Colposcopic Findings Prepubertal Assessed For Sexual Abuse: Genital Girls
Colposcopic Findings Prepubertal Assessed For Sexual Abuse: Genital Girls
Colposcopic Findings Prepubertal Assessed For Sexual Abuse: Genital Girls
CONTROVERSY
Arch Dis Child: first published as 10.1136/adc.73.5.465 on 1 November 1995. Downloaded from http://adc.bmj.com/ on 14 May 2019 by guest. Protected by copyright.
Colposcopic genital findings in prepubertal girls
assessed for sexual abuse
C J Hobbs, J M Wynne, A J Thomas
Physical signs in 107 children with concerns regarding CSA Repeat examination frequently formed part
Erythema labia 49 Thickening of hymenal edge 50
of ongoing assessment and follow up in cases
Erythema vestibule 72 Rounding of hymenal edge 31 with or without court direction. These exami-
Localised erythema (symmetrical) 59 Distortion of hymenal rim including nations may assist interpretation retrospec-
Arch Dis Child: first published as 10.1136/adc.73.5.465 on 1 November 1995. Downloaded from http://adc.bmj.com/ on 14 May 2019 by guest. Protected by copyright.
Localised erythema (asymmetrical) 16 bumps 64
All erythema 93 Hymen transection/deep notching 50 tively of earlier findings. Photographs, case
Abrasion labia 3 Hymen transection/notch position notes, and medical reports were discussed at
Abrasion vestibule 2 12 o'clock 3
Bruise labia 1 Position 6 o'clock 25 monthly peer review meetings.
Bruise vestibule 1 Position 11/1 o'clock 8 Findings were recorded on a protocol of 46
Discharge 9 Other position 25
Wart 1 Hymen loss of symmetry 62 genital and 28 anal signs with known associ-
Friable fourchette 6 Adhesions: hymen to surrounding ation with CSA. Wider information about the
Tear fourchette 1 structures 5
Posterior midline avascular area 9 Hymenal remnants 6 case contributing to the diagnostic jigsaw of
Labial adhesion (extent 2-12 mm, mean Hymen: decreased vascularity 2 CSA9 was discussed and cases allocated into
6 mm) 20 Hymen: increased vascularity 9
Hymenal orifice visible 90 Hymen septum 0 one of three categories: suspected, probable, or
Hymenal orifice gaping 46 Vaginal ridge 13 confirmed.
Hymenal orifice not opening 19 Vaginal abrasion 1
Hymenal orifice transverse diameter Vaginal erythema 3 A suspected case included one where there
64 mm 37 Urethral swelling 12 were grounds for concern insufficient for child
Hymenal orifice transverse diameter Urethral dilatation 14
>4 mm 45 Periurethral bands 2 protection procedures to be commenced.
Hymenal orifice transverse diameter Mean (mm) hymenal orifice transverse These cases were usually followed up while
unmeasured 8 diameter age 20-59 months (29) 4-23
Hymen attenuation 26 Mean (mm) hymenal orifice transverse continuing to discuss with the parents and
Abrasion hymen 1 diameter age 60-99 months (35) 4-26 professional colleagues diagnostic options
Contusion hymen 1 Mean (mm) hymenal orifice transverse
Swelling hymen 31 diameter age 100 months plus (18) 6-17 including CSA.
A probable case was one where a summation
of findings was sufficiently worrying, in the
a group of children where sexual abuse was sus- view of the paediatricians, to warrant immedi-
pected. Consecutive prepubertal girls referred ate or continued involvement of social agencies
with concerns regarding CSA examined and for the development of a specific plan of
photographed by the colposcope were studied. investigation.4 Examples included children
A full paediatric assessment and clinical with emotional or behavioural indicators of
examination was performed by a single exam- sexual abuse or less than gross physical signs or
iner. The genital examination was undertaken an infection known to be sexually transmitted
with the child at the end of an examination in some cases.
