Child Sexual Abuse in Emergency Medicine Workup

Chlamydia trachomatis culture: Chlamydia vaginitis or proctitis may be present without obvious signs of discharge, erythema, or inflammation. Oral chlamydia is rare. DNA tests using polymerase chain reaction (PCR) may offer more sensitivity in detection of C trachomatis and N gonorrhoeae. Since they are often less expensive and may be simpler to obtain, these tests may be useful for initial screening of urine or vaginal/urethral swabs. Follow-up must be ensured because the gold standard for courtroom acceptance of results remains culture-proven infection. PCR positive tests need to be followed up with culture testing.^[11]

• Cultures should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with C trachomatis, the child has physical findings of sexual abuse, or there is patient or parental concern regarding possible infection.
• Not all children in whom sexual abuse is suspected require cultures for STDs. Clinical judgment should be based on the presence of the above factors, as well as the local epidemiology of STDs.
• In boys, a urethral swab (premoistened) should be obtained only if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.
• Cultures for Chlamydia species should be obtained after rape kit swabs using a Dacron, rayon, or cotton tipped swab on plastic or aluminum (may use batch tested calcium alginate). Indirect testing methods for chlamydia (eg, ELISA testing) should not be performed in the prepubertal child. PCR of urine or vaginal swabs may be helpful in screening, but the gold standard in children is still culture results.

Neisseria gonorrhoeae culture: Gonorrhoeae vaginitis infection usually results in a purulent discharge. However, infection, particularly rectal and oral infections, may be subclinical.

• Cultures of all 3 areas (oral, rectal, and vaginal/urethral should be obtained if any of the following are present: symptoms of vaginitis (discharge) in the prepubertal girl, the perpetrator is known to be infected with N gonorrhoeae, the child has physical findings of sexual abuse, or there is patient or parental anxiety regarding possible infection.
• Not all children suspected of being abused need cultures for STDs, and clinical judgment should be based on the presence or absence of the above factors as well as the local epidemiology of STDs.
• In boys, a urethral swab (premoistened) should be obtained if urethral discharge, dysuria, erythema, or positive urine leukocyte esterase is present.
• Cultures should be performed using cotton-tipped swabs inoculated onto Thayer Martin plates and incubated in a carbon dioxide enriched environment.

  • Attention should be given to isolating the appropriate Neisseria species.
  • First-catch urine cultures in male adolescents may be used instead of swabs.
  • Biochemical and enzyme substrate or serologic techniques should confirm isolates.

A wet prep can be obtained from patients with a vaginal discharge to determine the presence of Trichomonas vaginalis or bacterial vaginosis.

• A potassium hydroxide (KOH) preparation assists in ruling out a yeast infection.
• A fishy odor when KOH is added to the discharge indicates bacterial vaginosis.
• In addition, a Papanicolaou (Pap) smear may show false-positive results for yeast (see Vaginitis).

Any ulcerated lesions should be cultured for herpes simplex virus and typed. In the absence of lesions, routine cultures are not recommended. Isolation of herpes in the genital area of a prepubertal child does not always result in suspicion of sexual abuse. Transmission of herpes can be from autoinoculation of oral lesions for Type I or Type II in children.

Most prepubertal vaginas harbor bacteria as normal flora. Thus, a Gram stain of discharge in prepubertal females is usually not indicated.

Molluscum contagiosum located in the genital area may be consistent with sexual transmission.

Human papillomavirus (HPV) may be present in prepubertal and pubertal children as a result of congenital transmission (up to 2-3 y), hand contact, household transmission, or sexual transmission.

• Children with HPV may require testing for other STDs, and the HPV should be typed in order to determine if an oncogenic type is present.
• The diagnosis is usually clinical; however, some laboratories use DNA assays. Biopsy is rarely necessary.

Other laboratory tests

• Syphilis: If a genital lesion is present, fluid can be obtained for darkfield microscopy. Serology (eg, VDRL, RPR, ART) should be obtained at the time of abuse (if at risk) and 6-12 weeks later.
• Hepatitis B

  • If the victim is incompletely or previously unimmunized, a hepatitis B vaccine should be given as soon as possible.
  • The patient should also be tested for hepatitis B surface antigen and antibody.
  • If the alleged offender is known to have acute hepatitis B, passive immunoprophylaxis with hepatitis B immune globulin (HBIG) should be given.
  • If the vaccine has already been given, no further treatment for hepatitis B is necessary.
• Human immunodeficiency virus

  • If possible, a serologic test should be obtained on the alleged offender.
  • The child should be tested for HIV when in areas of high prevalence of HIV and if the alleged perpetrator is a known drug abuser or is HIV positive. In general, local protocols for HIV prophylaxis and testing should be followed. In New York State, the Department of Health protocol for HIV currently requires testing and prophylaxis for all victims of sexual assault who are evaluated within 36 hours of the incident.
• The testing should occur at the time of the first evaluation (baseline), and 3 months, 6 months and 12 months.

Pelvic sonogram: This study may be indicated in children who have a septate hymen and need an evaluation for a bifid genitourinary tract. Children with vaginal discharge without resolution despite appropriate evaluation and treatment may need a pelvic sonogram to rule out congenital genital tract abnormalities or foreign bodies.

A rape kit should be utilized if the child presents for an examination within 96 hours of the sexual abuse. Some authors have reported finding evidence in children beyond this time frame.^{[12, 13]} Collection of clothing to examine for forensic evidence is usually indicated within this time frame and possibly beyond. Determination of the need for evidence collection is multifactorial and includes not only timing but accessibility of local resources and providers skilled in obtaining this evidence. The emotional state of the child and family and the individual case history should guide this decision. Most rape kits are available for the adult sexual assault victim and can be adapted for pediatrics. Child sexual abuse victims may not require all of the tests contained within the adult kit.

The rape kit is usually provided by the local law enforcement agency and has a specific protocol, including a chain of evidence procedure. Isolation of areas to swab for semen or other evidence may be enhanced by use of a Woods lamp (which shows the fluorescence of alkaline phosphatase in semen). Other materials may fluoresce with the Woods lamp, including urine. Research has suggested that other methods of screening are more effective for the presence of semen, such as use of a BlueMaxx 500 light source.^{[14, 15]}

Colposcopic photo documentation of genital findings is useful for both clinical and legal purposes.^{[16, 5]} The colposcope is used to document normality and for comparison to cases in which children later return with abnormal findings. The colposcope can also be used to address altered body image, identify discrepancies in examinations, provide information to the nonoffending parent, and assist the examiner by magnifying the image onto a video screen or using optics.

These images can provide legal evidence, possibly reduce the child's anxiety, and can be used as a teaching and research tool. The colposcope is not necessary for examination of child sexual abuse but is generally considered state of the art for most expert child sexual abuse evaluations.

Using an otoscope can enhance magnification and photographs can be taken with a 35-mm or digital camera.