Submit a write-up based on the Iatrogenic Hymenal Case Study (PDF). After reading the case study about M.J., document a write-up of her female genitalia system. Pay attention to proper sequencing of t
LWW/TEM lwwj063-11 March 12, 2005 15:45 Char Count= 0 TopEmerg Med Vol. 27, No. 1, pp. 87–89 c 2005 Lippincott Williams & Wilkins, Inc. Case Study Iatrogenic Hymenal Injury Mary J. Spencer, BA, MD, FAAP B LEEDING from the genitalia of a prepu- bertal girl is not uncommon, is rarely se- rious, and can usually be managed by the gen- eral physician. 1–3 Todelineate the etiology of bleeding, a complete history is important, specifically inquiring about general health, trauma, hygiene, infection, scratching, vaginal discharge, recent antibiotic use, bubble bath, masturbation, and other more rare conditions such as lichen sclerosis and atopic dermatitis. The possibility of sexual abuse must also be considered. A general physical examination with careful evaluation of the genitalia should be performed. The genital examination is best accomplished with the child in a frog-leg po- sition, using separation with lateral traction of the labia majora, gently pulling the labia toward the examiner for better visualization of genital structures. In questionable cases, it may be necessary for better magnification and lighting with the use of an instrument such as the colposcope for maximum visualization of genital structures. In the following case, when the examina- tion of the cooperative child by the emer- gency department physician revealed no gen- ital pathology or source of bleeding, the child From the Children’s Medical Group, Escondido, Calif. Corresponding author: Mary J. Spencer, BA, MD, FAAP, Children’s Medical Group, 910 East O Nio # 103, Escon- dido, CA 92525 (e-mail: [email protected]). wasreferred for further evaluation. An unsuc- cessful examination with a pediatric specu- lum was attempted on a now frightened and uncooperative child. The child was then ex- amined under general anesthesia, which led to misinterpretation of the genital findings. CASE HISTORY M.J. is a bright 6-year-old girl seen in the emergency department for genital bleeding noted by the child that day while at school recess. The child denied any injury, urinary tract symptoms, and insertion of any object or genital touching by herself or by others. Phys- ical examination by a pediatrician revealed neither genital pathology nor source of bleed- ing; the child was relaxed and cooperative during the examination. The urinalysis and urine culture were negative. Since there was avague history of occasional yellow vaginal discharge, the child was referred to a family practitioner with expertise in the genital ex- amination of children for foreign body. On vi- sual examination, a “scant white discharge” wasnoted, but a foreign body was not visual- ized. The examiner then attempted a specu- lum examination, but was unsuccessful be- cause of pain and the poor cooperation of the child. The child was then referred to a gyne- cologist, who attempted a“speculum exami- nation at least 10 times” without success even with oral sedation; hence, examination under 87 LWW/TEM lwwj063-11 March 12, 2005 15:45 Char Count= 0 88 T OPICS IN EMERGENCY MEDICINE /JANUARY –M ARCH 2005 Figure 1.Hymenal tear at arrows 4 and 7 o’clock. general anesthesia was then performed. The examination revealed a “hymenal orifice 40 to 50 mm horizontally and 20 to 30 mm vertically with superficial hymenal bleeding at 4 and 7 o’clock”(Fig 1), with an area of focal erythema at 10 o’clock (Fig 2). Anal tears and erythema weredescribed from 3 to 9 o’clock. Photographs were then taken with a col- poscope for forensic purposes. Neither for- eign body nor source of bleeding was seen on examination under anesthesia. Cultures were obtained forGonorrhea,Streptococcus,Can- dida,Chalmydia,andTrichomonasfrom the vagina and rectum; the results were negative. Figure 2.Erythema at 10 o’clock at arrow. APap smear was also negative. The examin- ers interpreted the physical findings as highly suspicious for sexual abuse and called Child Protective Services and the local Child Abuse detectives. The child was immediately placed in a child abuse care facility. When the child wassubsequently interviewed by the hospi- tal’s social worker experienced in the inter- view of abused children, the child again de- nied any type of genital or anal contact. Her mother stated the child was carefully super- vised and unlikely to have been abused. A col- poscopic examination performed by the hos- pital’s child abuse physician 19 days later re- vealed the hymen measured 8 by 10 mm, with healed hymenal concavities at 4 and 7 o’clock and mild general hypervascularity (Fig 3). The focal erythema at 10 o’clock had resolved. The anus and rectum were normal. The case was closed for lack of evidence of sexual abuse. Recently, there has been an increased awareness and concern about sexual abuse in children by many physicians providing med- ical care. Prepubertal girls presenting with genital bleeding are particularly worrisome to the child and her family. There are a few published articles concerning interpretation of genital bleeding in children. 