Genital and anal injuries requiring surgical repair in females less than 21 years of age

Topical Tranexamic Acid to Control Vaginal Laceration Bleeding after Sexual Assault

BACKGROUND

Sexual assault survivors may sustain vaginal trauma that requires intervention in the emergency department, or operating room.

CASE REPORT

We describe the case of a 16-year-old female who was referred to the emergency department for evaluation of continued bleeding from a vaginal laceration following sexual assault 38 h prior. The bleeding limited the medical forensic medical examination, but she was hemodynamically stable. After the application of tranexamic acid (TXA)-soaked gauze, the patient's bleeding was controlled and the wound was able to be evaluated and the examination completed. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: To our knowledge, this is the first case in the literature that describes the use of topical TXA in a patient to achieve hemostasis in a vaginal laceration sustained from sexual violence.

Surgical management of traumatic perineal injury in female children: A report of two cases

INTRODUCTION AND IMPORTANCE

Perineal trauma is uncommon in paediatric population,accounting for about 0.2 to 8 % of all paediatric trauma. The goal of surgical management is to ensure adequate anatomical reconstruction with good functional outcome and cosmesis. A novel surgical technique derived from posterior sagittal anorectoplasty (PSARP)was recently described for reconstruction of perineal injuries due to sexual assault in children. We report our experience with the utilization of this technique for perineal reconstruction in 2 girls with fourth-degree traumatic genito-anal injury.

CASE PRESENTATION

The first patient is a 6 year old girl who presented 2 months post perineal injury following a fall.Previous multiple attempts at repair in peripheral hospital failed.She had Initial debridement,wound irrigation and divided sigmoid colostomy for stool diversion done.Definitive reconstruction was performed 5 months later.The second patient is a 14 year old girl that presented 6 days following perineal trauma sustained while riding a bicycle.Primary repair was also attempted before referral,with subsequent wound breakdown.Wound debridement and colostomy creation was done and surgical reconstruction carried out 6 months later.Following definitive repair,the colostomies in both patients were closed at 2 and 3 months respectively.Both patients are fully continent of stool and have excellent cosmetic outcome during postoperative follow up.

CLINICAL DISCUSSION

The surgical technique allows for effective dissection and proper reconstruction of the perineal body and anorectal sphincters.It also avoids unnecessary dissection and tissue disruption as the intact posterior rectal wall and anal sphincters are left undisturbed.

CONCLUSION

The Surgical technique derived from the principles of posterior sagittal anorectoplasty gives excellent functional outcome in perineal trauma.

Female pediatric and adolescent genitalia trauma: a retrospective analysis of the National Trauma Data Bank

PURPOSE

Pediatric genitalia injury represents 0.6% of all pediatric trauma. It is crucial for providers to understand whether pediatric patients are at risk for violent mechanisms, such as rape, assault, or other abuse. Therefore, we sought to perform a large database analysis of pediatric and adolescent female genitalia trauma, comparing mechanisms of injury (i.e., sexual abuse) and need for operative intervention between adolescent and pediatric cohorts.

METHODS

The National Trauma Data Bank was queried (years 2007-2015) for female patients ≤ 16 years old with external genitalia (vaginal or vulvar) trauma. Two groups were compared: pediatrics (< 12 years old) and adolescents (12-16 years old).

RESULTS

Out of 303,992 female patients, 3206 (1.1%) were identified to have genitalia trauma with the majority being pediatric patients (92.1%) and with injury to the vagina (62.6%). Pediatric patients with vaginal injury were less likely to be victims of rape (4.1% vs. 17.3%, p < 0.001) and assault (2.1% vs. 7.2%, p < 0.001) but more likely to be victims of other abuse (9.5% vs. 3.4%, p = 0.003). More of the adolescent patients with vaginal trauma required repair (58.7% vs. 43.2%, p < 0.001). Pediatric patients with injury to the vulva were less likely to be victims of rape (0.7% vs. 2.8%, p = 0.01) and motor vehicle accidents (4.2% vs. 11.0%, p < 0.001).

CONCLUSION

Genitalia trauma occurs in 1.1% of pediatric and adolescent trauma cases with the vagina being more commonly injured compared to the vulva. Adolescent patients with vaginal injuries were more likely to be victims of rape and assault and required repair more often, while those with vulvar injuries were more likely due to motor vehicle accidents. Health care providers must be aware of these at-risk populations and the differences between them to identify female victims of violence and provide resources to assist with recovery.

