The Exam

The gynecological exam can be a positive, educational experience. There are many techniques a health care provider can use to help women with developmental disabilities through the exam.

A. Tips for the Exam

The needs of individual patients will determine which of these tips are appropriate.

• It is generally advisable to defer blood drawing, giving injections, and other potentially disturbing experiences until after completion of the exam.
• If the patient wishes, let her bring someone with her into the exam room. Sometimes a relative or care giver will want to come into the exam room with the patient. Ask the patient in a private place what she wants and tell the care giver or relative that your protocol requires you to follow the patient's choice.
• Be aware of the potential for sensory overstimulation related to lighting, air currents, the texture and noise of the paper on the exam table, etc. If necessary make adjustments to reduce sensory overload. Some people with disabilities such as autism may readily experience sensory overstimulation.
• Provide pleasant sensory experiences such as music, pictures on the ceiling, a pleasant atmosphere, and a comfortable temperature. Sometimes dim lights are soothing, though it is usually better if the patient can be alert and see what is going on.
• Go slowly. Talk the patient through the exam. Tell her what you are doing and have her control the speed. Let her know she can ask you to stop.
• Use a smaller speculum, a baby-sized speculum, or do a finger exam. Consider doing a "blind" Pap by inserting the swab without a speculum.
• Unless contraindicated by medical concerns, do the bimanual exam first. It may be psychologically less traumatic than inserting an instrument.
• If the patient cannot relax her abdominal wall, ask her to press her hand over her pelvic area and then place your hand over hers, although it may be more difficult to feel the uterus this way.
• Provide blankets as well as standard drapes to provide more security and privacy.
• Allow enough time for the patient to try different positions for comfort.

Mary's First Pelvic Exam An example of positive provider/patient interaction
Provider:	OK Mary, now I am going to put in the speculum. I have warmed it up.  Can you feel how warm it is?
Mary:	Yes, I can feel it.
Provider:	Now I am separating the outer lips of your vagina and beginning to put it in. Can you feel it? How are you feeling now?
Mary:	OK, I'm OK. (A little nervously)
Provider:	I am going really slowly. Remember to breathe deeply. Are you still in your rose garden (or other "safe place)? What color are the roses? My favorite is yellow. How are you?
Mary:	It's OK.
Provider:	Tell me when you are ready to have me put it in further.
Mary:	It's up to you.
Provider:	Now I am putting it in further. How is this?
Mary:	No. No.
Provider:	OK. Now I have stopped. Breathe deeply, Mary. Smell the roses. Should we pick one?  Are you still holding that finger? We just have a little further to go. Tell me when you are ready.

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This provider, using the assistance of complimentary health techniques, helps the patient to retain control over her own body during this frightening procedure.
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B. Tips for the Clinical Breast Exam and Breast Self Exam (BSE)

Adapt the breast exam to the needs of each patient. For example, if the patient has impaired balance or poor upper body control, you can do a visual inspection of her breasts while she is seated. Work with the patient to increase her ability to do BSE. But if her ability to do BSE remains quite limited, it is best to repeat the clinical breast exam more often than is typically advised for the general female population.

• Consider demonstrating parts of the exam on a friend, care giver or health care provider.
• For palpitation, stabilize the patient's arm with pillows or one of your hands, if necessary.
• The clinical breast exam is a wonderful opportunity to educate the patient on BSE.
  • Educational tools, such as breast models with lumps to find, are very helpful.
  • Guide the patient's hands through a self-exam.
• If you have a pamphlet with illustrations of BSE, show it to the patient as you guide her through the steps illustrated in the card.
• Be sure your take-home materials match the techniques you are modeling.
• It may be possible for the patient to have a partner or friend help her do BSE at home. It may be helpful to involve this person in the clinic session.
• Point out and emphasize parts of the exam the patient will be able to do
  • Observing changes in a mirror
  • Noticing how her breasts feel
  • Examining the parts of her breasts that she is able to reach
  • Examining both breasts with one hand
  • Using thumb, palm, or back of hand in examination
  • Doing BSE in several shorter sessions
• Some women will find it easier to start doing BSE in the shower or bathtub, as this is a place they are accustomed to being naked and to touching themselves. The soap can also make it easier to move their hand over the skin.

