Anal and male anatomy: examination, findings and the evidence base - PowerPoint Presentation

1. Anal and male anatomy: examination, findings and the evidence baseDr Jamie CarterDesignated Doctor for Child Safeguarding, Sussex & CSARC SussexWith thanks to Dr Jo Gifford, Dr Lindsay Logie &Prof Neil Macintosh, Chair of anal signs working groupNot to be distributed, shared or reproduced without author’s permissionChild Sexual Assault and the Forensic Examination (Level 3+) 20th April 2023

2. Session overviewBoys’ genitalia:Normal anatomy, puberty & examinationPatterns of injuryEvidence-baseAnal signsNormal anatomy & examinationTerminologyDilatationLacerationEvidence baseDifferential diagnosis/common court lines of enquiryHealing of perianal injuries

3. AnatomyPenis has shaft & glansGlans covered by foreskinCoronal sulcus is the groove at the base of the glansFrenulum is the membrane on the under surface of the glans which attaches immediately behind the external urethral orificeScrotum & testes Remember orientation: dorsum & ventrum Genital signs in boys

4. Tanner pubertal stages

5. Pubic hair

6. Genital examination of boys Early assessment (<72 hours)Systematic Careful inspection of external genitalia including underside (ventrum) of the penisForeskin, if present, should be gently retracted if possible to view the urethral meatus, frenulum to see if recent or old injuryScrotum should be gently palpated (& check perineum & underside)Can he retract his own foreskin?

7. Male injuriesPhysical abuse or sexual abuse?Boys genitalia may be targeted for inflicted injury:e.g. punishment for self-touching/enuresisLigatures, sharp force, pull/sheering, blow, burn, bite/suction, abrasions, swelling, haematomas

8. Genital signs in boys:Evidence statement – 4 case series & 1 comparative study 

9. So What?

10. Common court questionsCould this be accidental, medical or congenital?Could it be self-inflicted?Is this CSA or NAI?

11. Male signs - differential diagnosisCongenital vs acquiredInflicted vs accidentalHSP, idiopathic scrotal oedemaPenoscrotal webbing

12. Example report phrases – male genital injuriesThe RCPCH Evidence Statement on accidental genital injuries in boys is as follows: “the literature on accidental blunt force trauma to the genitalia in boys is very limited…injuries described were bruises and lacerations, commonly to the perineum and scrotum. Injuries to the penis and frenulum were rarely reported”.There is a paucity of literature on non-sexually inflicted injury (physical abuse) to the genitalia in boys, but the pattern of injury could reasonably be assumed to be as for accidental kicks and blows. There is also a relative paucity of literature on genital signs of sexual abuse in boys, with only 4 case series and one comparative study meeting the criteria for inclusion in the RCPCH systematic review. Genital injuries including bruising, lacerations, scars, burns and bites. It includes injuries from suspected sexual and physical abuse but does not detail the type of injuries by abuse type.

13. 2015 RCPCH male genital injuries“The prevalence of reported injury to the external male genitalia as a result of sexual abuse is less than 1% to 7%“(i.e. the majority of male sexual abuse does not result in genital injury) “genital injuries in sexually abused boys occur predominantly to the penis, whereas testicular or scrotal injuries are more frequently associated with accidental injury, although there are also injuries to these anatomical areas in cases of abuse”The RCPCH Evidence Statement on male genital injuries, accidental injuries compared to abusive injuries in the Physical Signs of Sexual Abuse includes “There were no incised wounds described in any of the cases of accidental injury”.The overall clinical impression of the combination of scrotal and penile injuries is one of targeted inflicted genital injury.

14. 2023 RCPCH male genital injuries2023 update of the review has not included any new evidence that allows the evidence statements, key messages or issues for clinical practice to be significantly amended.From the limited available evidence, genital injuries are reported uncommonly in boys who have experienced CSA.Injuries to the penis are the most prevalent sign in boys who have experienced CSA, however numbers reported in studies are small.1,2,7,17Lacerations of the frenulum and scrotal injuries were also reported in boys who have experienced CSA, however numbers reported in studies to support this are very low.1,5Injuries to the scrotum are more commonly reported in boys who have an accidental cause for genital injury.7

15. Anal signs

16. Anal margin/vergesurrounding anusRectumDentate line* Columns of MorgagniLongitudinal section of ano-rectal areaAnal canalPelvic diaphragmInternal anal sphincterDeep external sphincter Superficial external sphincter*also called pectinate line

