ABSTRACT
An 11-year-old boy is brought for physical examination prior to being placed in a foster home. His mother has a long history of drug abuse. While the boy lived with her and her boyfriend, Child Protective Services were called by the boy’s teacher, who saw that he was coming to school hungry in unwashed clothes. She also told authorities that he had been found in the bathroom ‘harassing’ another boy by pulling his clothes off and locking him in a bathroom stall. Prior to his physical examination, he reveals to a skilled interviewer that his mother’s boyfriend would often ‘come in his bed’ and ‘hurt him’ while his mother was asleep, but he has difficulty talking about the details as his attention and concentration are poor and he becomes angry and smashes toys when asked about the details of his abuse at home. His height and weight are below average for his age and he appears thin, with dry, scaling, eczematous patches on his skin. His anogenital examination is shown in Image 73. https://s3-euw1-ap-pe-df-pch-content-public-p.s3.eu-west-1.amazonaws.com/9780429170423/e1d751c1-a9c7-4bb9-9d59-53742c84031a/content/fig73.jpg"/>
Are the physical findings consistent with sexual abuse?
What laboratory testing was indicated for this patient?
What medications were indicated for this patient?
166The anogenital examination shows total anal dilation: specifically, dilation of the external and internal anal sphincter, so that the rectum is visible. Although the only finding diagnostic of penetration is semen (or other fluid or foreign body) in the anus (or vagina), total anal dilation has been shown to have a statistically significant correlation with penetration. 1 Findings with higher specificity for anal penetration include anal laceration, fissures and soiling. Yield of physical findings increases significantly when the patient is placed in the prone knee-chest position for examination. However, it is important to remember that a majority of cases, even in acute sexual assault, will have non-specific or absent physical findings.
The boy should have been offered a complete evaluation for sexually transmitted infections, including anal, penile and pharyngeal culture for Neisseria gonorrhoeae and anal/penile culture for Chlamydia trachomatis. He can also be offered urine NAAT testing for N. gonorrhoeae and C. trachomatis. He should have also been offered baseline serologic testing for syphilis, hepatitis B and C (depending on the immunization status), and human immunodeficiency virus (HIV). Repeat serology testing should then have been performed at 3 and 6 months post-assault, although with newer more sensitive methods, fewer tests are needed. 2
Many experts do not indicate post-exposure chemoprophylaxis to prepubertal victims of sexual assault because the incidence of sexually transmitted infection (STI) in these patients is low. However, this patient underwent a high-risk exposure with an adult perpetrator and was offered post-exposure prophylaxis for N. gonorrhoeae and C. trachomatis as well as HIV (if an assault has occurred within the past 72 hours). Antibiotics can include a combination of a third-generation cephalosporin, such as a single intramuscular dose of ceftriaxone, as well as an oral macrolide (for prophylaxis of gonorrhea and chlamydia, respectively). 2 The patient should also be offered a course of antiretroviral medications for prophylaxis of HIV. As a full course of antiretroviral medication is indicated for 28 days, the patient should have frequent follow-up visits to monitor for tolerance of the medications as well as for emotional support. 2 A referral to a mental health specialist is indicated.