C. Equipment and Equipment Modifications

High quality accessible equipment is now available. This equipment includes exam tables that can be lowered and offer side, foot, leg and knee support, and mammogram machines that enable women to have a mammogram without standing or leaning. Before purchasing new equipment, though, try to see the pieces in use and talk to both providers and patients who have used them. Equipment such as obstetrical stirrups and high-low exam tables facilitate safer, easier transfers and positioning, but vary in quality and "user friendliness". Some women with developmental disabilities feel safer in a wide padded table. Side bars that can be raised and lowered can help a woman be and/or feel safer. (SeeAppendix III for detailed information about equipment.)

Preparing the Exam Room

• Make sure there is space for a wheelchair to turn or for a sign language interpreter to be visible to the patient. Move or remove furniture if necessary.
• Take the paper covering off the exam table if it hinders transfers and positioning
• Using padded and/or strapped stirrups can increase the comfort and safety of the patient

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D. Alternative Positions for the Pelvic Exam

Whenever possible, decisions about positioning should be made by the patient and the practitioner together, depending on each woman's specific needs. Many women cannot comfortably assume the traditional (lithotomy) pelvic exam position. Alternative positions may be easier for women with a wide range of disabilities, including arthritis, multiple sclerosis, cerebral palsy, stroke and spinal cord injury. The conditions that may indicate the use of an alternative position include, joint stiffness and inflammation, paralysis, lack of muscle control, pain (hip, back, etc.), muscle weakness, spasticity, lack of balance, or muscular contractions.
In any position it is important that the patient feel safe and well supported and experience the least discomfort possible. If spasticity and lack of muscle control are problems, both she and the practitioner should be confident that she will not fall, be hurt, or hurt someone else.

The Knee-Chest Position

This position does not require the use of stirrups. It is particularly good for a woman who feels most comfortable and balanced lying on her side.
The patient lies on her side with both knees bent, her top leg brought closer to her chest; or her bottom leg can be straightened while the top leg is still bent close to her chest. The speculum can be inserted with the handle pointed either in the direction of the woman's abdomen or back. Because the woman is lying on her side, the practitioner should be sure to angle the speculum towards the small of the patient's back and not straight up towards her head. Once the speculum has been removed, the woman will need to roll onto her back.
The assistant may provide support for the patient while she is on the exam table, help the woman straighten her bottom leg if necessary, or support the patient in rolling onto her back for the bimanual exam. If the patient cannot spread her legs, the assistant may help her elevate one leg.



 

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The Diamond-Shaped Position

This position does not require the use of stirrups. A woman must be able to lie flat on her back in order to use this position.
The woman lies on her back with her knees bent so that both legs are spread flat and her heels meet at the foot of the table. The speculum must be inserted with the handle up. The bimanual exam can be easily performed from the side or foot of the table.
The assistant may help the patient support herself on the table and hold her feet together in alignment with her spine to maintain this position. A woman may be more comfortable using pillows or an assistant to elevate her thighs and/or use a pillow under the small of the back.


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The V-Shaped Position

This position may or may not require stirrups. The patient must be able to lie comfortably on her back to use this position.
The patient lies on her back with her straightened legs spread out wide to either side of the table. Or she can hold one leg out straight and keep one foot in a stirrup. The speculum must be inserted with the handle up and the bimanual exam can be performed from the side or foot of the table.
One or two assistants are needed to support each straightened leg at the knee and ankle. The patient may be more comfortable if her legs are slightly elevated or if a pillow is used under the small of her back or tailbone.

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The OB Stirrups Position

Obstetrical stirrups provide much more support than the traditionally used stirrups. This position allows awoman who has difficulty using the foot stirrups to assume the traditional pelvic exam position.
The woman lies on her back near the foot of the table with her legs supported under the knee by obstetrical stirrups. The speculum can be inserted with the handle down. The bimanual exam can be performed from the foot of the table.
The patient may want assistance in putting her legs into the stirrups. The stirrups can be padded to increase comfort and reduce irritation. A strap can be attached to each stirrup to hold a woman's legs securely in place if the woman prefers this increased support.

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The M-Shaped Position

This position does not require the use of stirrups. This position allows the patient to lie with her entire body supported by the table.
The woman lies on her back, knees bent and apart, feet resting on the exam table close to her buttocks. The speculum must be inserted with the handle up. The bimanual exam can be performed from the foot of the table.
If the woman feels her legs are not completely stable on the exam table, an assistant may support her feet or knees. If a woman has two leg amputations, an assistant may elevate her legs to simulate this position.


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E. Getting on the Table

One of the major benefits of hi-low exam tables is that transfers are simpler and safer for both patient and staff. The protocols of the clinic or medical office often limit what staff are able to do to assist a patient. The patient is the expert in transferring from the wheelchair or in using assistants to climb onto the exam table. The transfer method must be appropriate to the woman's disability, the room space and the exam table. The woman, assistants and practitioner must all thoroughly understand the transfer method they are using before they proceed.