Surgical repair of genital injuries after sexual abuse

Introduction: Genital injuries occur in half of cases of sexual assault through digital or penile penetration as well as the use of objects. Women aged >45 years are more likely to have physical injury and anogenital lesions, transmission of STI and HIV. This review focuses on the evidence about surgical reconstruction of the pelvic floor anatomy of adolescents and adult women sexually assaulted during adolescence or adulthood.

Method: A systematic literature search was performed in PubMed and Orbis plus for articles published in English and German from June 2008 to June 2018. The literature search was performed in October 2018 by topic combining the following Medical Subject Headings: genital trauma, genital injuries, sexual assault, rape, surgical repair, treatment.

Results: 34 records of descriptive studies were identified and 16 full-text articles were included in the present review. Due to the limited number of articles retrieved, articles were not excluded based on methodological design. Superficial genital lesions are common and usually left untreated. For deep vaginal or anal lacerations, intraperitoneal bleeding is usually assessed by means of and additional CT scan or diagnostic colposcopy, cystoscopy, rectoscopy and laparoscopy. Complete reconstruction of the injured is done after. To prevent rectovaginal fistula and uncomplicated primary wound healing a temporary colostomy can be performed.

Conclusion: Although most of genital injuries due to sexual assault do not require any major surgical intervention, there is a lack of good quality evidence regarding the best diagnostic and surgical approach to restore deep lesions of genital organs as well lack evidence on contributors to poor wound healing. Therefore, clinical protocols that standardize examination as well as surgical management are encouraged to be developed.

Child sexual abuse - Initial suspicion and legal outcome

OBJECTIVES

To evaluate the association of primary reason to suspect child sexual abuse with the legal end-point in medically examined, police reported cases.

STUDY DESIGN

Observational post hoc analysis of retrospective review of records of 155 medically examined, police reported alleged child sexual abuse (CSA) cases during 2001-2009. Primary referral indications for medical examinations or criminal investigations were analyzed with an end-point in the legal process. The data consists of official investigation documents from University Hospital records, police, crime laboratories, state prosecutor, and courts of Law.

RESULTS

The median age of the children was 7.1 years (range 11 months-17.5 years) at the time when suspicion of sexual abuse was reported to police. Conviction of the alleged perpetrator was significantly more likely in cases where the child's disclosure was the reason for the initial suspicion of CSA, compared to cases with referrals for "suspicious circumstances" (39/92, 42.4% vs. 7/37, 19%, p<0.001). In 92 (59.5%) cases the initial suspicion of CSA arose from child's disclosure. The forensic interviewer's report supported more likely CSA allegations where the suspicion of CSA arose by child's clear, detailed and credible disclosure of what had happened, compared to the other initial reasons of suspicion (35/61, 57.4% vs. 13/42, 31.0%, p=0.001). In child's age category of 4-9 years conviction was significantly more likely where the initial suspicion of CSA arose with child's disclosure, compared to other reasons of suspicion (21.45, 46.7% vs. 5/27, 16.7%, p=0.001). No association was found regarding to whom the initial suspicion of CSA arose and legal outcome. Forensic interviewer's report supported the allegation of CSA more often if the suspicion was arose first to a neutral person (p=0.019). Legal outcome of conviction was associated with child's disclosure of perpetrator's physical contact regardless of how the suspicion arose (45/99, 45.5% vs. 10/46, 21.7%, p<0.001).

CONCLUSION

The reason which initially arise a suspicion of child sexual abuse plays an important role in the criminal investigation. Initial suspicion of CSA by child's disclosure, an eyewitness or objective material may lead to higher conviction rates. If a concerning physical symptom or finding arise the suspicion of CSA, referral to expert consultation is recommended to prevent unnecessary allegations and investigations. Other possible differential diagnostic medical conditions need to be evaluated. Furthermore, when child's disclosure arise a suspicion of CSA, it needs to be thoroughly investigated, regardless to whom the child discloses to.

Severe Blunt Perineal Trauma in Children: A Retrospective Analysis of 28 Patients

Purpose

The current study was designed to determine the common mechanisms of blunt perineal trauma (BPI) and associated injuries in paediatric patient. The initial management and outcome concerning such injuries are discussed.

Materials and methods

The hospital records of 28 paediatric patients who were treated surgically between April 2004 and November 2010 because of BPI were reviewed retrospectively. The initial clinical examination under conscious sedation (EUCS) in each patient was performed by both an experienced emergency physician and a paediatric surgeon to obtain a complete physical examination.

