of 3. Each child was examined by a pediatrician or a nurse practitioner with extensive experience in the colposcopic examination of children and trained in site-specific procedures and protocols to ensure consistency of photographic documentation. In addition, for guaranteeing interobserver reliability, each case was documented using the Cyromedic MM 6000 colposcope with 35-mm camera. Each child was originally examined in the supine position, and when abnormalities were noted, the child was reexamined in the prone position. When appropriate, children were reexamined under anesthesia before surgical repair of serious injuries. Only cases in which both the acute and the healed trauma were clearly documented with 35-mm photographs were included in the study, thereby guaranteeing consistency in data collection and agreement between examiners. Appropriate cultures and forensic evidence were obtained, and established chains of evidence were maintained for both clinical and laboratory evidence. Caregivers were provided with schedules for return appointments, and compliance was voluntary.

Demographic and historical information were collected and entered into a prospective database, which was updated with subsequent appointments. Slides were processed in compliance with the same procedures and protocol used for the preservation of evidence and maintaining strict patient confidentiality. All medical records and photographs were reviewed at the time of each examination by each participating medical professional and again by the authors at the conclusion of the study. Photographs of the healed trauma were then separately reviewed to verify minor or nonspecific findings.

Variables documented by this study included injuries grouped by 1) location: perihymenal, labia majora and minora, hymen, posterior fourchette (PF), and fossa navicularis (FN) and anus; 2) type of injury and pattern of healing; and 3) history from the child. CVC policy/protocols dictate that any child with acute trauma will be followed until healing is complete. The protocol for this study set a schedule of appointments at 1) 3 days, 2) 2 weeks, 3) 2 months, and 4) if necessary, until the injuries had healed. Parents and caregivers who agreed to participate in this study were given a schedule of return appointments. However, of the original 109 children selected for this study, 94 children returned for follow-up until injuries had healed. There were no significant differences in the nature or the severity of the acute injuries documented in the children who returned compared with those who did not. Most children were reexamined at 3 to 7 days, at 2 to 3 weeks, and/or until injuries had healed. Six girls were followed to puberty. However, because of the variable compliance by caregivers, the data analysis focused on the nature of the acute injuries and ultimate patterns of healing rather than on timing the healing process. The goal of the study was to document the appearance of healed trauma, not the rates of healing.

Before final data analysis, all medical records, including history, clinical, and photographic documentation, were reviewed. Terminology was standardized to comply with accepted definitions.²

	RESULTS

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The study population was 85.7% Hispanic, 8.3% black, 1.2% Asian, and 4.8% white. There were 81 (86.1%) girls (mean age: 69.56 months) and 13 (13.8%) boys (mean age: 61.43 months), who were divided into 3 groups: 1) girls who were sexually abused (n = 48; mean age: 62 months), 2) girls and boys with anal trauma (n = 19; mean age: 71.9 months), and 3) girls with trauma after surgery or accidental injury (n = 27; mean age: 66 months).

Sixty-two children, 92.5% of those referred for possible sexual abuse, either gave their own history of sexual abuse or the abuse was substantiated by an adult. Five girls were preverbal, and the injuries occurred while under the care of a solitary caregiver. In the 62 with a history of sexual abuse, most perpetrators were known to the child; 11 (17.7%) were assaulted by a stranger; 19 (30.6%) by fathers, stepfathers, or live-in boyfriends; 19 (30.6%) by neighbors and acquaintances; and 13 (20.9%) by extended family members. Forty-three of 62 (69.3%) children gave a history of severe abuse (ie, digital or penile penetration of the vagina or anus that caused pain, dysuria, and/or bleeding). However, a history of penile-vaginal penetration (24) was more common in stranger assaults occurring in 8 (33%) of the girls who were assaulted by strangers. In the 19 children who reported anal penetration, only 1 was assaulted by a stranger, whereas 3 (15.7%) reported abuse by fathers or father substitutes; extended family members or neighbors made up the remainder (78.9%).

Healing patterns varied by location and type of trauma (Table 1). Of the 75 girls with history of vaginal penetration or trauma, 47 (62.6%) were found to have trauma to the PF and/or FN. Of the 12 cases of abrasions or hematomas, only 1 healed with vascular changes (Figs 1 and 2). In the 35 cases with tears, 11 (31.4%) healed completely and 2 (5.7%) healed with nonspecific labial fusions; 16 (45.7%), including 4 after surgery, healed with vascular changes, and 6 (17.1%) developed scars after surgery (Figs 3 and 4).