Pivot Transfer

Standing in front of the woman, the assistant takes the woman's knees between her/his knees, grasps the woman around the back and under the arms, raises her to a vertical position and then pivots the patient from her wheelchair to the table. The exam table must be low enough for the patient to sit on; therefore, a hydraulic high-low table may be needed when using this transfer method

Cradle Transfer

Kneeling beside the woman, the assistant puts one arm under both of the woman's knees and puts the other arm around her back and under her armpits. The assistant stands and carries the woman to the table, or two assistants can grasp each other's arms behind the patient's back and under her knees.

Two-Person Transfers

In all two-person transfers, the assistants must work together to lift the woman over the arms of her wheelchair from a sitting position onto the exam table. A stronger, taller person should always lift the upper half of the patient's body.
Method #1 requires the patient to fold her arms across her chest. The assistant standing behind her kneels down, putting her/his elbows under the patient's armpits and grasps the patient's opposite wrists. The second assistant lifts and supports the woman under her knees.
Method #2 can be used if the patient cannot fold her arms. The assistant standing behind the patient puts her/his hands together if possible so there is less likelihood of losing hold of the patient. The second assistant lifts and supports the woman under her knees.

Transfer Tips and Equipment

• The patient should direct the transfer and positioning process, if at all possible.
• Not all non-ambulatory women need assistance, and some ambulatory women may need assistance. Be aware of individual needs. Don't stereotype.
• Assistants should keep their backs straight, bend their knees and lift with their legs.
• Assistants should not overestimate their ability to lift. Try a test lift or try lifting the woman just over her wheelchair before attempting a complete transfer.
• Assistants who feel that they may drop a patient during a transfer should not panic. Explain to the woman what is happening to reassure her. Assistants will usually have time to lower the patient safely to the floor until they can get additional help.
• Some disabled women use a slide board, which forms a bridge from the wheelchair to the exam table for the patient to slide across. In order for this method to work, the table and chair must be approximately the same height. Most exam tables are, however, quite a bit higher than most wheelchairs. High/low exam tables will facilitate the safest and easiest transfer. A wider table can also make transfers and positioning easier even if it is not adjustable in height.
• The patient or an assistant can help by preparing equipment. Women who use wheelchairs should explain how to apply the brakes, detach the footrests and armrests or turn off the motor in the case of an electric wheelchair. If the patient wears adaptive devices such as leg braces or supportive undergarments, she should explain how to remove them if necessary and where to put them.
• Women who use urinary equipment should direct assistants in the moving or straightening of catheter tubing. The patient may wish to unstrap her leg bag and place it on the table beside her or across her abdomen for proper drainage. Assistants should be reminded not to pull on the tubing or allow kinks to develop.
• Check with the patient to make, sure she is comfortable and balanced after the transfer is completed.
• Watch out for jewelry, clothing, tubing or equipment that might catch or otherwise interfere with the transfer

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F. If Your Patient Is Blind or Visually Impaired

Prior to the exam, the practitioner can offer the patient the opportunity to examine the speculum, swab or other instruments, which will be used during the exam. Few patients will ask to do this, but most, whether or not they have a disability, want to. If three-dimensional genital models are available, they can be used both to acquaint the woman with her anatomy and to demonstrate the steps of the exam process. During the exam, explain what is happening and about to happen.
Practitioners or assistants should remember to identify themselves upon entering the exam room and inform the woman if it is necessary for them to leave.
Ask the patient what kind of orientation and mobility assistance she needs. Clinic or office staff should verbally describe and assist the woman in locating where she should put her clothes; where the various furnishings are positioned; where and how to take a urine sample, if one is needed; how she can approach the exam table; and how to position herself on the table and put her feet in the stirrups. Ask the patient for permission before touching her to guide or maintain contact with her.
A white cane and guide dog are mobility aids used by many visually impaired people. If a woman is accompanied by a guide dog, do not pet or distract the dog. The dog is trained to respond only to its mistress. A woman may prefer to keep her guide dog or white cane nearby in the exam room. Do not move either of these items without the patient's permission.

