Examination of children and adolescents for sexual assault or abuse should be arranged so as to minimize further trauma. The decision to evaluate the individual for sexually transmitted infections must be taken on a case-by-case basis.
Health care workers dealing with children and adolescents must respect and maintain confidentiality. They should be trained to elicit a good medical and sexual history and know how to overcome the patient's fear of pelvic examination.
Situations involving a high risk of STI and a strong indication for testing include:
• alleged offender known to have an STI or to be at high risk for STI
• symptoms and signs of STI on physical examination
Special care must be taken in collecting the required specimens in order to avoid undue psychological and physical trauma to the patient. The clinical manifestations of some sexually transmitted infections are different in children and adolescents as compared with adults. Some infections are asymptomatic or unrecognised. A paediatric speculum is rarely, if ever, needed in examination of prepubescent sexual assault victims. Indeed, in these situations, skill, sensitivity and experience are more essential than any specially developed technology. Practitioners undertaking examinations and specimen collection should be specially trained in child and adolescent abuse/assault evaluation.
The scheduling of examinations should depend upon the history of assault or abuse. If initial exposure is recent, infectious agents acquired through the exposure may not have produced sufficient concentrations of organisms to result in positive tests at an initial examination. A follow-up visit, approximately 1 week after the last sexual exposure to repeat the physical examination and to collect additional specimens, is important in such cases to allow sufficient time for infections to incubate.
Similarly, to allow sufficient time for antibody to develop, an additional follow-up visit at approximately 12 weeks following the last sexual exposure is also necessary to collect sera. A single examination may be sufficient if the child or adolescent has been abused over an extended period of time and/or the last alleged episode of abuse occurred some time before the patient presents for medical evaluation. The following recommendation for scheduling examinations is a general guide. The exact timing and nature of follow-up contacts should be determined on an individual basis, however, and take psychological and social needs into consideration.
An initial examination and any follow-up examinations should include:
• Cultures for N. gonorrhoeae and C. trachomatis from specimens collected from the pharynx and anus in both sexes, the vagina in girls, and the urethra in boys. Cervical specimens should not be collected from prepubertal girls. In boys, a meatal specimen of urethral discharge is an adequate substitute for an intraurethral swab specimen when a discharge is present. Only standard culture systems for the isolation of N. gonorrhoeae should be used.
• Wet-mount microscopic examination of a vaginal swab specimen for T. vaginalis infection. The presence of clue cells suggests bacterial vaginosis in a child with vaginal discharge. The significance of clue cells or other indicators of bacterial vaginosis as an indicator of sexual exposure in the presence or absence of vaginal discharge is unclear.
• Tissue culture for herpes simplex virus (where available) and dark-field microscopy or direct fluorescent antibody testing for T. pallidum from a specimen collected from vesicles or ulcers in children of all ages and in adolescents.
• Collection of a serum sample to be preserved for subsequent analysis if follow-up serological tests are positive. If the last sexual exposure occurred more than 12 weeks before the initial examination, serum should be tested immediately for antibody to sexually transmitted agents. Agents for which suitable tests are available include T. pallidum, HIV and hepatitis B virus. The choice of agents for serological tests should be made on a case-by-case basis.
EXAMINATION AT 12 WEEKS FOLLOWING ASSAULT
An examination at approximately 12 weeks following the last sexual exposure is recommended to allow time for antibody to infectious agents to develop. Serological tests for the following agents should be considered: T. pallidum, HIV, hepatitis B virus.
The prevalence of infections with the above agents varies greatly among communities. It will be important to know whether risk factors are present in the abuser/assailant. Also, results of hepatitis B virus tests must be interpreted carefully, since hepatitis B virus may be transmitted by non-sexual modes as well as sexually. Again, the choice of tests must be made on a case-by-case basis.
There are few data upon which to establish the risk of a child acquiring a sexually transmitted infection as a result of sexual abuse. The risk is believed to be low in most circumstances, though documentation to support this position is inadequate.
Presumptive treatment for children who have been sexually assaulted or abused is not widely recommended since girls appear to be at lower risk of ascending infection than adolescent or adult women and regular follow-up can usually be assured. However, some children or their parents/guardians may be very concerned about the possibility of contracting an STI, even if the risk is perceived to be low by the health care practitioner. Addressing patient concerns may be an appropriate indication for presumptive treatment in some settings.
SUSCEPTIBILITY AND CLINICAL PRESENTATION OF STI IN CHILDREN AND ADOLESCENTS
There are differences in the epidemiology of STI in adolescents and adults, and though clinical presentations are similar, adolescents are regarded as being more biologically susceptible to infection and at increased risk of morbidity. Some of these differences have been obscured through the common practice of reporting adolescents (10-19 years) in the same category as "youth" (15-24 years) and through general inattention to young females who are married and pregnant.
In the majority of cases, the presentation of a STI is similar to that seen in adults. At the time of puberty and adolescence the female genital tract undergoes changes in response to increasing levels of ovarian hormones. Along with the anatomical and physiological changes the vaginal epithelium begins to secrete mucus. The mucus secretion causes the adolescent girl to develop a white vaginal discharge, which is physiological. Generally, therefore, vaginal discharge is a poor predictor of the presence of either gonococcal or chlamydial infection.
In pre-pubescent girls the columnar epithelium extends from the endo-cervical canal to the porto-vaginalis of the cervix. This cervical ectropion, normally present in 60-80% of sexually active adolescents, is associated with an increased risk of C. trachomatis infection. Also N. gonorrhoea, which infects columnar epithelium, readily colonises this exposed surface. Exposure to oncogenic pathogens such as human papilloma virus enhances the risk of dyskaryosis and carcinoma at an early age. Additionally, because cervical mucus production and humoral immunity are absent until ovulation begins, the risk of complications are higher in the immature adolescent exposed to infection as opposed to the physically mature woman. Ascending infection and subsequent pelvic inflammatory disease (PID) are consequently more frequent in the sexually active pre-pubescent adolescents and those in early puberty.
Approximately 85% of gonococcal infection in the female will be asymptomatic. However, there may be vulval itching, a minor discharge, urethritis or proctitis. In pre-pubescent girls, a purulent vulvo-vaginitis may occur.
Similarly C. trachomatis infection is asymptomatic in the majority of cases. Symptoms which may occur in the adolescent are inter-menstrual bleeding, post-coital bleeding and an increase in vaginal secretions.
GENITAL ULCER DISEASE
Presentation of syphilis is the same in the adolescents and adults. The stages of primary chancre, secondary syphilis manifestations, latent syphilis and serological responses are the same in both groups.
Warts present as condylomatous, papular of flat lesions.
Trichomonas vaginalis, candidiasis and bacterial vaginosis are the three usual pathological causes of vaginal discharge. T. vaginalis is sexually transmitted and causes an offensive malodorous discharge with vulval soreness and irritation. It may also present no symptoms at all.
Candida albicans is uncommon in adolescents prior to puberty. If present, the adolescent may have a discharge, vulval itching, dyspareunia, a peri-anal soreness or a fissuring at the introitus. Attacks of Candida vulvitis may be cyclical in nature and correspond to menstruation.
Bacterial vaginosis does not produce a vulvitis and the adolescent will not complain of itching or soreness.