couch in the supine frog-legged position. The A confirmed case was one where the child
colposcope head (with extension lens) was provided a clear disclosure of abuse, or a per-
positioned 300 mm (12 inches) from the petrator admitted the offence, or where gross
perineum. Anal examination, not reported physical signs of genital or anal trauma without
here, was undertaken in the left lateral position other reasonable explanation were present or a
with buttocks separated. sexually transmitted disease known to be sexu-
Photographs were taken at various magnifi- ally transmitted in virtually every case was pre-
cations (7 X to 21 X) after verbal consent of the sent.4
parent, and child where appropriate, had been
obtained. The camera was operated by remote
foot switch. Results
Hymenal opening and relaxation was One hundred and nine prepubertal girls with a
achieved by either labial separation or labial mean age of 70 4 months (range 12-124
traction. Transverse and vertical (antero- months) were included. There were 18 sus-
posterior) hymenal opening diameters were pected, 52 probable, and 39 confirmed cases.
measured using short lengths of Perspex rule In two children entirely normal findings were
or tape measure held just in front of the present; 107 children exhibited one or more
hymen to avoid parallax error. Anteroposterior findings as detailed in the table.
diameter measurements are not included Genital erythema was very commonly
because of difficulties of precise measurement. present and on its own is a finding with low
Hymenal diameter varies with the method of specificity for abuse. It was predominantly
examination used.8 Measurements were made labial, introital, or both. A common pattern
using labial separation. was inner surface reddening of the labia
Initial assessment of the genitalia was made minora. Bilateral symmetrical reddening of the
with thigh abduction without labial separation. labia majora in a distinct vertical band is some-
The presence of a visible hymenal orifice times referred to as 'tramline reddening'. A
(described as gaping) in this situation was noted. more unusual pattern was patchy, asymmetri-
Routine examination in the knee-chest cal, and uneven reddening which may reflect
position as commonly practised in North localised injury.
America was not used. Medical examinations Acute signs consistent with injury were
unfortunately are not always supported by commonly seen. Swelling in 33 in the absence
professional colleagues or parents in this coun- of discharge or signs indicating infection is
try. Adding a further (undignified) routine evidence of injury. Follow up of this sign is
examination position to the procedure could important as other evidence of injury may
increase resistance. However, the position was become visible as swelling settles. The diameter
occasionally used to visualise the anatomy of of the hymenal orifice may change as swelling
the posterior hymen. subsides.
Cases were excluded if adequate photo- Bruising, abrasions, and acute tears of labia,
graphs were not available. vestibule, and hymen were less commonly
Colposcopic genitalfindings in prepubertal girls assessed for sexual abuse 467
Arch Dis Child: first published as 10.1136/adc.73.5.465 on 1 November 1995. Downloaded from http://adc.bmj.com/ on 14 May 2019 by guest. Protected by copyright.
EU 00
o 00
OD 6-
0
present in 42% and 13% and transection in
.x 45 - EIOIOJlOED
M00 0J
00 00 56% and 46% of gaping and non-gaping
4- om respectively. Mean age of the groups was 77-6
-~~
~
oo00
lM
Arch Dis Child: first published as 10.1136/adc.73.5.465 on 1 November 1995. Downloaded from http://adc.bmj.com/ on 14 May 2019 by guest. Protected by copyright.