G. If Your Patient Is Deaf or Hearing Impaired

Prior to the exam, your patient may wish to examine the instruments that will be used during the exam. If three-dimensional genital models are available, they can be used to acquaint the patient with her anatomy as well as review the exam process.
The patient should choose which form of communication she wishes to use during her exam: a sign language interpreter, lip reading or writing. Although a patient may use an interpreter throughout most of the patient visit, she may decide not to use the interpreter during the actual exam. Many patients will feel more comfortable with a female interpreter. If an interpreter is used, the patient and the practitioner should decide where the interpreter should stand. The interpreter may stand by the practitioner at the foot of the table or, for more privacy; she may stand nearer the patient at the head of the table. When working with an interpreter, the practitioner should speak directly to the patient at a regular speed instead of to the interpreter. If the patient wishes to lip read, the practitioner should be careful not to move her face out of her sight without first explaining what she is doing. The practitioner should always look directly at the patient and enunciate her words clearly when lip-reading is preferred.
Ask the patient if she wants to see what is going on. Her head may be elevated so that she can see the practitioner and/or interpreter. The drape that is used to cover the woman's body below her waist can be eliminated or kept between her legs. Some patients may wish to view the exam with a mirror while it is happening.
If an American Sign Language (ASL) interpreter is needed, this service must be arranged before the day of the exam. See Appendix III for interpreter resources.

H. Other Exam Related Issues

Bowel and Bladder Concerns

Some women with developmental disabilities do not have voluntary bladder or bowel control (e.g., women with severe cerebral palsy). A woman s bladder or bowel routine could affect the pelvic exam.
A woman's bowel movement routine may require the same type of physical stimulation that she will experience during the speculum, bimanual or rectal exam. A bowel move
ment can occur during the pelvic exam. The patient or the patient's care provider should inform the practitioner if this might occur.
If a woman is catheterized, it is not necessary to remove the catheter, as it will not interfere with the pelvic exam in any way. An indwelling catheter need not be removed during the exam unless it is not working and another catheter is available for insertion. The two types of indwelling catheters are the urethral, which is inserted directly into the woman's urethra, and the suprapubic, which is inserted directly into the bladder through a surgically made opening below her navel. Both allow urine drainage through tubing into a leg bag. The leg bag, usually attached to a woman's leg by a strap, should be empty at the start of the exam so it will not need to be drained later.
If a woman uses an intermittent catheterization system, she urinates by manually opening her bladder sphincter at regular intervals during the day. Tactile stimulation in her pelvic area during the exam could cause her bladder sphincter to open, with resulting incontinence. The patient may consider scheduling her pelvic exam appointment around her urinary schedule.

Hypersensitivity

Before the exam, the patient may want to inform the provider of any hypersensitive areas of her body to help prevent possible discomfort or spasms during the exam. Some women may experience variable responses to ordinary tactile stimulation such as spasms or pain. Others experience generalized discomfort and agitation that makes medical care difficult. Often, sensitive areas can be avoided or an extra amount of lubricating jelly can be used to decrease friction or pressure.

Spasticity

Spasms may be a common aspect of a woman's disability. Ranging from slight tremors to quick, violent contractions, spasms may occur during a transfer, while assuming an awkward or uncomfortable position, or from stimulation of the skin with the speculum. If spasm occurs during the pelvic exam, the assistant should gently support the spasming area (usually a leg, arm or abdominal region) to avoid any injury to the patient. Spasms should be allowed to resolve before continuing with the exam.
The intensity and frequency of spasms can be significantly affected by subjective perceptions such as feelings of physical security. A woman who experiences spasms should never be left alone on the exam table where a spasm could pose a serious danger to her. An assistant should stand near the exam table and maintain physical contact with the patient to ensure both safety and a feeling of security.

PHYSICAL EXAMINATION OF PREPUBERTAL AND PUBERTAL GIRLS

Evaluating the Child for Sexual Abuse

SHEELA L. LAHOTI, M.D., NATALIE MCCLAIN, R.N., M.S.N., C.P.N.P., REBECCA GIRARDET, M.D., MARGARET MCNEESE, M.D., and KIM CHEUNG, M.D., University of Texas Medical School at Houston, Houston, Texas

Am Fam Physician. 2001 Mar 1;63(5):883-893.

  Related Editorial

Child victims of sexual abuse may present with physical findings that can include anogenital problems, enuresis or encopresis. Behavioral changes may involve sexual acting out, aggression, depression, eating disturbances and regression. Because the examination findings of most child victims of sexual abuse are within normal limits or are nonspecific, the child's statements are extremely important. The child's history as obtained by the physician may be admitted as evidence in court trials; therefore, complete documentation of questions and answers is critical. A careful history should be obtained and a thorough physical examination should be performed with documentation of all findings. When examining the child's genitalia, it is important that the physician be familiar with normal variants, nonspecific changes and diagnostic signs of sexual abuse. Judicious use of laboratory tests, along with appropriate therapy, should be individually tailored. Forensic evidence collection is indicated in certain cases. Referral for psychologic services is important because victims of abuse are more likely to have depression, anxiety disorders, behavioral problems and post-traumatic stress disorder.