Results

Among the 28 paediatric patients, twenty-two girls and six boys, aged 2 to 12 years experienced BPI. Fall onto a rough surface was the main cause for BPI in 21 patients (75%) and the rest had a motor vehicle-pedestrian crash. Five patients had concomitant anal or rectal injuries. There were concomitant urinary tract injuries in eight patients of whom three had combined lacerations or contusions of the perineum and disruption of the posterior urethra. There was concomitant complete rupture of proximal urethra from bladder in one patient. The remaining 4 patients with urinary tract injuries suffered from periurethral lacerations. The fifteen patients without anorectal or urethral injuries had concomitant vaginal or vulvar lacerations.

Conclusion

All paediatric patients who sustained severe BPI should be checked for multi-system trauma and those undergone routine EUCS to evaluate the extent of concomitant injuries should pay particular attention to the anorectal and urogenital tracts. Primary repair of such injuries is often recommended as the initial treatment of choice.

Surgical Repair of an Impalement Genital Injury from an Inline Skating Accident in a 7-Year-Old Prepubertal Girl: A Case Report

BACKGROUND

In girls who present with vaginal trauma, sexual abuse is often the primary diagnosis. The differential diagnosis must include patterns and the mechanism of injury that differentiate accidental injuries from inflicted trauma.

CASE

A 7-year-old prepubertal girl presented to the emergency department with genital bleeding after a serious accidental impaling injury from inline skating. After rapid abduction of the legs and a fall onto the blade of an inline skate this child incurred an impaling genital injury consistent with an accidental mechanism. The dramatic genital injuries when repaired healed with almost imperceptible residual evidence of previous trauma.

SUMMARY AND CONCLUSION

To our knowledge, this case report represents the first in the medical literature of an impaling vaginal trauma from an inline skate and describes its clinical and surgical management.

Pediatric Urology for the General Surgeon

Pediatric urology spans the neonatal period through the transition into early adulthood. There are a variety of common pediatric urologic conditions that overlap significantly with pediatric surgery. This article reviews the pertinent pathophysiology of a few key disease processes, including the pediatric inguinal hernia and/or hydrocele, cryptorchidism, and circumcision. General surgeons may find themselves in the position of managing these problems primarily, particularly in rural areas that may lack pediatric subspecialization. An understanding of the fundamentals can guide appropriate initial management. Additional focus is devoted to the management of genitourinary trauma to guide the general surgeon in more acute, emergent settings.

Case Series: Vaginal Rupture Injuries after Sexual Assault in Children and Adolescents

BACKGROUND

Vaginal rupture after sexual assault is a rare but life-threatening occurrence requiring prompt recognition and treatment. Herein, we describe four such cases in children. Our purposes are to increase clinicians' awareness of the physical trauma that a sexual abuse victim can suffer and increase recognition that these victims require immediate trauma services.

CASES

Each patient had obvious hymenal and vaginal lacerations with a vaginal apical rupture injury and secondary acute blood loss. None of the four victims sustained infectious sequelae.

SUMMARY AND CONCLUSION

Providers should have a low threshold for managing sexual abuse victims as trauma cases when they have obvious hymenal and vaginal lacerations and genital bleeding, proceeding expeditiously to examination using general anesthesia when appropriate.

Penetrating injury of the vagina, bladder and omentum in a woman with 5 months gestation: case report and review of the literature

Intra-peritoneal bladder and visceral injuries from impalement of the perineum in women are exceedingly rare. This kind of injury has not been previously reported in a pregnant woman. The evaluation and surgical management of a pregnant woman is a challenging surgical problem. Preoperative evaluation of the uterus and fetus is balanced with minimal use of radiographic studies. Multiple organs can be damaged with this type of injury, necessitating careful evaluation and operative planning. We report a rare case of transvaginal impalement injury with through-and-through bladder rupture and intra-peritoneal injury in a 5 months pregnant woman. We discuss diagnostic and management strategies and review the literature.

Severe vaginal laceration in a 5-year-old girl caused by sudden hydro-distention

BACKGROUND

Severe vaginal trauma in young girls is uncommon. We describe a 5-year-old girl who presented a vaginal laceration following sudden hydro-distention.

CASE

A 5-year-old girl was transferred to our institution for vaginal trauma with severe bleeding. Her brother had directed the nozzle of a functioning garden hose against her vulva. She presented pain and persistent vaginal bleeding without external genital lesions. Surgical exploration revealed a laceration of the right vaginal wall. The vagina was sutured and the bleeding stopped.

SUMMARY AND CONCLUSION

This case illustrates a rare mechanism of severe vaginal laceration, in a young girl, by hydro-distention. Though there are often no external lesions the internal lesions can be severe causing significant bleeding. Certainly in these cases aggressive diagnostic evaluation is necessary.

