6.

Grubb

BP,

syncope

Geraed

and

C,

Rousch

epilepsy

with

K,

et

head-up

al.

Differentiation

tilt

testing.

of

Ann

Intern

convulsive

1991;

Med.

115:871-896
7. Lempert

R, Bauer

of induced

M, Schmidt

syncope.

Perianal
Months

D, Berlin

Neurology.

Findings
of Age

C. The clinical

phenomenology

skin.4

in Infants
or Younger

by one

of two

METHODS

Review
Board approval
each child was examined

examiners.

Infants

were

and informed,
writand photographed

positioned

on

an examina-

tion table in the supine

position
with legs extended.
Gentle lateral
traction
was applied
to the buttocks
to expose
the anus. A handheld Nikon
F3 camera
was used to take approximately
two photographs
Nikkor

of

the

perianal

area

of

each

infant.

A 105-mm

micro-

lens with attached

extension
ring and ring flash provided
1:1.2 magnification.
Findings
reported
reflect those observed
photographically.
Recorded
characteristics
included
the number
and location
of skin
tags,

fissures,

smooth

or

ulcerated

areas

were

located

adjacent

to

the

RESULTS

Infants
were
recruited
for this study
at a single
center
between
January
7, 1990, and January
31, 1991. Recruitment
of infants
18
months
of age took place
at the time of a health
supervision
visit
(n = 29) or through
a letter
sent to children
born
at this institution
(n - 60) between
August
1989 and February
1990. The parents
of
all girls
were
asked
whether
they
suspected
that
their
daughter
may have
been
sexually
abused
in the past.
Children
with
a history
of possible
sexual
assault
were
excluded
from
participation.

With Institutional
ten parental
consent,

smooth

18

Due to the recent

increase
in the number
of cases of
suspected
sexual
assault,
a need
has arisen
for better
knowledge
and
understanding
of the genital
anatomy
in the prepubertal
girl. In spite
of the fact that
abuse
involving
the rectum
has been
reported
in up
to 40% of young
girls
assaulted,
little
normative
data exists
on the appearance
of the anonectal
region.
In the single
study
of penianal
findings
in nonabused
girls,
McCann
et a!2 documented
that findings
previously
reported
to be suggestive
of sexual
abuse,
including
erythema,
smooth
areas,
skin
tags,
and
anal dilation,
commonly
occurred
in 161 female
subjects up to 11 years
old. However,
this study
lacked
adequate
numbers
of infants,
with
only
12 subjects
younger
than
2 years
of age.
Comparison
data
on
anorectal
anatomy
of very
young
patients
are especially
critical,
as anal
abuse
is more
common
than
vaginal
penetration
in girls aged
0 through
5#{149}3
The purpose
of this study
was to document
in a
triethnic
population
the anatomy
of the perianal
region in infants
18 months
of age without
a history
of
sexual
assault.
This
information
should
help
clinicians who evaluate
infants
for possible
sexual
assault
differentiate
normal
anatomical
findings
from
posttraumatic
changes.
AND

Wedge-shaped

as excess skin which

tissues.4
Fissures
were
as superficial
loss of

perianal
skin folds. Location
was noted using the face of a clock
with the infant in the supine position,
with the 12 oclock position
located
superiorly
near the posterior
fourchette
and the 6 oclock
position,
inferiorly.

1991;41:127

MATERIALS

the anal sphincter.4

Skin tags were defined
did not disappear
with stretching
of nearby
identified
as deep linear clefts, and ulceration

areas,

and

human

papifioma

lesions (warts) and the presence

of anal gaping.
Variations
in
pigmentation,
classified
as increased
or decreased,
were noted as
were rashes
or areas of redness.
A rash was defined
as discrete
maculopapular
lesions,
and redness
as a confluent
area of redness
near the anal orifice. Anal gaping
was defined
as 1 cm dilation
of

