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Child Sexual Abuse

The types of hymens; there are three basic types, the names aren’t important, what is important is that when you do examine a child and you make note of the hymen, that you actually draw a little diagram in the chart and refer to it in such a way that another examiner would be able to rely on your findings of child sexual abuse or molestation. This is called a circumferential or sometimes an annular hymen and what we have here is a nice symmetrical, circular opening in the hymen and this is the hymen and this is the hymenal membrane that you see over here, labia clitoris. When we talk later about sexual abuse we are going to be looking for signs of trauma and when trauma occurs in sexual abuse, that is, the attempted blunt force penetrating trauma.

So from 9 o’clock to 3 o’clock, but posteriorly, and we will be looking for lacerations that occur from the edge of the hymen down to the point of attachment. The hymen is a very very delicate membrane and tears will occur after blunt force penetrating trauma, but they will carry down to the edge or the base. They will not result in little tiny nicks. Injuries occur posteriorly because anteriorly the pubic rami protect most of the soft tissue so when force is applied, this is the path of least resistance. Here we have what I referred to before as a posterior rim hymen, you can call it a U-shaped hymen, it doesn’t matter, the idea is to be aware that in this type of hymen anteriorly it will blend with the vaginal wall, so your posteriorly is the only area where you expect to find tissue. I have seen some evaluations where evaluators have called this as hymen absent in the anterior half and regarded it as a sign of sexual abuse. That is not the case, this is just how this type of hymen happens to look. Here is the edge, and we will be looking for trauma posteriorly if it does occur. The vaginal mucosa is very easily visualized with this type of hymen, so the fact that you can see vaginal mucosa.

Then the third main type of hymen is this fimbriated or redundant hymen and these kind of leaflets to this hymen kind of push outward like a half turned cuff on a sleeve, so again these little leaflets here are not signs of scarring from any previous type of abuse, this is normal in this type of hymen.

Now moving to photographs from the diagrams, here now you see the circumferential hymen, nice perfectly symmetrical opening here, normal hymenal tissue going all the way around, the posterior rim or crescentic hymen with the normally visualized vaginal mucosa right there, nice hymenal tissue going all the way down to the point of attachment, no lacerations. Another example of a posterior rim hymen, here is the edge right here, the fibriated or redundant hymen that you see here and you get a little better idea of the 3-D quality to this type of hymen in this case. Sometimes when these types of hymens, when these little tissues stick together, we float a little saline.

Let’s look at a few common conditions and I will try to give you a little history here, if I don’t know what I am looking at, I try to describe it to myself first, so I think we can agree that this is a newborn, we see residual estrogen effects, the usual history you get from the newborn nursery nurse who happens to be changing the diaper and notices this thing pooching out of the hymenal area. More than likely this is just a sebaceous cyst of the hymenal tag, and these kinds of things are usually attached to the rim of the hymen by a tiny stock, and when you take a Q-tip to run around the edge here, you will make the determination. Now, what’s this; it looks like a pre-pubertal child.

What’s this, it’s a radiograph, it’s an x-ray that is probably older than most of the people in this room, and it has to be a newborn because of the whole person fed onto one picture, it looks like we have the head here, and the feet here, and we have contrast medium in an organ or cavity that seems to be pushing up on the intestines with all the air here, and the bladder anteriorly and the rectum with air back here.

The treatment here again, in this case what you will usually get a history of, classic history of an adolescent that presents with secondary sexual characteristics, good breast development but primary amenorrhea. With the advent of ultrasound, as I said, we are making the diagnosis earlier and earlier, and sometimes we even make it in the preadolescent who is just beginning to develop. We usually follow them with ultrasounds and when we get to a tanner stage of about two or three we know that menarche is eminent and that is when we will take the child to the operating room. Do not attempt to do this in the office, this membrane can be thick, you can encounter bleeding, and in a terrified 12 or 13-year-old , you are not going to have a very cooperative patient, so this should be addressed in the operating room. Associated abnormalities in what other organ system? Renal. It can run from 17 to 25%,.

Now, what’s this? It looks like a newborn, first of all or a young baby, judging by the size of the fingers compared to the vaginal orifice, and where we would like to see a hymen, we see a polypoid grape like mass, and mother gives a history of intermittently seeing a drop or two of blood on the diaper. So the diagnosis is, sarcoma bacteroides, the statistics are in your hand out regarding the incidence. It used to be one of the most lethal cancers of childhood, and it’s now used very often as an example of how milestones in chemotherapy have allowed for nearly 100% survival. So it’s the most common soft tissue sarcoma in children, seventh leading cause of cancer deaths 90% before the age of five, almost two-thirds before the age of two, the term sarcoma bacteroides was introduced by our old friend Dr. Pfannenstiel, and the tumor arises beneath the epithelium and it forces that type of growth in a grape-like formation and this is considered a variant of embryonal rhabdomyosarcoma.

We have a pre-pubertal female and we have the labia, the clitoris, we have this very symmetrical round, red, not that many things in gynecology are symmetrical. Here is another example and as you can see I have taped over the legend here so you don’t have any give aways and we see sort of a round, symmetrical, red lesion with a central dimple. We don’t see a urethra separately, we see a hymen separately down here, what’s anterior to the hymen so this is urethral prolapse. The central dimple is kind of the give away.