It is estimated that by the age of 18, 12 to 25 percent of girls and 8 to 10 percent of boys have been victims of sexual abuse.1 With this high prevalence, it is likely that primary care physicians will encounter child victims of abuse in their practice. Because the diagnosis of sexual abuse often has significant psychologic, social and legal ramifications, evaluating children who allegedly have been sexually abused can be anxiety provoking for physicians, as well as for patients and their families. It is important that the physician be knowledgeable about the basic evaluation of children for sexual abuse and cognizant of the resources available in the community.

Definition

Sexual abuse is defined as any sexual activity that a child cannot comprehend or give consent to, or that violates the law.2 The sexual activity may include fondling, oral-genital, genital and anal contact, as well as exhibitionism, voyeurism and exposure to pornography. Sexual abuse must be differentiated from “sexual play” or age-appropriate behavior. In sexual play, the developmental level of the participants should be similar, and the activity should occur without coercion. For example, preschool children viewing each other's genitalia without force is considered to be “normal,” while a developmentally more mature child engaging a young child in sexual behavior warrants investigation. Perpetrators may be relatives or nonrelatives and are most frequently male.3 Adolescent perpetrators are not uncommon, and many have a personal history of sexual and/or physical abuse.4

Presentation

Concern about possible sexual abuse should be raised when children exhibit behavioral changes or have anogenital or other medical problems. Behavioral changes include sexual acting out, aggression, problems in school, regression (e.g., return to thumb sucking, use of a security blanket), sleep disturbances, depression and eating disturbances. Sexual acting-out behavior is the most specific indicator of possible sexual abuse.5 Medical problems include anogenital trauma, bleeding, irritation or discharge, dysuria, frequent urinary tract infections, encopresis, enuresis (especially after continence has been achieved), pregnancy, diagnosis of a sexually transmitted disease (STD) and oral trauma. Children may present with somatic complaints such as recurrent abdominal pain or frequent headaches resulting from the psychologic stress.

Interviewing the Child

Even in legally confirmed cases of sexual abuse, most children do not have physical findings diagnostic of sexual abuse. Therefore, the child's disclosure is often the most important piece of information in determining the likelihood of abuse. Investigative interviewing should be performed by the appropriate agencies and, if possible, by forensic interviewers. In addition, physicians should ask questions relevant to medical diagnosis and treatment. The child should be interviewed, preferably alone, using open-ended questions such as “Has anyone ever touched you in a way that you didn't like or in a way that made you feel uncomfortable?” It is important to keep a neutral tone of voice and manner when the child responds and to ask the child to elaborate in a nonleading manner. The medical interview may be admissible in court as an exception to hearsay; thus, careful documentation of questions and responses is critical. Questions and answers should be recorded verbatim.6

Physical Examination

The physician should maintain a gentle and calm demeanor and be considerate of the apprehensive child. It is helpful to explain the examination beforehand to the patient and caretaker. A complete physical examination, including careful documentation of any lacerations, ecchymoses or petechiae, is critical. Physical examination of the oral cavity includes inspection of the hard and soft palate for bruising or petechiae, and inspection of the frenulum for any lacerations that can result from forced oral penetration.

If the sexual assault has occurred within 72 hours of the physical examination, forensic evidence collection should be conducted. Rape evidence collection kits are available in the emergency department of most hospitals. Evaluation of acute sexual assault may be conducted in an emergency department setting or, if available, at a children's advocacy center. In nonacute cases, the office of the family physician has the benefit of being a familiar location for the patient.

Magnification and illumination are essential when examining the genitalia. An otoscope or, if available, a colposcope can be used. Demonstration of the instruments before use can be helpful in alleviating a child's fears about the examination. Colposcopy allows enhanced illumination and magnification as well as photographic documentation. If photographic documentation is unavailable, diagrams can be used to illustrate abnormalities.