View larger version (80K): [in this window] [in a new window]   Fig 1. Case 45, 7-year-old with history of straddle injury in bathroom. Note (arrow) bruising and abrasion of PF and labia majora.

View larger version (88K): [in this window] [in a new window]   Fig 2. Case 45, 2 weeks later with residual, midline hypovascularity (arrow).

View larger version (104K): [in this window] [in a new window]   Fig 3. Case 17, 5-year-old with straddle injury, laceration of the PF and FN.

View larger version (94K): [in this window] [in a new window]   Fig 4. Case 17, 8 days later after surgical repair. Large arrow indicates scarring of the PF. Small arrow indicates area of the FN that has not completely healed in 8 days.

View larger version (81K): [in this window] [in a new window]   Fig 5. Case 53, 6-year-old who disclosed digital vaginal penetration by cousin. Note partial tear of the hymen at 6 o’clock (arrow) and abrasion at the base of the hymen at 7 o’clock (below arrow).

View larger version (88K): [in this window] [in a new window]   Fig 6. Case 53, 12 days later, hymen and perihymenal trauma completely healed. Hymen is smooth-edged with a shallow notch or concavity at 6 o’clock.

View larger version (102K): [in this window] [in a new window]   Fig 7. Case 7, 28-month-old found with blood in her underwear after being left with a babysitter. Note (arrow) acute transection of the hymen at 5 o’clock (magnification x10).

View larger version (109K): [in this window] [in a new window]   Fig 8. Case 7, 12 days later, acute trauma has healed. Using water, the hymen is floated showing the persistence of the complete transection (magnification x6).

View larger version (105K): [in this window] [in a new window]   Fig 9. Upper left. Case 23, 5-year old sexually assaulted by uncle; acute injuries include complete transection of the hymen at 6 o’clock (arrow) and laceration of the FN and PF.

View larger version (132K): [in this window] [in a new window]   Fig 12. Lower right. Case 23, 6 years after surgical repair. Effects of estrogen visible; longitudinal intravaginal ridge (small arrow) remains prominent, hymen is normal (large arrow) in appearance except for area of hypovascularity that persists at 6 o’clock and extends to FN.

In 31 cases of anal trauma, 19 (61.2%) presented with a history of anal penetration or trauma; an additional 9 (29.0%) girls gave a history of vaginal penetration but were found to have anal trauma. One girl was referred for accidental trauma, and 2 preverbal children were also found to have anal injuries. Anal injuries were documented externally at the anal verge. Anal abrasions, 13 (41.9%) of 31, healed quickly and completely. There were 18 (58.2%) cases with perianal tears or surgical trauma. Four tears were transiently associated with changes in anal tone. Only 3 (9.6%) cases of the 31 healed with anatomic changes; 1 tag and 2 with scaring and hyperpigmentation after surgery (Figs 13 and 14).

View larger version (135K): [in this window] [in a new window]   Fig 13. Case 81, 5-year-old immediately after surgical removal of extensive perianal condyloma acuminata.

View larger version (127K): [in this window] [in a new window]   Fig 14. Case 81, 6 months after surgery with scarring and hyperpigmentation.

	DISCUSSION

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

Penile-vaginal penetration was associated with the most significant injuries and included 14 tears to the PF and 12 complete transections and 2 partial tears of the hymen. There were no complete hymenal tears (4 partial tears) associated with digital-vaginal penetration. Hymenal trauma was associated with a history of sexual assault in 23 (53.4%) of 43 cases, compared with 8 (32%) of 25 accidental injuries. Of the 17 complete hymenal transections, 12 (70.5%) were associated with a history of penile-vaginal penetration; 1 occurred in a preverbal child, and 4 occurred in girls with penetrating accidental injuries. All tears occurred in the posterior 180 degrees, between 4 and 8 o’clock, except for 1 accidental avulsion injury. Hymenal abrasions were more commonly found in the ventral 180 degrees. In the 75 girls who were evaluated for genital trauma, only 15 (20%) persisted with significant genital findings (ie, a transection of the hymen) and 2 were repaired with complete healing. In the remaining 80%, there was no increase in the hymenal diameter or irregularity or narrowing of the hymen. There were no significant angularities or concavities of the hymen. These findings support the recent study¹⁹ comparing a group that was selected for nonabuse with children who were referred for possible sexual abuse. In that study, the only hymenal transection was documented in the group that was referred for possible abuse.