Eighty-nine
17.6 months
the subjects
of the study

female
infants
ranging
in age from 1 to
were
photographed.
The mean
age of
was 10.7 months.
The racial distribution
population
was 44% (39/89)
black,
29%
(26/89)
white, non-Hispanic,
26% (23/89)
Hispanic,
and 1% (1/89)
Asian.
An increase
or decrease
of the skins
pigmentation
near the anus was noted
in nine infants
(Table).
Six
black
and one white
subject
had increased
pigmentation.
A decrease
in pigmentation
was observed
in
one black
infant,
and a second
black infant
had both
areas of increased
and decreased
pigmentation.
Five
infants
had a rash.
A confluent
area of redness
was
observed
near the anus
in an additional
six subjects.
Smooth
areas
adjacent
to the perianal
folds
were
found
in 26% (23/89)
of subjects
ranging
in age from
3
to 15 months
old (Fig 1). This characteristic,
which
was observed
in the midline
only, occurred
at the 6
oclock position
in 83% (19/23)
of the infants
and at
the 12 oclock
position
in 26% (6/23)
of those
who
had this finding.
Two of the 23 girls
had a smooth
area both
inferionly
and superiorly.
A smooth
area
was observed
more
often
in white
non-Hispanic
infants
(48%)
than
in blacks
(30%)
on Hispanics
(22%).
Three
infants
were
observed
to have
an anal skin
tag. A 15-month-old
white
and a 1-month-old
Hispanic child had this finding
superiorly
at the 12
oclock
position,
(Fig 2). Photographs
of a 13-monthold white
child,
who had been
in the supine
position
for approximately
2 minutes,
showed
both a skin tag
at the 6 oclock
position
and venous
pooling
inferionly (Fig 3). A fissure
was observed
at the 12 oclock
position
in one 14-month-old
girl.
Warts,
areas
of
ulceration,
or anal
gaping
were
not observed
in a
single
infant.
DISCUSSION
Perianal
findings
reported
to be associated
with
abuse
include
anal
gaping,7
rectal
fissures,57
wedge-shaped
smooth
or thickened
areas,6
penianal
erythema,57
penianal
swelling,5
venous
engorgement,57
skin tags,47
perineal
scarring,47
rectal
and
sphincter
tears,
and human
papilloma
virus
lesions.4
Limited
information,
however,
is known
on the fre-

TABLE.

Perianal

Findings

in the

Sample

(n

89)

virus

Received
Reprint
atrics,

for

Jul

to (A.B.B.)

University

PEDIATRICS

emy

publication

requests

of Texas
(ISSN

0031

13, 1992;
Depts

Medical
4005).

accepted

Oct

13, 1992.

of Obstetrics

and

Gynecology

Branch,

Copyright

Galveston,

Ti.1

Pedi-

Acad-

area

pigmentation

EXPERIENCE

AND

REASON

23

26

10

Skintag

1
0

I
0

pooling

Fissure
Ulceration
Anal
gaping

Downloaded from by guest on November 27, 2016

838

Redness
Venous

and

TX 77555-0587.

1993 by the American

of Pediatrics.

Smooth

Fig
sition

1. Smooth

area

in a 12-month-old

at the 6 oclock

po-

child.

Fig 3.
Fig
oclock

2. Fifteen-month-old

with

a longitudinal

rectal

tag at the

12

and

Thirteen-month-old
pooling

venous

with

a skin

tag at the 6 oclock

position

inferiorly.

position.

quency
of these
findings
in a nonabused
population.
One study
recently
documented
erythema,
increased
pigmentation,
venous
engongement,
smooth
areas,
skin tags, and anal dilation
in children
up to 11 years
of age without
an assault
history.2
This
study
confirms,
with
a tniethnic
infant
population,
that variations
in pigmentation,
smooth
areas,
and
skin
tags
occur
in the absence
of reported
abuse.
The
etiology
of these
anatomic
characteristics
is
uncertain.
McCann
et al2 speculate
that smooth
areas
result
from
a congenital
absence
of muscle
fibers
in
the midline.
Munam4
observed
skin
tags in 14% of
sexual
abuse
victims
and noted
that these
may occasionally
form
as part
of the healing
process.
Both
rectal
tags and fissures
have been postulated
to result
from
trauma
induced
by passage
of hard
stools,8
although
these
findings
were
observed
infrequently
in