Genital findings in normal 'non-abused' The most commonly held view with regard
children and after CSA have been the subject to transverse hymenal diameter is that a
of a number of reviews.2 11-20 Studies in this diameter >4 mm in the prepubertal child is
area fall into those of newborns, 'non-abused' associated with CSA.2 The results of the
populations,'3 16 18 and clinical samples of present study are consistent with the findings
children suspected or confirmed to have been of previous studies supporting this view.19-21
abused.'2 14 15 17 20 21 Findings of major importance in diagnosing
There are problems with all studies of nor- penetrative injury to the hymen are the
mality or those selected for non-abuse because presence of a transection, a hymenal scar, and
it is inevitable that some abused children will attenuation or loss of hymenal tissue. A tran-
be inadvertently included. However, studies section or tear in the hymen heals quickly and
have attempted to reduce this risk.'3 16 18 may result in either a normal appearance, an
Various findings from this study require indentation, a notch, or major deficit in the
discussion in the light of other work. Labial hymen. It is important to be sure when exam-
adhesions are usually diagnosed in the ining the hymen that only fixed irregularities in
preschool child and they spontaneously resolve various examination positions and degrees of
during childhood. Very minor degrees of relaxation are described. Sometimes cotton
superficial fusion are common in infancy with wool buds can be used to tease out suspicious
examination by the colposcope.'3 16 In studies areas or knee-chest examination performed to
of 'non-abused' children over the age of 12 stretch a loose posterior hymen.
months, labial fusion over 2 mm in length is In this study, minor bumps associated with
less common. Thick and extensive fusion is vaginal ridges and tags have not been described
said to be more likely to be associated with as there is good evidence for their normality.
trauma.11 In this series 18% had labial fusion However, major and fixed notches (often with
and this is comparable with other studies of adjacent bumps) particularly associated with
sexually abused children.'5 22 asymmetry, evidence of widening of the
Configuration of the hymen depends on age. hymenal opening and a positive history from
The thicker redundant hymen of infancy is the child of painful penetration, have been
replaced by a thinner structure whose con- included to indicate a previous and healed
figuration includes posterior rim (crescentic) transection. The possibility that such notches
and annular variants. These different hymenal represent a congenital finding remains,
configurations have been considered in assess- although posterior hymenal notches (6
ing the cases but not included in the descrip- o'clock) appear to be very unusual in 'non-
tions. When oestrogen concentrations increase abused' samples.'3 This was the commonest
at puberty the hymen thickens and the appear- site for a notch in this study, present in 25
ances change markedly. These changes are children. In contrast anterior notches have
obvious and children demonstrating them are been described in normal children but must
not included here. also occur in CSA. Asymmetry of the hymen
Much attention has focused onto hymenal and increased diameters would add to con-
orifice measurements. The opening can be cerns about this area.
measured in both transverse (horizontal) and Scars of the hymen are unusual and seen in
anteroposterior (vertical) diameters but if the only four children. Attenuation of the hymen
hymen is of posterior rim configuration, that is (actual loss of hymenal tissue as the result of a
deficient anteriorly, it may be difficult to find a traumatic process23) is thought to follow
suitable place from which to measure the chronic abuse when the hymen is rubbed away.
anteroposterior diameter. Anteroposterior When gross, the hymen appears as a thin rim of
measures have been omitted from this study. tissue. Lesser degrees require a consideration
In the studies of 'non-abused' children, of the thickness of hymenal tissue and the
examination position, degree of relaxation evenness of its distribution. Attenuation is
(including anaesthesia), and age affected the frequently associated with a wide hymenal
results. "I Labial traction gives the largest trans- orifice and in this study with a gaping orifice.
verse measurements. The colposcopes used in Thickening, asymmetry, and rounding of the
this study do not incorporate integral eyepiece hymenal edge are also thought to be associated
measuring devices. Therefore labial separation with CSA. It was unusual in these children to
has been used with an external measuring encounter the fine lacy or wispy hymen well
device. demonstrated in some texts.13 Obviously care
A clear relationship between age and trans- must be taken when examining the genitalia
verse hymenal diameter was not present in this not to distort the symmetry of the tissues.
study between 20-99 months, unlike other Changes in the appearance of the urethral
studies,8 13 which have shown increasing diam- orifice are findings increasingly discussed in
eter with increasing age. The results suggest relation to CSA.3 It is probably important to
that a gaping hymenal orifice is more likely to specify the method of examination in assessing
be related to a hymen that is attenuated and their significance. There is no agreed definition
has a wider orifice even allowing for the greater of dilatation. The appearances of the urethra
mean age of the gaping group. The data vary considerably. Here 'dilatation' describes a
support the view that this sign is important as a urethra where a distinct open orifice exists on
Colposcopic genitalfindings in prepubertal girls assessed for sexual abuse 469
labial separation. The degree of dilatation can 5 Hobbs CJ, Wynne JM. The sexually abused battered child.