PHYSICAL EXAMINATION OF PREPUBERTAL AND PUBERTAL GIRLS

Examination of the genitalia of the prepubertal girl is best performed with the child in the frog-leg, frog-leg while sitting on caretaker's lap or prone knee-chest position (Figures 1a,1b and 1c). In the frog-leg position, the child is supine with the knees apart. If the child is anxious, the examination may be performed while the child is sitting on the caretaker's lap. In the knee-chest position, the child is prone, with knees, chest and head in contact with the table, and the back is in lordosis. It is necessary to perform an examination in the prone knee-chest position to confirm or exclude abnormalities of the posterior aspect of the hymen.7 Pubertal girls can be examined in the lithotomy position.

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FIGURE 1A.

Frog-leg position for examination of the external genitalia.

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FIGURE 1B.

Frog-leg position with patient on caretaker's lap.

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FIGURE 1C.

Prone knee-chest examination position.

Because the examination position can influence findings, it is important to document the position in which the child was examined.8 The use of labial traction can greatly enhance visualization of the hymen. The labia majora are gently retracted between the thumb and forefinger with force applied downward and outward (Figure 2). When performing the anogenital examination, it is important to be familiar with pre-pubertal anatomy and normal variants. The most common hymenal configurations are crescentic, annular, cuff-like, septate (Figures 3a,3b,3c and 3d) and fimbriated.

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FIGURE 2.

Changes in the examination position can affect the appearance of the hymen. (Top) An 11-year-old girl examined in the supine frog-leg position. (Bottom) The same child examined in the prone knee-chest position. Note that the irregularities resolve in the knee-chest position.

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FIGURE 3.

Normal variants of the hymen: (A) crescentic, (B) annular/cuff, (C) collar/cuff-like, (D) septate.

Locations of abnormalities should be described as on a clock face with the urethra in the 12-o'clock position and the anus at the 6-o'clock position. In prepubertal girls, use of the speculum is reserved for unexplained bleeding and may require an examination with sedation. In pubertal girls, estrogen causes the hymenal tissue to become thicker and more compliant; therefore, detection of trauma can be more challenging (Figure 4). The use of a moistened cotton swab to gently move the hymen may be helpful in viewing all aspects of a fimbriated or redundant hymen. Another method of improving visualization of the pubertal hymen requires the use of a Foley catheter. The catheter is inserted into the vagina, the balloon is inflated and, with mild retraction, the hymen is stretched (Figure 5).

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FIGURE 4.

Estrogen changes the appearance of the hymen. (Left) Annular hymen in a prepubertal girl. (Right) Annular hymen in a pubertal girl.

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FIGURE 5.

Foley catheter technique for examination of the pubertal hymen. A Foley catheter is inserted, the balloon is inflated and slight retraction is given. This method allows better visualization of the redundant areas of the hymen.

PHYSICAL EXAMINATION OF PREPUBERTAL AND PUBERTAL BOYS

A genital examination of boys may be performed with the patient in the sitting, supine or standing position. The physician should examine the penis, testicles and perineum for bite marks, abrasions, bruising or suction ecchymoses. Evaluation of the anus may be performed with the patient in the supine, lateral recumbent or prone position with gentle retraction of the gluteal folds.

Physical Findings

Results of a physical examination will be within normal limits in 80 percent of child victims of sexual abuse.9 The absence of physical findings can be explained by several factors. Many forms of sexual abuse do not cause physical injury. Although the lay public and law enforcement representatives may be fixated on vaginal penetration, sexual abuse may be nonpenetrating contact and may involve fondling, oral-genital, genital or anal contact, as well as genital-genital contact without penetration. Mucosal tissue is elastic and may be stretched without injury, and damage to these mucosal surfaces heals quickly. Finally, many victims of sexual abuse do not seek medical care for weeks or months after the abuse, and superficial abrasions and fissures can heal within 24 to 48 hours.10

Most patients have normal and nonspecific findings on examination. These findings include the following: (1) hymenal tags, bumps or mounds, (2) labial adhesions, (3) clefts or notches in the anterior half (between the 9- and 3-o'clock position) of the hymen, (4) vaginal discharge, (5) erythema of the genitalia or anus, (6) perianal skin tags, (7) anal fissures and (8) anal dilatation with stool in the ampulla. Physical findings that are concerning but not diagnostic of sexual abuse include the following: (1) notches or clefts in the posterior half of the hymen extending nearly to the vaginal floor, confirmed in all positions, (2) condylomata acuminata in a child older than two years who gives no history of sexual contact, (3) immediate, marked anal dilatation and (4) anal scarring.11

Physical findings that are diagnostic of penetrating trauma include: (1) acute laceration or ecchymosis of the hymen, (2) absence of hymenal tissue in the posterior half, (3) healed hymenal transection or complete cleft (Figure 6), (4) deep anal laceration and (5) pregnancy without a history of consensual intercourse (Table 1).1,11

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FIGURE 6.