a study
of 171 children
with
gastrointestinal
complaints.9
The presence
of a smooth
area in a 3-monthold and a tag in a 1-month-old,
in this report,
suggests
a congenital
etiology
of
these
findings;
however,
a study
of newborns
is needed
to confirm
that they are not acquired
during
infancy.
Anatomic
features
reported
in this paper
are limited to those
noted
on photographs.
This
technique
has been accepted
as the standard
in both clinical
and
research
settings
to document
anatomic
details
of the
external
genitalia.10-12
Use
of photographs
allows
confirmation
of all findings
and eliminates
intenobserver
differences.
One area of concern
is whether
sexually
abused
children
could
have
been
included
in this sample.
The young
age of the subjects
decreases,
but does not
eliminate,
the possibility
of prior
assault.
All parents
were
queried
about
the possibility
of abuse.
It was

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EXPERIENCE

AND

REASON

839

not possible
to interview
the subjects
as all were
prevenbal.
Sexual
behavior
checklists,
which
may assist in detecting
sexual
assault
in olden children,
have
not been
developed
for girls younger
than 2 years
of
age.13
In any event,
even
if this sample
included
a
small
number
of assaulted
children,
the frequency
of
smooth
areas
(26%) and tags (3% to 11 %) detected
in
this study
and
that
of McCann
et a12 makes
it unlikely
that these
findings
are secondary
to assault.
As very
young
children
are preverbal,
increased
emphasis
is placed
on physical
findings
to document
sexual
assault.
However,
anonectal
abuse,
which
is
more
common
than
vaginal
penetration
in young
patients,
is difficult
to prove
on examination
alone.
Few findings
are pathognomic
of abuse.
Even
when
lacerations
occur,
it may
not be apparent
on subsequent
examination
as the rectum
can heal
without
evidence
of scarring
by gross
inspection
within
2
weeks.14 The presence
of venereal
disease
or sperm
indicates
abuse,
but these
are rarely
detected.
One
study
of older
children
who
verbalized
a clear
history of anal assault
demonstrated
that
16% had no
posttraumatic
changes.4
A negative
examination,
therefore,
does
not eliminate
the possibility
of prior
anal assault.
Due to the difficulty
of documenting
assault
in the
pnevenbal
child,
practitioners
must
have a high index
of suspicion.
Routine
inspection
of the external
genitalia
at health
supervision
visits
may
assist
in the
detection
of acute
injuries.
Due to the ability
of the
penianal
area
to heal rapidly,
however,
detection
of
abuse
in the pneverbal
child
remains
a clinical
challenge.

B.

ABBEY
ANA

MD

BERENSON,

PA-C

SOMMA-GARCIA,

STEPHEN

MD

BARNE-I-I-,

Depts

of Obstetrics

University

and

of Texas

Gynecology

Medical

and

Pediatrics

Branch

Galveston
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1. Hobbs

CJ,

importance

Wynne

JM.

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examination.

1 Voris

2. McCann
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J, Simon

abuse

M, Wells

for nonabuse:

selected

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Child

English

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boys

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and

findings

a descriptive

girls:

the

1989;13:195-210

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1989;13:179-193
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CJ,

nosis.
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Wynne

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sexual

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5. Hobbs

JM.

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Textbook

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CI.

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MJ, Dunklee,

8. Shandling
Behrman

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a common

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Lazar

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ACKNOWLEDGMENTS
We thank
for

staff

840

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entry

for their

Astrid

Heger,

and

analysis,

MD,
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13.

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the

pediatric

assistance.

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faculty

Friedrich

tive

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behavior

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Perianal Findings in Infants 18 Months of Age or Younger

ABBEY B. BERENSON, ANA SOMMA-GARCIA and STEPHEN BARNETT
Pediatrics 1993;91;838
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.

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Perianal Findings in Infants 18 Months of Age or Younger

ABBEY B. BERENSON, ANA SOMMA-GARCIA and STEPHEN BARNETT
Pediatrics 1993;91;838

The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/91/4/838

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright 1993 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.

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