Arch Dis Child 1990; 65: 423-7.
extend up to several millimetres and confusion 6 Teixeira RG. Hymenal colposcopic examination in sexual
with the vaginal orifice is possible. In our offences. Am J Forensic Med Pathol 198 1; 2: 209-14.
7 Woodling BA, Heger A. The use of the colposcope in the
experience using labial separation, the urethral
Arch Dis Child: first published as 10.1136/adc.73.5.465 on 1 November 1995. Downloaded from http://adc.bmj.com/ on 14 May 2019 by guest. Protected by copyright.
diagnosis of sexual abuse in the pediatric age group. Child
orifice usually appears closed. Abuse Negl 1986; 10: 111-4.
8 McCann J, Voris J, Simon M, Wells R. Comparison of
There is less information available from the genital examination techniques in prepubertal females.
literature regarding normal and abnormal Pediatrics 1990; 87: 926-9.
9 Hobbs CJ, Wynne JM, Hanks HGI. Child abuse and neglect -
urethral orifice appearances. Gardner reports a dinician's handbook. Edinburgh: Churchill Livingstone,
that urethral dilatation occurred in 28% of her 1993.
10 Berkowitz CD, Elvik SL, Logan MA. A simulated
sample of 79 prepubertal girls presumed non- 'acquired' imperforate hymen following the genital
abused, using labial traction.18 McCann and trauma of sexual abuse. Clin Pediatr (Phila) 1987; 26:
307-9.
colleagues reported in a sample of 93 girls 11 Hobbs CJ, Wynne JM. The evaluation of child sexual abuse.
selected for 'non-abuse' aged 10 months to 10 In: Hobbs CJ, Wynne JM, eds. Bailiere's Clinical
Paediatrics. Vol 1. London: Bailliere Tindall, 1993: 1-29.
years that 15% showed urethral dilatation with 12 Muram D, Elias S. Child sexual abuse - genital tract
labial traction.16 However, it is also known that findings in prepubertal girls. II comparison of colposcopic
and unaided examinations. Am J Obstet Gynecol 1989;
objects can be threaded into the urethra and 160: 333-5.
even postpubertal urethral coitus has been 13 Berenson AB, Heger AH, Hayes JM, Bailey RK, Emans SJ.
Appearance of the hymen in prepubertal girls. Pediatrics
described.24 1992; 89: 387-94.
Follow up of a 4 year old known to have 14 Herman-Giddens ME, Frothingham TE. Prepubertal
female genitalia: examination for evidence of sexual
been abused with urethral dilatation and abuse. Pediatrics 1987; 80: 203-8.
abnormal genital and anal signs, showed fluc- 15 Emans JS, Woods ER, Flagg NT, Freeman A. Genital find-
ings in sexually abused, symptomatic and asymptomatic,
tuating dilatation until she was protected. girls. Pediatrics 1987; 79: 779-85.
Further information is needed on this physical 16 McCann J, Wells R, Simon M, Voris J. Genital findings in
prepubertal girls selected for non-abuse: a descriptive
sign. study. Pediatrics 1990; 86: 428-39.
The colposcope has proved to be acceptable 17 Muram D. Child sexual abuse - genital tract findings in pre-
pubertal girls. Am J Obstet Gynecol 1989; 160: 333-5.
to children, parents, and doctors and is being 18 Gardner JJ. Descriptive study of genital variations in
used routinely in Leeds for examination in healthy, nonabused premenarchal girls. J7 Pediatr 1992;
120: 251-7.