Management of child victims of acute sexual assault: Surgical repair and beyond

Aim:

To evaluate the outcome of definitive repair of anogenital injuries (AGI) in child victims of acute sexual assault.

Settings and Design:

It is a prospective study of emergency care provided to child victims of acute sexual assault at a tertiary care Pediatric Surgical Unit in Maharashtra, India.

Material and Methods:

Out of 25 children, who presented during January 2009-December 2010 with suspected sexual assault, five children (one male and four female, between 4-9 years of age), had incurred major AGI. These children underwent definitive repair and a diverting colostomy. Perineal pull-through was performed in the male child with major avulsion of rectum. One 4-year-old girl with intraperitoneal vaginal injury required exploratory laparotomy in addition.

Results:

The postoperative period and follow-up was uneventful in all our patients. Four out of five patients have excellent cosmetic and functional outcome with a follow-up of 2-4 years. Our continence results are 100%.

Conclusion:

Children with acute sexual assault need emergency care. To optimally restore the distorted anatomy, all major AGI in such children should be primarily repaired by an expert, conversant with a child’s local genital and perineal anatomy. Along with provision of comprehensive and compassionate medical care, prevention of secondary injuries should be the ultimate goal.

Macroscopically detected female genital injury after consensual and non-consensual vaginal penetration: a prospective comparison study

OBJECTIVE

The aim of this study was to compare the prevalence, type and pattern of macroscopically detected female genital injury after consensual and non-consensual vaginal penetration to further an understanding of the forensic significance of genital injury in women reporting sexual assault. A secondary aim was to identify any effect of a range of possible variables upon the likelihood of genital injury resulting from vaginal penetrative sexual intercourse.

STUDY DESIGN

Two groups of reproductive age women (aged 18-45 years) were prospectively recruited within 72 h of a single episode of vaginal penetrative sex, and macroscopically examined for the presence of bruises, abrasions and lacerations at twelve external and internal genital sites. Forty one women who presented for forensic examination after reporting a sexual assault to police were recruited to the non-consensual group and 81 women who presented for routine cervical screening or with sexual health concerns to a primary health care service to the consensual group. Each group was examined by a different group of doctors, all of whom were experienced in both forensic genital examination and gynaecological examination of healthy and diseased sexually active women. Data collection and examination protocols were the same for both groups.

RESULTS

The key finding was a statistically significant difference in genital injury prevalence between women who were vaginally penetrated non-consensually and consensually; 53.7% of the non-consensual group (22/41) and 9.9% of the consensual group (8/81) were found to have at least one genital injury [OR 10.57, CI (4.07, 27.42), p < 0.00001]. Penetration with finger/s and possible pre-existing genital 'infection' were found to be significantly associated with the presence of injury in the univariate analysis after adjusting for consent. Logistic regression demonstrated that women penetrated without consent were 19.5 times more likely to sustain at least one genital injury, than those penetrated consensually [OR 19.53, CI (6.03, 63.24)] and that a penetration scenario that included finger/s was 4.2 times more likely to result in at least one genital injury than penetration without finger involvement [OR 4.25, CI (1.42, 12.78)], when controlling for other variables in the model. Whilst a comparatively low injury prevalence in the consensual group limited interpretation, results revealed possible differences in genital injury typology and pattern resulting from non-consensual and consensual vaginal penetration. Lacerations were seen after both consensual and non-consensual vaginal penetration, while abrasions and bruises were seen exclusively in the non-consensual group.

CONCLUSION

This study demonstrated a significant consent group difference in genital injury prevalence and the highest macroscopically detected genital injury prevalence rate resulting from non-consensual vaginal penetration identified to date. Results also indicate that vaginal penetration with finger/s increases the likelihood of sex-related injury. The difference in type of injury sustained as a result of non-consensual and consensual vaginal penetration was an unexpected finding, and warrants further investigation. These results highlight the importance of a standardised means of detecting genital injury based on consistent injury definitions, examination protocols, and examiner experience and suggest that macroscopic genital examination may be uniquely placed to detect consent group differences in injury typology and pattern if they exist.

Complete anal sphincter complex disruption from intercourse: A case report and literature review

INTRODUCTION

Anal sphincter injuries are uncommon injuries outside of obstetric practice - but they may cause disastrous complications.

PRESENTATION OF CASE

We present a case of complete anal sphincter disruption from anal intercourse in a 25 year old woman. Clinical management is presented and technical details of the repair are discussed. She had an uneventful post-operative course and good continence after 154 days of follow up.