1–3 Of the mi- nor genital injuries in prepubertal girls, strad- dle injuries are the most frequently reported Figure 3.Healed lacerations at 4 and 7 o’clock ar- rows at 3 weeks postinjury. LWW/TEM lwwj063-11 March 12, 2005 15:45 Char Count= 0 Iatrogenic Hymenal Injury89 minor genital traumatic accidents presenting with genital bleeding. 4 Unfortunately, many physicians asked to evaluate obscure genital bleeding in the pre- pubertal child are not trained to examine and evaluate genital trauma and may misinterpret physical findings. In the present case, the child was seen promptly for evaluation of gen- ital bleeding, but several errors were made. First, only rarely is it necessary to perform speculum examination in a prepubertal child. Since this child was so cooperative initially, an otoscope, or if better visualization is nec- essary, a 5-mm pediatric cystoscope, and ir- rigation to cleanse and expand the vaginal canal exposing a foreign body can be used. 2 Any speculum, regardless of size, could dam- agethe hymen, thus possibly obscuring foren- sic hymenal trauma associated with abuse. 4In the case presented, the child was subjected to multiple unsuccessful speculum examina- tions, which caused acute tears in the hy- men at the 2 sites, in addition, relaxation of the genital and anorectal tissues is known to be associated with general anesthesia. Relax- ation of the hymenal orifice during anesthe- sia has previously been described; such alter- ation may change both size and configuration of the hymenal and anal openings. 4,5 Relax- ation of genital and anal tissues has also been described after death and has led to the mis- diagnosis of premortem genital and anal sex- ual assault. 6,7 In the present case, a reexamina- tion of the child 9 days after the speculum ex- amination revealed healed concavities at the 4 and 7 o’clock positions on the hymen. These healed lesions are similar in appearance toTable 1.Criteria for the use of speculum in children No Premenarheal child, lack of estrogen No Uncooperative or unable to tolerate speculum when necessary YesMenarcheal girl consenting to the examination No Collection of cultures for sexually transmitted diseases No Any age child who refuse the speculum examination YesGeneral anesthesia or conscious sedation when necessary concavities, which have been demonstrated in the follow-up examination of known sex- ual assault in a prepubertal child. The anal ex- amination was entirely normal in the follow- up examination of the child. In the present case, misinterpretation of physical findings during anesthesia was associated with seri- ous consequences for the child and family, as the child was removed from her home for a week. In summary, a careful and thorough ex- amination should be performed with colpo- scopies documentation if sexual abuse is sus- pected. Speculum use in a prepubertal child may damage genital structures, rarely yields significant information, and can obscure pre- vious trauma to the hymen. Criteria for the use of speculum in children are listed in Table 1. General anesthesia markedly relaxes genital structures and should not be misinterpreted as sexual abuse. REFERENCES 1. Altchek A. Nonendocrine vaginal bleeding. In: Lipshitz F,ed.Pediatric Endocrinology.3rded. New York, NY: Marcel Decker; 1966. 2. Altchek A. Comprehensive therapy.Pediatr Adolesc Gynecol.1995;21(5):235. 3. Baldwin DD, Land HM. Common problems in pedi- atric gynecology.Urol Clin North Am.1995;22:161. 4. Pokorny S, Pokorny WJ, Kramer W. Acute genital in- jury in the prepubertal girl.Am J Obstet Gynecol. 1992;166:1461–1467.5. Bays J, Chewning M, Kelter L, Sewell R, Steinberg B, Thomas P. Changes in hymenal anatomy dur- ing examination of prepubertal girls for possible sexual abuse.Adolesc Pediatr Gynecol.1990;3:42– 46. 6. Reece RM.Child Abuse: Medical Diagnosis and Man- agement.Pennsylvania: Lea & Fiebeger; 1974. 7. Kerns D, Ritter M, Cha P, Thomass R. Concave hymenal variations in suspected child abuse victims.Pediatrics. 1990;99:265–272.