CSA. A more comfortable and detailed exami- 19 Cantwell HB. Vaginal inspection as it relates to child sexual
nation with ease of photographic recording are abuse in girls under thirteen. Child Abuse Negl 1983; 7:
171-6.
the main advantages. Photographs allow dis- 20 Cantwell HB. Update on vaginal inspection as it relates to
cussion with peers and can be used for teach- girls under thirteen. Child Abuse Negl 1987; 11: 545-6.
21 Heger A, Emans SJ. Introital diameter as the criterion for
ing, audit, and research. Second medical sexual abuse. Pediatrics 1990; 85: 222-3.
opinions can be given without the need to 22 Berkowitz CD, Elvik SL, Logan MA. Labial fusion in pre-
pubescent girls: a marker for sexual abuse? Am J7 Obstet
re-examine the child. Changes on follow up Gynecol 1987; 156: 16-20.
examination can be better appreciated. Some 23 Emans SJ. Sexual abuse in girls: what have we learned about
genital anatomy? 7 Pediatr 1992; 120: 258-61.
examiners feel that the colposcope may not 24 Shikla VK, Tripathi VNP. Urethral coitus. Urology 1982;
allow any more to be seen than with simple XEX: 542-3.
magnification by the otoscope or illuminated
hand lens.12 Peer review allows objective
assessment of complex information outside the Commentary
tensions of the consulting room. Doctors are Practice in the area of the medical diagnosis of
supported in discussing a difficult diagnosis CSA continues to evolve as new observations
usually with major implications for child, and experiences are added to our knowledge
family, and professionals. base. For the past decade, professionals in the
In conclusion, this study of children seen field have been working toward agreement as
with concerns regarding CSA has demon- to terminology (for example, the draft guide-
strated the effective use of the colposcope in lines for descriptive terminology proposed by
the examination of the genitalia in prepubertal the American Professional Society on the
girls. All findings should be carefully docu- Abuse of Children) and the implication of var-
mented. Interpretation of findings is made in ious physical findings with regard to CSA.1-6
the wider context of the history and previous Clinicians have gathered in consensus panels
examinations. to categorise physical findings such as those
There is now greater consensus over the specific or diagnostic for CSA, those strongly
significance of physical signs in CSA. An suggestive of CSA, and non-specific abnormal-
association between urethral dilatation and a ities which may be the results of CSA but are
gaping hymenal orifice and CSA is suggested also found in the non-abused population. The
from this study. Other findings associated with quality of data collection has improved consid-
CSA in other studies have been confirmed. erably with -careful application of sound study
We thank Keymed for their continuing and generous support design aimed at decreasing potential bias: for
with colposcopes. The following colleagues have regularly example, the use of larger study populations, of
attended peer reviews and supported this work: L Allison, J normal controls for comparison, of panels of
Clarke, P Gorham, F Lawrenson, S Lee, J Robertson, and S
Wyatt. experts evaluating colposcopic photographs,
and of thorough documentation of CSA
1 Butler-Sloss E. Report of the inquiry into child abuse in independent of the physical findings.
Cleveland 1987. London: HMSO, 1988. Although a standardised, agreed upon list of
2 Royal College of Physicians. Physical signs of sexual abuse in
children. A report of the Royal College of Physicians. normal and abnormal findings is still under
London: RCP, 1991. development by the American Professional
3 Hobbs CJ, Wynne JM. Child sexual abuse - an increasing
rate of diagnosis. Lancet 1987; ii: 837-41. Society on the Abuse of Children, independent
4 Frothingham TE, Barnett RAM, Hobbs CJ, Wynne JM. studies have arrived at similar conclusions
Child sexual abuse in Leeds before and after Cleveland.
Child Abuse Review 1993; 2: 23-34. albeit obscured by differences in terminology.