Child sexual abuse Differential Diagnosis

Child sexual abuse Differential Diagnosis

Beside the normal findings, normal variants and unspecific findings, there are a number of important differential diagnoses to consider when evaluating children with abnormal anogenital findings for possible sexual abuse.

One of the areas of concern is accidental genital injuries. The pattern of injury and accompanying history however frequently provide sufficient information for differentiating them from abusive trauma. Most accidents result from straddling, referring to children falling on hard objects like a bicycle bar or a furniture arm with their genital area. Usually this causes an injury of the external genital structures which are crushed between the object and the underlying bones. The injuries involve the labia majora and minora and the clitoral hood and rarely involve the deep and protected structures like the hymen and the posterior fourchette. Published reports regarding accidental genital injuries describe them to be mostly minor and superficial, located anterior, external and unilateral. In most cases of accidental injuries the hymen is not involved [Dowd et al., 1994; Bond et al., 1995; Pokorny et al., 1992; Pokorny, 1997; West et al., 1989].

Exceptions are rare cases of accidental penetrating injuries [Boos, 1999]. Other types of injury reported in the literature include a case of posterior vaginal laceration near the hymen by a water slide accident [Kunkel, 1998], seatbelt injuries in motor vehicle accidents [Baker, 1986] and midline splitting injuries with and without hymenal involvement due to inline skating accidents [Herrmann and Crawford, 2002]. All reports stress the overwhelming importance of the history which tends to be spontaneous, acute and dramatic. It is consistent with the injuries and does not change over time or between different caretakers or between caretakers and child. Also, the immediate consultation of medical help favors the diagnosis of accidental trauma.

Dermatologic conditions which need to be differentiated from sexual abuse include erythema and excoriations in unspecific skin irritation or infection, diaper dermatitis, lack of hygiene, irritant substances (bubble bath, cosmetic care products), moniliasis, genital varicella and oxyuriasis. Recurring vaginitis is often an area of concern, especially when expressed in the context of custody debates. The child returning from the separated father after a weekend visit with red genitals may as well have experienced a paternal lack of hygiene, or his aversion to properly clean the genital area because he fears allegations of sexual abuse. Although abuse is possible and parental separation may result from nondisclosed abusive family constellations, research indicates much lower numbers of abused children in this context as commonly thought [Corwin et al., 1987].

Vaginitis is the most prevalent pediatric gynecology health problem and requires a systematic approach and broad differential diagnosis. Unclear and recurring vaginitis should warrant concern and further evaluation but is never diagnostic per se [Vandeven and Emans, 1993; Bays, 2001].