Healing Patterns in Anogenital Injuries: A Longitudinal Study of Injuries Associated With Sexual Abuse, Accidental Injuries, or Genital Surgery in the Preadolescent Child
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.
- sexual abuse
- child abuse
- sexual assault
- genital injuries
- anogenital injuries
- accidental genital injuries
- healing of anogenital injuries
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.
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
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).
Hymenal trauma was found in 37 (49.3%) of 75 cases. All 37 cases of hymenal trauma reported penile or digital vaginal penetration or accidental penetrating injury. Twelve (32.4%) of 37 were abrasions or hematomas; 11 healed completely and 1 healed with a slight angularity. Eight (21.6%) of 37 partial tears healed completely with a smooth, translucent hymeneal edge, but 5 cases were noted, after healing, to have a shallow notch at the site of the injury (Figs 5 and 6). Seventeen (45.9%) of 37 were transections of the hymen (Figs 7 and 8), and in 6, surgical repair was attempted; however, only 2 hymens were repaired successfully (Figs 9–12). The remaining 15 transections persisted, including the 6 followed to puberty. In 4 postpubertal examinations, the hymen appeared normal on visual inspection, but the hymenal transection was visible when the edges of the hymen were gently pushed aside using a cotton-tipped applicator. Perihymenal trauma was found in 39 (52%) of 75 cases. Thirty-seven cases presented with abrasions or hematomas, and 2 presented with tears. Abrasions and hematomas healed completely. Both tears, 1 from a splinter from a wooden slide and the other after surgery, healed with evidence of vascular changes of the perihymenal mucosa.
All trauma to the labia minora or majora (17 of 75 [22.6%]) healed without residua. The 2 cases of tears of the labia minora (clitoral hood) initially healed with erythema, then progressed to hypovascularity and eventually healed completely.
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).
This study also evaluated the location and type of injury by history from the child. A total of 67 boys and girls were referred for possible sexual abuse after genital trauma (Table 2). Twenty-four (50%) of the 48 girls either gave a history of penile-vaginal penetration or their abuse was witnessed by a third party. Nineteen (39.8%) described digital-vaginal penetration, and 5 girls were preverbal but were referred because of genital bleeding after being left alone with a caregiver. Nineteen (28.3%) of 67 children, 13 boys and 6 girls, presented with a history of anal penetration.
In the 94 cases that were evaluated for acute anogenital trauma and followed to healing, there were 171 separate injuries: 47 to the PF, 37 to the hymen, 39 to the perihymenal mucosa, 17 to the labia minora or majora, and 31 to the anus. Of the 171 injuries, only 25 (14.6%), including 2 hymenal tears repaired at surgery, healed with findings diagnostic of previous trauma.
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 nonabuse9,10,12 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.
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.
- ↵American Professional Society on the Abuse of Children. Glossary of Terms and the Interpretations of Findings for Child Sexual Abuse Evidentiary Examinations. Chicago, IL: American Professional Society on the Abuse of Children; 1998
- ↵Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreat.2001;6 :31– 36
- ↵American Professional Society on the Abuse of Children. Practice Guidelines: Photographic Documentation of Child Abuse. Chicago, IL: American Professional Society on the Abuse of Children; 1995
- McCann J, Wells R, Simon M, Voris J. Genital findings in prepubertal girls selected for non-abuse: a descriptive study. Pediatrics.1990;86 :428– 439
- ↵Berenson A, Heger A, Andrews S. Appearance of the hymen in newborns. Pediatrics.1991;87 :458– 465
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- ↵Finkel MA. Anogenital trauma in sexually abused children. Pediatrics.1989;84 :317– 322
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- ↵Heger A, Emans SJ, Muram D. Evaluation of the Sexually Abused Child. 2nd ed. New York, NY: Oxford University Press; 2000
- ↵American Professional Society on the Abuse of Children. Guidelines for the Psychosocial Evaluation of Suspected Sexual Abuse in Children. Chicago, IL: American Professional Society on the Abuse of Children; 1990
- Copyright © 2003 by the American Academy of Pediatrics