A 4-Year-Old Girl who Presents with Repeated Episodes of Vaginal Bleeding Found to Have Anogenital Warts

Wake Forest Baptist Medical Center, Winston-Salem, North Carolina.
Journal of Emergency Medicine (Impact Factor: 0.97). 07/2013; 45(5). DOI: 10.1016/j.jemermed.2013.05.021
Source: PubMed
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    ABSTRACT: This clinical report serves to update the statement titled "Guidelines for the Evaluation of Sexual Abuse of Children," which was first published in 1991 and revised in 1999. The medical assessment of suspected sexual abuse is outlined with respect to obtaining a history, physical examination, and appropriate laboratory data. The role of the physician may include determining the need to report sexual abuse; assessment of the physical, emotional, and behavioral consequences of sexual abuse; and coordination with other professionals to provide comprehensive treatment and follow-up of victims.
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    ABSTRACT: • HPV is widely prevalent and acquired from a variety of sources and a variety of routes. • The average age for presentation of AGW in prepubertal children is 3.75 to 4 years. (3)(4)(5)(6) • AGW in children younger than 4 years of age are typically acquired from nonsexual transmission. (5)(6)(7) • CSA must be considered in any child who has AGW; the older the child, the more likely the AGW has resulted from sexual abuse. However, thorough evaluation is necessary before determining if reporting to CPS is necessary. • Adolescents generally acquire AGW through sexual activity that is usually but not always consensual. Adolescents are now encouraged to be immunized against specific types of HPV to prevent cervical cancer. • AGW can be treated, but it is unclear whether lesions resolve more rapidly with treatment. (8)(9) Most AGW in young children and adolescents do not need to be treated because they resolve spontaneously. • AGW recurrence is common after treatment. In a child who has been a victim of CSA, recurrence does not necessarily mean the child has been reabused. (9).
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    ABSTRACT: The purpose was to evaluate the prevalence of sexual abuse in patients who were referred to a pediatric gynecologist for evaluation based on the clinical findings of anogenital warts. A retrospective analysis was performed on 131 patients between the ages 6 month and 9 years referred to a pediatric gynecologist after the finding of anogenital warts by a clinical provider, parent or caregiver. A complete physical examination under colposcopy by a the same, trained pediatric gynecologist was completed, and a complete medical and family history including maternal and sibling history for evidence of Human Papillomavirus (HPV) and anogenital warts. The legal system completed a full investigation to examine the sexual abuse allegations. In 131 patients with anogenital warts, a maternal history of warts, cervical dysplasia or both was present in 66 (50%). The remaining patients had either a negative maternal history for HPV clinical findings (54 patients or 41.2%), or maternal history was unknown (11 patients, or 8.3%). Of 131 patients, 81 (61%) patients had a sibling. Of those with siblings 40 (49.4%) had warts and 41 (50.6%) did not. Forty-five (34%) of the cases had a positive maternal history for warts, dysplasia or both but also had a sibling. In that cohort, 32 (71%) of the siblings also had anogenital warts. Three of 131 patients were ruled suspicious for sexual abuse by the legal authorities but not confirmed. Of those three patients two were female and one was male. Two had no maternal history for HPV and both of these patients had a sibling without anogenital warts. Most cases of anogenital warts in children are likely to be the result of non-sexual transmission, namely prenatal mode. Thus, these patients should be handled differently by the legal system unless other reasons for suspicion exist. This study also showed the importance of maternal gynecologic history.
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