Hymenal changes consistent with penetrating vaginal trauma. (Left) Healed transections are present at the 4- and 7-o'clock positions, and a notch is present at the 6-o'clock position. (Right) The hymen is absent as a result of chronic sexual abuse in this pubertal girl.

TABLE 1
Significance of Anogenital Findings in the Evaluation of Sexual Abuse in a Child

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Normal and nonspecific anogenital findings

Hymenal tags

Hymenal bumps or mounds

Labial adhesions

Clefts or notches in the anterior half of the hymen

Vaginal discharge

Genital or anal erythema

Perianal skin tags

Anal fissures

Anal dilatation with stool in ampulla

Physical findings that are concerning for sexual abuse

Notches or clefts in the posterior half of the hymen extending nearly to the vaginal floor, confirmed in all positions

Condylomata acuminata in a child older than two years who gives no history of sexual contact

Immediate, marked anal dilatation

Anal scarring

Physical findings that are diagnostic of penetrating trauma

Acute laceration or ecchymosis of the hymen

Absence of hymenal tissue in any portion of the posterior half

Healed hymenal transection or complete cleft

Deep anal laceration

Pregnancy without history of consensual intercourse

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Information from Hymel KP, Child JC. Sexual abuse. Pediatr Rev 1996;17:236–50, and Adams JA. Evolution of a classification scale: medical evaluation of suspected child sexual abuse. Child Maltreatment (In press).

Laboratory

Evidence collection should be performed if sexual contact occurred within 72 hours of the physical examination. Forensic evidence includes blood, semen, sperm, hair or skin fragments that could link the assault to an individual person, as well as debris (e.g., carpet fibers) that could link the assault to a location. Rape evidence collection kits are available and include detailed instructions for the handling of clothes and undergarments, and specimen collection. A history should include obtaining information about the assault, including the use of a condom or lubricants, and whether the victim has eaten, washed, voided, defecated, bathed or douched since the contact. The history should also note if the victim is menstruating or not.

Use of a Wood's lamp may be useful in the detection of semen. Areas that fluoresce should be sampled with a moistened cotton swab, and the specimen sent for laboratory analysis. Although many other substances fluoresce, the collection of semen can be vitally important in a legal case.12 The “chain of custody” ensures that the evidence has remained with the medical staff until given to a representative of a law enforcement agency before arrival of the specimens at the crime laboratory. Because these specimens are used only for forensic evidence, additional specimens are necessary if cultures are to be obtained.

The decision to obtain cultures and to perform serologic testing should be based on the likelihood of oral, genital or anal penetration and the presence of symptoms. Prepubertal females are more likely to be symptomatic if they have Chlamydia or gonorrhea. Pubertal females may be asymptomatic but remain infected. Local prevalence of STDs and risk factors of the child and the alleged perpetrator of abuse should also be taken into consideration. Risk factors for the child or adolescent include other history of sexual contact, multiple sexual partners, intravenous drug use and exchange of sex for food, shelter or money. Risk factors for the alleged perpetrator include a history of multiple sexual partners, intravenous drug use and STDs. Asymptomatic children who disclose only fondling have a very low incidence of STDs.13  The implications of common STDs for the diagnosis of sexual abuse are outlined in Table 2.5

TABLE 2Implications of STDs in the Diagnosis and Reporting of Sexual Abuse of Infants and Prepubertal Children

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When testing for Chlamydia and gonorrhea, it is vital that true cultures be obtained. If only nonculture methods (e.g., antigen detection or nucleic acid detection methods) are available, patients must be referred to a location where true cultures can be obtained. Antimicrobial treatment should not be initiated before cultures are obtained. In most states, results of nonculture methods are not admissible in court.14

In cases of acute sexual assault, it is important to remember that performing tests for gonorrhea, Chlamydia, trichomonas and bacterial vaginosis should occur two weeks following the assault if the patient did not receive prophylactic treatment at the time of the initial examination. Serologic testing may be performed for syphilis, human immunodeficiency virus (HIV) infection and hepatitis B (depending on immunization status) at six, 12 and 24 weeks following the assault.15(pp108–16)

