SUPLEMENTARY INFORMATION

GUIDELINE

Using sufficient light, magnification and appropriate positioning and applying gluteal

separation, the medical professional conducting the evaluation for child sexual abuse should inspect the buttocks, perianal skin and anal verge. Normal exam findings are common.

Nonetheless, the examiner must remain alert for signs of acute or chronic injury, infections and other medical conditions.

IMPORTANT NOTE: The genital and anal examination chapters in these Guidelines should be regarded as providing only basic overviews of the very complex processes involved in examining these areas and interpreting findings observed. Healthcare providers who endeavor to examine the anogenital area and to interpret examination findings related to abuse should meet the prerequisites and training recommendations outlined in “Training and Ongoing Education for Medical Evaluators of Non-acute Sexual Abuse in Children and Adolescents”.

It is further advised that pertinent textbooks and other references be relied upon for more comprehensive information and guidance (see “References,” Chapter 20, for many suggestions).

BASIC ANATOMY

The external part of the anus, the anal verge, consists of the tissue overlying the external anal sphincter and extending to the margin of the perianal skin. The anal verge is marked by rugae, which are

symmetric, circumferentially radiating folds. The anus may dilate, permitting inspection of the ampulla and the internal and external sphincters.

GENERAL ANAL INSPECTION

The examiner should inspect the buttocks, perianal skin and anal verge. The location of anal findings, like female genital findings, can be described using a clock face for orientation. Documentation should reference the position in which the child is being examined at the time the finding is noted and consider the top of the examination field (closest to the ceiling) to be at 12 o’clock.

The anus can be visualized well when the patient is in supine or prone knee-chest positions. If more convenient for the patient or examiner, the lateral decubitus position may also offer adequate

visualization of anal and perianal tissues.

Healthcare practitioners may refer to the “Classification Guide for the Medical Diagnosis of Child Sexual Abuse” in the Guideline section “Making the Diagnosis in Cases of Suspected Sexual Abuse in Children and Teens” for assistance with interpreting various anal findings.

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GENERAL ANAL INSPECTION

The examiner should inspect the buttocks, perianal skin and anal verge. The location of anal findings, like female genital findings, can be described using a clock face for orientation. Documentation should reference the position in which the child is being examined at the time the finding is noted and consider the top of the examination field (closest to the ceiling) to be at 12 o’clock.

The anus can be visualized well when the patient is in supine or prone knee-chest positions. If more convenient for the patient or examiner, the lateral decubitus position may also offer adequate

visualization of anal and perianal tissues.

Healthcare practitioners may refer to the “Classification Guide for the Medical Diagnosis of Child Sexual Abuse” in the Guideline section “Making the Diagnosis in Cases of Suspected Sexual Abuse in Children and Teens” for assistance with interpreting various anal findings.

NORMAL ANAL ANATOMY AND NORMAL VARIANTS

Studies conducted on both abused and non-abused children have demonstrated wide variability in the appearance of normal anuses. Very few anal findings may be considered diagnostic for penetrating trauma. Healthcare practitioners who evaluate children and adolescents for sexual abuse must be familiar with normal variants of anal anatomy and remain alert for signs of recent and past injury, as well as for signs of infection and other medical conditions.

CROSS-SECTIONAL VIEW OF THE ANUS

Reprinted by permission of the American Professional Society on the Abuse of Children, 940 NE 13^th Street, TCH 3B3406, Oklahoma City, OK 73104

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Commonly observed in the anal area are diastases ani, sometimes referred to as “clear areas,”

located in the anterior and/or posterior midline of the anus. These smooth, flat and somewhat fan-shaped areas are the result of a congenital difference in the superficial division of the external sphincter muscle fibers. These interruptions in the purse-string musculature surrounding the anal opening are normal anatomic variants, but are sometimes confused with scars. The presence of anterior midline tags and flattening of the anal verge and rugae during transient anal dilation have also been established as normal findings. A prominent anal verge is postulated to be related to the patient’s muscle tension during the examination and is also not considered to be the result of sexual abuse.

Increased pigmentation, particularly in non-Caucasian children, venous congestion, particularly after two minutes of hip flexion in supine or knee-chest positions, anal dilation to less than 15 mm are

common among non-abused children

SPECIAL CONSIDERATION: ANAL DILATATION

Many medical providers have been trained to become suspicious for sexual abuse when they note anal dilatation. It is true that persistent excessive anal dilatation may be the result of injury sustained from penetrating trauma to the anus. However, anal dilatation may be a normal finding and is common under certain conditions . Transient anal dilatation is frequently noted and may be related to passage of flatus or to variations in muscle relaxation. If stool is present in the rectal ampulla or vault, one or both of the anal sphincters may dilate. The examiner who notes anal dilatation when stool is also visible in the rectum is advised to repeat the anal inspection after the patient has had a bowel movement or on another day (hopefully, when defecation is not again imminent). Children who have had problems with constipation, encopresis or diarrhea may also present with anal dilation. When the patient has

neurological deficits, either chronic or acute, e.g., with neuromuscular disorders, when sedated or experiencing loss of consciousness or post mortem, the anus may normally dilate.