DISCUSSION

This is one of a handful of reported cases of anal sphincter disruption secondary to anal intercourse. The established risk factors in this case included receptive anal intercourse coupled with alcohol use. We review the pertinent surgical principles that should be observed when repairing these injuries, including anatomically correct repair and appropriate suture choice. There is little evidence to support simultaneous faecal diversion for primary repair of acute perineal lacerations.

CONCLUSION

Acute post-coital sphincter injuries should be treated operatively on an emergent basis, without diversion because they are low energy injuries with minimal tissue loss and excellent blood supply. Although repair of each injury should be individualized, the majority of these injuries do not require concomitant protective colostomy creation.

Unintentional and sexual abuse-related pediatric female genital trauma: a multiinstitutional study of free-standing pediatric hospitals in the United States

OBJECTIVE

To evaluate a large national database of free-standing pediatric institutions to define the characteristics of patients who have both unintentional and sexual abuse-related pediatric female genital trauma (PFGT), to describe variation in practice across institutions and between trauma and nontrauma hospitals, and to determine factors associated with diagnostic evaluation and surgical repair of PGFT.

METHODS

We performed a retrospective cohort using the Pediatric Health Information System (PHIS) discharge database with information from 41 freestanding children's hospitals. We identified inpatient and emergency department visits for female patients younger than 18 years of age with International Classification of Diseases, Ninth Revision diagnosis codes for nonobstetric PFGT discharged in the 5-year period between January 1, 2003 and December 31, 2007.

RESULTS

We identified 5664 patients with PFGT, with 64% having been evaluated in state-designated trauma centers. Although overall only 4.2% (236/5664) underwent a diagnostic evaluation, independent of age, mechanism of injury, associated injuries, and insurance status, patients evaluated in a trauma center were 2.6 times more likely to have a diagnostic evaluation. Patients who underwent a diagnostic evaluation were 18 times more likely to have a surgical repair. Other factors associated with increased odds of diagnostic evaluation included age group and specific mechanisms of injury.

CONCLUSION

Among institutions in PHIS, diagnostic evaluation and surgical repair is rarely performed and is defined by variability in approach between hospitals--especially between trauma vs nontrauma institutions. This study of PFGT suggests that aggressive diagnostic evaluation in the operating room may be beneficial for this population.

Injuries from intimate partner and sexual violence: Significance and classification systems

While intimate partner violence (IPV) and sexual violence (SV) are highly associated with injury, the healthcare and legal significance of these injuries is controversial.

PURPOSE

Herein we propose to explore the significance of injury in IPV and SV and examine the current status of injury classification systems from the perspectives of the healthcare and criminal justice systems. We will review current injury classification systems and suggest a typology of injury that could be tested empirically.

FINDINGS

Within the published literature, we found that no commonly accepted injury typology exists. While nuanced and controversial issues surround the role of injury detection in the sexual assault forensic examination, enough evidence exists to support the continued pursuance of a scientific approach to injury classification. We propose an injury typology that is measurable, is applicable to the healthcare setting and criminal justice system, and allows us to use uses a matrix approach that includes a severity score, anatomic location, and injury type. We suggest a typology that might be used for further empirical testing on the validity and reliability of IPV and SV injury data.

CONCLUSION

We recommend that the community of scientists concerned about IPV and SV develop a more rigorous injury classification system that will improve the quality of forensic evidence proffered and decisions made throughout the criminal justice process.

Update on child maltreatment

PURPOSE OF REVIEW

The authors explore the literature published in the past year addressing child maltreatment issues, including sexual abuse, physical child abuse, inflicted head trauma, and child abuse prevention.

RECENT FINDINGS

The body of knowledge about child abuse and its mimics continues to expand. Evident in this year's literature is the challenge which the diagnosis of child abuse creates for clinicians. Although further strides are being made toward universal education of providers, it is clear that there is still a reluctance to report abuse to child welfare agencies. The legal repercussions of diagnosing abuse can be extensive, and there has been a proliferation of medical defense experts who disagree with the commonly accepted tenets of abusive injury and who are vocal in the literature.

SUMMARY

It remains the responsibility of pediatric providers to consider child maltreatment in the differential diagnosis of any unexplained injury or medical problem. Several studies document the high rate of spanking, slapping or shaking children, and primary care clinicians may be the first professionals in a position to begin the evaluation for possible child maltreatment. Despite the natural hesitancy to diagnose abuse, clinicians have an ethical and moral obligation to address this issue both in their practice and in their communities. The short-term and long-term costs to individuals who experience family violence have been well demonstrated and include not only emotional repercussions, but also chronic health conditions, which result in significant cost to society.