Genitourinary assessment: an integral part of a complete physical examination

Sexual Abuse as a Cause of Prepubertal Genital Bleeding: Understanding the Role of Routine Physical Examination

Although accidental trauma is the most common mechanism for genital bleeding, sexual abuse should be considered when the patient is prepubertal and/or a vague history of bleeding is provided. Prepubertal female genital exams should be completed routinely; this clinical technique is critical for pediatricians to assess pubertal progression, to identify pathologies or differences in sexual differentiation, and to narrow a broad differential diagnosis of bleeding. Physical evidence of sexual abuse on exam is rarely found, and therefore the diagnosis relies on a child's disclosure. Physicians should be cognizant of barriers to patient disclosure. In this commentary we aim to provide general pediatricians and trainees with a framework for evaluating genital/vaginal bleeding in prepubertal girls, by discussing the following: (1) the importance of a complete anogenital exam in generating a differential diagnosis; and (2) the possibility of sexual abuse as an etiology with recognition that the disclosure process is complex.

Evaluating Nurse Practitioners Perceived Knowledge, Competence, and Comfort Level in Caring for the Sexually Abused Child

OBJECTIVE

The purpose of this project was to evaluate nurse practitioners' (NPs') current approach and self-reported competence in the care of the sexually abused child in the primary care setting.

METHODS

A 50-question survey was distributed to 5,734 NPs who were members of a state nursing organization and nursing alumni. Inclusion criteria included NPs caring for pediatric patients in a primary care setting in New York State.

RESULTS

A total of N = 325 responses were obtained, and 110 participants met the inclusion criteria. Very few NPs felt competent to perform a medical forensic examination on a sexually abused child (25.5%), and even fewer felt competent to render a definitive opinion on sexual abuse (17.3%) or to testify in court (12.7%). Most NPs felt the need for more training on child sexual abuse (78.2%). Most would prefer to refer children who are suspected of sexual abuse to an expert (77.3%), but very few (19.1%) are being referred to a local resource, like a Child Advocacy Center when a parent calls the office with a concern.

CONCLUSION

More research is needed to evaluate clinical practices regarding child sexual abuse. NPs see value in pursuing specialist referrals for child sexual abuse but do not have access to the appropriate resources or are unaware of the availability within their community.

PRACTICE IMPLICATIONS

NPs should be aware of their own limitations and seek out education to improve their knowledge and skills. Forensic nurses are ideally situated to provide education on the available resources and the recommended clinical guidelines for referral.

A normal ano-genital exam: sexual abuse or not?

Sexual abuse is a problem of epidemic proportions in the United States. Pediatric nurse practitioners (PNPs) are at the forefront of providing care to children and families. The PNP is in a unique position to educate patients and families regarding sexual abuse and dispel common myths associated with sexual abuse. One such myth is that a normal ano-genital examination is synonymous with the absence of sexual abuse. This article will provide primary care providers, including PNPs, with a framework for understanding why a normal ano-genital examination does not negate the possibility of sexual abuse/assault. Normal ano-genital anatomy, changes that occur with puberty, and physical properties related to the genitalia and anus will be discussed. Photos will provide visualization of both normal variants of the pre-pubertal hymen and genitalia as well as changes that occur with puberty. Implications for practice for PNPs will be discussed.