The anal opening is typically round or oval with maximum dilation. Irregularity suggests that scar tissue may be distorting the appearance of the opening, since this tissue is less able to stretch with dilation. In considering the significance of anal dilation, the examiner must be mindful of the size of the opening, the shape of the opening, rapidity and frequency of dilation and whether stool is present at the time of dilation. Although there is still no definitive conclusion as to exactly at what point anal dilatation may be considered diagnostic for abuse, the medical evaluator should be concerned for abuse when noting a markedly irregular anal orifice or anal dilation which is 20 mm or greater in diameter (given that there is no stool in rectal vault, no bowel movement within the past 30 minutes, no history of chronic constipation or encopresis and no sedation or neurological deficits at the time). (Clinicians are referred to Chapter 15 of these Guidelines, “Making the Diagnosis in Cases of Suspected Sexual Abuse in Children and Adolescents” in which the Classification Guide for the Medical Diagnosis of Child Sexual Abuse addresses these considerations.)

ABNORMAL ANAL FINDINGS

Infections, a variety of medical conditions and trauma may produce abnormalities discovered on anal examination. Many abnormal findings may occur as a result of sexual abuse, but may also be produced

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by other causes. Clinicians evaluating children for sexual abuse should document abnormal findings and develop a differential diagnosis to consider the range of possible explanations for the abnormality observed.

Acute findings may include erythema, edema, petechiae, abrasions, hematomas, contusions, fissures and lacerations. Erythema, edema, petechiae, abrasions and fissures in the anal area may resolve within hours. Hematomas, contusions and lacerations are more persistent, but these too become less

detectable over time as healing proceeds. Erythema, edema and fissures may be related to acute injury but are also found in non-abused children, for example, young children with severe, sometimes

excoriating, diaper rash. Skin irritants such as bubble bath and non-cotton underpants, poor hygiene and a variety of disorders may produce these findings. Anal fissures may be the result of constipation or diarrhea or may be produced with the passage of a particularly large stool.

Lichen sclerosus, Crohn’s disease and hemolytic uremic syndrome can produce perianal skin changes that may be mistaken for abuse-related erythema, ecchymosis, abrasions and anal scarring. Prolonged diarrhea can provoke spasmodic contraction and dilation of the anal sphincter and venous dilation.

Fistula in ano may produce perianal scars and fissures. This disorder frequently presents as a draining pustule during the first year of life. In most cases surgical intervention is necessary. Eversion of the anal canal can result from sexual abuse as well as from a number of other conditions, including chronic constipation, acute diarrhea, suction injuries, cystic fibrosis, rectal polyps, surgical repair of imperforate anus and various neurological problems. Children with myotonic dystrophy present with an array of anal symptoms, including lax anal tone, perianal inflammation, fecal soiling and reflex anal dilation.

When a child presents with abnormal muscle tone or a neuromuscular disorder, an understanding of the underlying condition may facilitate interpretation of genital findings.

Sexually abusive insertion of objects into the anus can produce tearing, rectal perforation, bruising and eversion, yet these same findings may be caused via accidental injury, as with impalement injuries or as have occurred in rare cases of sitting on a swimming pool drain.

The literature discusses findings which may be suggestive of chronic abuse to include tags outside the midline, lax sphincter tone and thickened rugae with complete dilation of the external anal sphincter.

Dilation greater than 20 mm with no stool in the ampulla or an irregularly shaped anal opening may also signal the examiner to consider past penetrating trauma.

The anal area should be inspected for signs of sexually transmitted disease, including discharge and lesions. Clinicians are referred to the Guideline on “Sexually Transmitted Diseases” for more details regarding diagnosis and treatment of these conditions. Discovery of anal warts presents its own diagnostic challenges and should precipitate consideration of consultation with a child abuse medical specialist who has extensive experience and up-to-date knowledge regarding sexually transmitted diseases as they relate to child sexual abuse.

With all of the abnormal findings listed above, careful history gathering is critical in making a definitive diagnosis. Accidental injury, congenital conditions and acquired disorders can produce findings mimicking those caused by sexual abuse.

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