17. Examination position – Good practiceRecommended:Left lateral Supine knee chestcan be used but no comparitive evidence Prone Knee Chest – may be used to confirm a sign seen in one of the above, BUT SHOULD NOT BE the sole examination position usedSeparate buttocks x 30 seconds, flat palms Careful examination of anal folds is vital

18. Best Practice & The evidence2015 Purple book & 2023

19. Anal Exam: Important clinical signs

20. Factors affecting anal injury degree of penetration - including the size and nature of the penetrating object or body part degree of force used degree of resistance by the child use of lubricantnumber and frequency of episodes of anal penetrationchild's agetiming of the examination after the suspected penetration

21. Ditch Reflex Anal Dilatation!2008 Reflex Anal Dilatation  - Anal dilatation that occurs upon stroking the buttocks.Dilatation – Opening of the anus secondary to relaxation of the external (and possibly the internal) sphincter muscles with minimum traction of the buttocks. that occurs within 30 secs  and is greater than 20mms A-P diameter with no stool present in the rectal ampulla has been associated with prior anal trauma.Gaping = static phenomenonRAD = dynamic process

22. Terms to be abandoned about dilatationRAD – see terminology for dynamic anal dilatationGaping – instead use dilatation Laxity/decreased tone – this is a measure of tension or toneVisibly relaxed anus – abandon this term - it was only ever used by Clayden (1988)Funnelling – Is this external dilatation or what? UnclearWinking/twitching

23. Anal Dilatation (section 5.7 p107)

24. Dynamic anal dilatationDynamic if the dilatation is not present as the buttocks are separated but occurs over the first 30 seconds of observationExternal or total Note whether the dilatation is intermittentNote whether stool is visible or notAlways record the examination position & assess for other causes of dilatation 

25. Static (or immediate) anal dilatationUse this term ONLY if dilatation is present as the buttocks are separated AND when there is no change in the dilatation over a period of 30 secondsQualify with: External (only the anal canal seen) or Total (if rectum, with the columns of Morgagni above the dentate line, is visible)If dilation is total, estimate the maximal transverse diameter Note the presence or absence of visible stool

26. Anal Dilatation EvidenceUse of different terminology & positions make comparisons difficultNo good quality comparative studies of anally abused children or those selected for non-abuse reporting dilatation or dynamic anal dilatationUncertainty around rate of resolutionConsider other causes of anal dilatation e.g constipation, GA, neurological (static) 

27. Evidence statements dilatationDynamic anal dilatation or total dilatation of both internal and external anal sphincters in the absence of stool is associated with anal abuse.Dynamic dilatation over 30 seconds in the LL position is found in 10-30% of children who allege anal abuse, 1-18% who allege sexual abuse, and in only 0.7-1.2% selected for non-abuse without predisposing factors. There is no published evidence to ascertain whether the presence or absence of stool in the rectum visible via the dilated anal sphincter affects the significance of the finding. SO - get the child to pass stool & re-examine.

28. Anal Dilatation – evidence statement External anal dilatation is associated with anal abuse in 1 large study (Myhre & Adams 2013)1115 children'interpreting anal findings is a challenge''physical findings interpreted with caution in absence of disclosure' Interestingly 198 cases were deemed to be ‘likely anal abuse’ and no children had anal scars, however 67 were identified as having perianal skin tags.

29. RCPCH recommendation 2015All full thickness skin breaks should be called LACERATIONSfissuresPartial thickness are abrasions

30. Evidence Statement on Anal LacerationsHave been found in 15% - 20% of children who have been anally abused, 2% - 15% of those sexually abused (with no further details of the abuse) & 1% - 3 % of children selected for non-abuse

31. Common court questionsConstipationMultiple anal lacerationsNAIInflicted –self or another eg. scratching, object insertion, anal stretching (for constipation)

32. Example phrases in reportsAnal laceration describes a linear split to the skin around the anal circumference.  The term fissure has previously been used, particularly when superficial. Apart from rare cases of sharp force trauma, the usual cause of anal laceration is excessive stretch to the circumference of the anal opening, causing tearing of tissue. There is good evidence that anal lacerations are significantly more common in sexual abuse than non-abuse. The evidence statement is [….]Excessive stretching of the anal circumference may occur as a result of the passage of exceptionally large hard stool. I note the report that [name] had a history of constipation. Constipation is an extremely common problem in general Paediatric practice.In my experience, even among children with chronic severe constipation, more than one laceration at a time is extremely rare; most are superficial and heal rapidly, although for a minority of such children a laceration may become chronic (long-term due to repeated re-opening preventing healing) or reoccurring. I have only seen multiple lacerations in the context of sexual abuse allegations. It must be remembered that secondary constipation may occur as a psychological or physical (pain due to laceration) response to sexual abuse; therefore, the population attending secondary and tertiary constipation services are more likely than the general population to have experienced child sexual abuse. 