Partial tears of the hymen were documented between 4 and 8 o’clock on the hymen. These were documented in 4 cases of digital-vaginal, 2 cases of penile vaginal penetration, 1 case of straddle injury, and 1 preverbal child. Five healed with a residual shallow notch or slight narrowing of the hymen, not specific for penetrating trauma. Notches or clefts in the ventral 180 degrees are found in a high percentage of newborns and girls selected for nonabuse, and shallow posterior notches or clefts (as well as narrowing) are found in girls selected for nonabuse^9,10,12 and have been documented to occur at the similar rates in comparison studies.¹⁹

Injuries to the PF are the most common finding. Tears to the PF occur with similar frequency in both the group reporting sexual abuse (n = 14, 58.3%) and those referred for accidental trauma (n = 14, 51.8%). All types of trauma to the PF are more common in girls after accidental trauma. It is impossible to distinguish between trauma caused by assault or an accident. PF injuries may heal with vascular changes that are similar to nonspecific midline vascular sparing or a linea vestibularis.

Perihymenal trauma was commonly associated with straddle injuries or digital-vaginal penetration. All injuries healed completely or with small areas of hypovascularity. Most of labia minora and majora trauma was associated with straddle injuries and healed completely.

Anal trauma was documented in 30 of the 62 cases referred for sexual assault and in 1 case of a straddle injury. Most acute trauma occurred at 12 and 6 o’clock but healed quickly and completely. Anal scarring occurred only after extensive tissue damage secondary to surgical cauterization.

In comparing this large study with the 8 cases previously reported, the most consistent long-term anatomic finding associated with penetrating trauma is the complete transection of the hymen. Transections do not heal spontaneously without residua unless they are surgically repaired. Other forms of genital trauma (eg, partial tears, abrasions) heal in a matter of a few days, bringing pressure on the system to guarantee quick access to forensic experts and clinical documentation.

	CONCLUSIONS

TOP ABSTRACT METHODS RESULTS DISCUSSION CONCLUSIONS REFERENCES

 
Improved techniques and photographic documentation provide researchers and examiners with a basis for consistent research and peer review that promote a better understanding of hymeneal morphology, nonspecific genital findings, and healing patterns of genital injuries. Standardization of terminology has improved the understanding of anatomic variants, nonspecific as well as posttraumatic, and prevents the mislabeling of nonspecific or congenital findings.

There are usually no acute or chronic residua to sexual contact. Most examinations for possible sexual abuse are normal or nonspecific because of the nature of the abuse of children, the child’s perception of the abuse, and a delay in disclosure that allows injuries to heal. Most important, this report demonstrates that even in cases of child sexual abuse with a clinical history of pain and bleeding and in which acute injuries have been documented, only 14.6% (including 2 repaired at surgery) of these injuries healed or would have healed with significant anatomic changes. In addition, in light of the number of children who are injured by family members and acquaintances, more research needs to be done to clarify the impression that children are less likely to be physically injured during sexual abuse by someone known to them.

Finally, this study shows that attempting surgical repair of serious anogenital trauma may provide a more normal-appearing vaginal introitus and hymen. Approximating serious lacerations of the PF and FN is the standard of care in most referral centers. In addition to promoting healing, this provides a more normal appearance to the vaginal introitus, much like a repair of an episiotomy after vaginal delivery. Extending the repair to include the hymen is cosmetic. However, with regional and cultural emphasis on "virginity" and "intactness," these repairs are well worth attempting.

View larger version (98K): [in this window] [in a new window]   Fig 10. Upper right. Case 23, 6 months after surgical repair. Hymen has area of hypovascularity from 4 to 8 o’clock and prominent longitudinal intravaginal ridge at 8 o’clock.

View larger version (121K): [in this window] [in a new window]   Fig 11. Lower left. Case 23, 11 months after surgical repair prone position. Hymen appears normal with only a shallow notch at the site of the hymeneal repair.

	FOOTNOTES

Reprint requests to (A.H-H.) Center for the Vulnerable Child, 1240 North Mission Rd, Tr 11, Los Angeles, CA 90033. E-mail: aheger{at}aol.com

	REFERENCES

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This Article Abstract Full Text (PDF) P3Rs: Submit a response Alert me when this article is cited Alert me when P3Rs are posted Alert me if a correction is posted Citation Map Services E-mail this article to a friend Similar articles in this journal Similar articles in ISI Web of Science Similar articles in PubMed Alert me to new issues of the journal Add to My File Cabinet Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via CrossRef Citing Articles via ISI Web of Science (12) Citing Articles via Google Scholar Google Scholar Articles by Heppenstall-Heger, A. Articles by Zaragoza, T. Search for Related Content PubMed PubMed Citation Articles by Heppenstall-Heger, A. Articles by Zaragoza, T. Related Collections Adolescent Medicine

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