Treatment

MEDICAL

Antimicrobial therapy should be initiated in prepubertal children based on the results of laboratory testing. Prophylactic antibiotics for the treatment of gonorrhea, Chlamydia, trichomonas and bacterial vaginosis should be given to sexually active adolescents following an acute sexual assault (Table 3).15(pp49–75)Following acute sexual assault, pregnancy prophylaxis should be offered to adolescent girls after an informed consent has been obtained and urine pregnancy test results are negative. Prophylactic treatment must be started within 72 hours of the assault with two tablets of emergency contraceptive pills (Ovral or Preven) given immediately and two tablets given 12 hours later.16 Because nausea is a common side effect, antiemetics may also be prescribed. Postexposure hepatitis B vaccination (without hepatitis B immunoglobulin) should also be offered at the time of the initial examination if the child has never been immunized. Follow-up doses should be administered one to two and four to six months after the first dose.15(pp108–16)

TABLE 3
Prophylactic Antimicrobial Therapy Following Acute Sexual Assault in Sexually Active Adolescents*

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Gonorrhea
Ceftriaxone (Rocephin), 125 mg intramuscular in a single dose
	or
Cefixime (Suprax), 400 mg orally in a single dose
	or
Ciprofloxacin (Cipro), 500 mg orally in a single dose
	or
Ofloxacin (Floxin), 400 mg orally in a single dose
	and
Chlamydia
Azithromycin (Zithromax), 1 g orally in a single dose
	or
Doxycycline (Vibramycin), 100 mg orally twice daily for seven days
	and
Bacterial vaginosis and trichomonas
Metronidazole (Flagyl), 2 g orally in a single dose
	or
Metronidazole, 500 mg orally twice daily for seven days
	or
Clindamycin 2 percent cream (Cleocin), one full applicator (5 g) intravaginally at bedtime for seven days
	or
Metronidazole 0.75 percent gel (MetroGel–vaginal), one full applicator (5 g) intravaginally twice daily for five days

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*—Treatment should include coverage for gonorrhea, Chlamydia, trichomonas and bacterial vaginosis.

Information from Centers for Disease Control and Prevention. 1998 guidelines for treatment of sexually transmitted diseases. MMWR Morb Mortal Wkly Rep 1998:49–75.

PSYCHOSOCIAL

The family physician has a unique perspective in the assessment of a child victim of sexual abuse. The ongoing relationship with the parent(s) and the child(ren) may provide the physician with valuable insight regarding the protective nature of one or both parents toward their children. Another issue is the importance of caution when the alleged perpetrator of abuse is a parent or step-parent. The physician must remain unbiased, especially when parental custody disputes are involved.

Care of a child victim of sexual abuse and the family should include a referral for psychologic services. Sexually abused children are at greater risk for depression, anxiety disorders, behavior problems, increased sexual behavior and post-traumatic stress disorder. Adult survivors are also at greater risk for depression, anxiety disorders and interpersonal difficulties. One mediating factor that decreases psychologic distress should be emphasized: the presence of a supportive adult who believes the child's disclosure and takes protective action.17

Child advocacy centers specialize in the evaluation and treatment of sexual abuse victims and the prosecution of sexual abuse perpetrators. Such resources are available in many communities. These centers often include social services, law enforcement agencies, legal services and medical evaluation. The advocacy center can be a resource for services or for a medical consultation. Local advocacy centers can be located by calling the National Children's Alliance at 800-239-9950.

For children with a protective parent and an unrelated perpetrator, child protective services may not be involved. In these cases, law enforcement may be involved; for example, a 2-year-old girl who is raped by a neighbor and the parents have already notified the police. In these instances, it is prudent to refer the family to social services. Social workers can aid the family in locating services. Many victims of sexual abuse are eligible for assistance from the Crime Victim's Compensation Funds, which can be used to reimburse various costs, including psychologic services.

REPORTING GUIDELINES

Physicians are mandated to report suspected cases of child sexual abuse to the local child protective services agency. When sexual abuse is suspected or when a child discloses a sexual abuse event, a report should be made. In most states, the person who reports the suspected abuse case will not be held liable if the report is made in “good faith.” The Guidelines of the American Academy of Pediatrics for reporting abuse based on the history and physical examination are presented in Table 4.5

TABLE 4Guidelines for Making the Decision to Report Sexual Abuse of Children

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Final Comment

By working with law enforcement and social service agencies, the family physician can play an integral role in establishing a protective environment for the child victim of sexual abuse to begin the healing process. Child sexual abuse is a complex problem that requires the family physician to evaluate and treat the patient using a multidisciplinary approach. It is important to be comfortable in the initial evaluation of the child and to be aware of the many resources and agencies available within the community. A thorough history and physical examination by a trusted family physician can help alleviate anxiety for the child and the family.