When evaluating preteenaged girls for sexual abuse, detecting vaginal gonococcal infections is important information both from a legal standpoint, as it confirms sexual contact, and from a medical standpoint, as the child will need treatment and further evaluation for other sexually transmitted diseases (STDs). Because vaginal gonococcal infections are being detected in <3% of our study population of girls ages 1 to 12 years being evaluated for sexual abuse in Raleigh, NC, selective criteria that could limit the number of girls cultured and yet not exclude those with vaginal gonococcal infections would be useful.³ To determine if the selective criteria suggested by the American Academy of Pediatrics (AAP) Committee on Child Abuse and Neglect and those of a recent study by Siegel et al would accomplish this, the following study was performed (Table 1).^1,2

Table 1. Selection Criteria for Vaginal Gonococcal Cultures [View Table]

METHODS

Informed consent to be studied was obtained from all the girls' parents or guardians. This study was approved by the Wake Medical Center Institutional Review Committee.

RESULTS

Table 2. Results [View Table]

Case 1

Case 2

Case 3

Case 4

All 84 girls with vaginal gonococcal infections would have been detected by culturing only the girls who met the selective criteria of the AAP Committee on Child Abuse and Neglect as we interpreted them, or the more selective culturing criteria of Siegel et al (Table 1), as Cases 1 and 2 gave a history of having vaginal intercourse with an alleged perpetrator known to have gonorrhea, Case 3 had gonococcal urethritis detected by a urine culture, and Case 4 had a preteenaged sibling with gonorrhea detected 11/2 years earlier. (Case 4 had a negative vaginal culture at that time).^1,2

DISCUSSION

In 1995, a study by Siegel et al did gonococcal vaginal cultures on children being evaluated for sexual abuse who met what they interpreted the Committee on Child Abuse and Neglect of the AAP's selective criteria to be.^1,2 These were: that the child had a history of genital discharge or contact with the perpetrator's genitalia, the child had a genital discharge or genital trauma on examination, the child had a history of consensual sexual activity, the child was Tanner III or greater, the child had sexual contact with a perpetrator known to have a STD, or there was a family member with a STD. In their study, of 704 female children ages 3 weeks to 18 years evaluated, 462 met these criteria. In this group, there were 6 of 249 prepubertal girls who met these criteria and had vaginal gonococcal infections. All six also had a vaginal discharge. Based on these six cases and a review of the literature on the subject, Siegel et al's conclusions and recommendations were that "in prepubertal girls, cultures for N gonorrhoeae need only be obtained when a discharge is present at the time of examination or if the child is felt to be at high risk for STD acquisition" (defined as having a STD diagnosed, a sibling with a STD, contact with a perpetrator known to have a STD, or contact with multiple perpetratorsall girls Tanner stage III or greater should be tested for STDs).² Siegel et al felt that the decision to test may also be influenced by physician experience, presence of hymenal trauma, and the local epidemiology of STDs.

Having a vaginal discharge would meet the selective criteria of the AAP Committee on Child Abuse and Neglect and those of Siegel et al for doing a vaginal culture. The question of whether or not to limit performing vaginal cultures for N gonorrhoeae is really confined to whether or not to culture all preteenaged girls being evaluated for sexual abuse who do not have a vaginal discharge, or limiting it to certain situations when they do not have a vaginal discharge. A vaginal gonococcal infection in a girl under age 13 years without a vaginal discharge is an uncommon situation, being found in only 5% of 84 girls with vaginal gonococcal infections in our study. The strength of our study was that it contained preteenaged girls with the rare situation of having a vaginal gonococcal infection without a discharge. This enabled us to examine the selective criteria in these important cases. Despite of its size, the weakness of our study is that there were only four such cases, making it hard to generalize our results to the population at large. There are three published reports with a total of nine cases of asymptomatic preteenaged girls with vaginal gonococcal infections.⁶ It is unclear in these reports if asymptomatic means no vaginal discharge. Assuming it does, these cases include one reported by Tunnessen and Jastremski, a two-year-old girl detected when they evaluated the siblings of a 5-year-old girl with a vaginal gonococcal infection and a discharge, and two reported by Sgroi, sisters ages 5 and 8 years old who were detected when evaluating the household where a nonrelated 5-year-old girl with vaginal and conjunctival gonococcal infections (both with a discharge) had stayed for one week. None of these three children had a history of sexual contact^6,7 Six asymptomatic girls <10 years old were reported by Folland et al⁸ They were identified because three were sexual contacts of children with symptomatic gonococcal infections, two were relatives of children with symptomatic gonococcal infections, and one was an associate of children with asymptomatic gonococcal infection. These nine girls would have been cultured using the AAP Committee on Child Abuse and Neglect selective criteria. They all would have been cultured using Siegel et al's selective criteria if the two cases of Sgroi's (unrelated household contacts of a child with gonorrhea) and three cases of Folland et al's (two child relatives and a child associate of children with gonorrhea) would have been considered siblings by Siegel et al^2,7,8 Dejong, in a study of gonococcal infections in girls younger than 14 years old, reported that 5 of 15 girls with vaginal gonococcal infections did not have a vaginal discharge.⁹ All were sexually abused. It is not stated if these five girls were preteenaged, if they had other venereal diseases, if other siblings in the family had venereal diseases, if there was genital contact, or anything about their perpetrators, making it hard to apply the selective criteria of the AAP Committee on Child Abuse and Neglect or those of Siegel et al to these cases.^1,2 It will take many large studies to collect enough preteenage girls with vaginal gonococcal infections without a discharge to be certain selective criteria for culturing girls in this group are very accurate.

CONCLUSIONS

All girls being evaluated for sexual abuse and having a vaginal discharge should have a vaginal culture performed for N gonorrhoeae. With the current state of knowledge about gonococcal vaginal infections without a vaginal discharge being so limited, the final decision as to whether to obtain gonococcal vaginal cultures on all preteenaged girls being evaluated for sexual abuse who do not have a vaginal discharge, or to limit culturing based on selective criteria suggested by the AAP Committee on Child Abuse and Neglect, or those suggested by Siegel et al (but modified to also include child household contracts, child relatives, or child associates with a STD), will be based on whether one is willing to risk missing the rare case of a girl with a vaginal gonococcal infection that does not have a discharge and may possibly not fit the selected criteria chosen.^1,2 It is a decision each physician will have to make individually, depending on what he or she feels is best when balancing what the detrimental effect of missing a rare case of a vaginal gonococcal infection without a discharge will be on that child versus the beneficial effect of not doing vaginal cultures on many children who do not need them.