33. Other Anal signs

34. Evidence Statement on Anal/perianal ErythemaAnal/perianal erythema, is seen in a small proportion of children who allege sexual abuse & in children selected for non-abuse.Non-specific finding in respect of CSAIt is more likely to be seen if examined early.But "no good quality studies comparing erythema in anally abused vs non-abused children"Consider all causes

35. Name 3 causes of anal/perianal erythemaTraumaInfectionSelf-inflictedPoor hygieneFaecal soilingLactose intoleranceAmmoniacal dermatitisDiarrhoeaEczemaInflammatory bowel disease

36. Evidence Statement on Perianal venous congestion (PVC)Evidence suggests that perianal venous congestion occurs in both children who have been sexually abused and children selected for non-abusePractice tip: observe INITIAL appearance as this will help distinguish bruising from congestionreview in different positionspalpate

37. PVC – definition? "Collection of venous blood in the venous plexus of the perianal tissues that blanches with pressure, creating flat or swollen purple discoloration, may be localised or diffuse"

38. Evidence Statement on Anal/perianal BruisingAnal/perianal bruising is found in 1% to 2% of children alleging sexual abuse & in 10% in two studies selected for anal penetration. It is more commonly seen when the examination is early after the abuse.Anal bruising has not been reported in children selected for non-abuse

39. Evidence Statement on Anal Scars & tagsHave been found in up to 32% of children who have been anally abused, only 1% to 2% of those sexually abused (type not specified) but have not been found in children selected for non-abuseAnal tags outside the midline have only been found in abused children.Consider congenital anomalies eg. median raphe, diastasis ani, congenital perineal groove, anorectal malformation

40. Accidental anal traumaWhere anal injury is reported following blunt force trauma to the anogenital area, this is usually an extension of genital or perineal traumaMost accidental injuries are witnessed or present with a clear history of eventsLimited evidence suggests that isolated anal injury most commonly results from penetrative sexual abuse

41. 4 perianal healing studiesMultiple anal lacs in toddlers run over by slow cars

42. Evidence statementHealing of anal injuriesEvidence from 4 studies shows that most anal injuries heal without sign of previous trauma. Minor injuries heal quickly and completely while more extensive injuries heal to leave scar tissue and/or skin tagsThe presence of scars or perianal skin tags suggests significant lacerations or surgical trauma

43. Devil is in the detail.... behind the evidence statementWatkeys (2008): consecutive case series of 73 children who alleged penetrative anal abuse; 10/73 children had anal scars. 9/10 children examined more than 7 days after the alleged abuse & in 9/10 the position of the scar on the anus was not mentioned. McCann (1993) follow-up study - 4 children who had been anally abused & reported that 1 of these children (who had multiple acute anal lacerations on the initial examination) developed a skin tag but no anal scarBruni (2003): children whose perpetrators admitted anal penetration of children following court action. In a cohort of 50 cases which included 6 cases of penile penetration of the anus & 44 who had experienced digital penetration of the anus = 84% of cases had anal scars. Anal scars were seen in all positions around the anus, with 38% in the midline (the 12 & 6 o’clock positions), 36% away from the midline & 26% in both locations. 

44. Medical reports – anal signsMedical definitions & explanations: Midline refers to the 6 and 12 o’clock positionsAnal scar is a healed anal laceration (which itself is an acute or fresh break in the peri-anal skin) in the anal verge Anal scars can result from injuries caused by the following: Accidental anogenital straddle (eg. landing on a hard bar) mechanism, crush or impalement injury, past surgical interventions or anal abuse. An anal scar can be confused with a midline fusion defect (a developmental anomaly), diastasis ani etcDiastasis ani is a smooth, often wedge-shaped lesion in the midline. Diastasis ani is a congenital variant characterized by an apparent absence of muscle fibres in the midline of the external anal sphincterMedian raphe is a rare developmental anomaly in the midline.

45. Take home messages: Anal signsUse left lateral position if possible to confirmExplore perianal foldsGet child to pass stool if in doubt (DAD)Dilatation – dynamic or staticLacerationsBruisesScars & tagsConsider other causes in your interpretation/analysis of signInjuries heal quickly (72hours)Scars are good evidence of significant traumaAscertain (alleged) mechanism of anal penetration & link it to physical sign & then evidence-baseIf quoting articles MUST read full versionFurther studies are needed…