|Year : 2013 | Volume
| Issue : 3 | Page : 105-111
Management of child victims of acute sexual assault: Surgical repair and beyond
Minakshi Sham1, Dasmit Singh1, Uma Wankhede2, Abhijeet Wadate2
1 Department of Pediatric Surgery, Byramjee Jeejeebhoy Medical College, Pune, Maharashtra, India
2 Department of Obstetrics and Gynecology, Byramjee Jeejeebhoy Medical College, Pune, Maharashtra, India
|Date of Web Publication||3-Aug-2013|
G/101, Sudarshan Apartments, Behind Spencer's Daily, Karve Nagar, Pune - 411 052, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To evaluate the outcome of definitive repair of anogenital injuries (AGI) in child victims of acute sexual assault. settings and Design: It is a prospective study of emergency care provided to child victims of acute sexual assault at a tertiary care Pediatric Surgical Unit in Maharashtra, India. Material and Methods : Out of 25 children, who presented during January 2009-December 2010 with suspected sexual assault, five children (one male and four female, between 4-9 years of age), had incurred major AGI. These children underwent definitive repair and a diverting colostomy. Perineal pull-through was performed in the male child with major avulsion of rectum. One 4-year-old girl with intraperitoneal vaginal injury required exploratory laparotomy in addition. Results : The postoperative period and follow-up was uneventful in all our patients. Four out of five patients have excellent cosmetic and functional outcome with a follow-up of 2-4 years. Our continence results are 100%. Conclusion : Children with acute sexual assault need emergency care. To optimally restore the distorted anatomy, all major AGI in such children should be primarily repaired by an expert, conversant with a child's local genital and perineal anatomy. Along with provision of comprehensive and compassionate medical care, prevention of secondary injuries should be the ultimate goal.
Keywords: Anogenital injuries, acute sexual assault, child abuse, emergency management, definitive surgical repair
|How to cite this article:|
Sham M, Singh D, Wankhede U, Wadate A. Management of child victims of acute sexual assault: Surgical repair and beyond. J Indian Assoc Pediatr Surg 2013;18:105-11
|How to cite this URL:|
Sham M, Singh D, Wankhede U, Wadate A. Management of child victims of acute sexual assault: Surgical repair and beyond. J Indian Assoc Pediatr Surg [serial online] 2013 [cited 2018 Jan 23];18:105-11. Available from: http://www.jiaps.com/text.asp?2013/18/3/105/116043
| Introduction|| |
Sexual assault and sexual abuse, though often not acknowledged, are very much prevalent in our society. 
Children with severe injuries inflicted by sexual assault are usually referred to tertiary referral centers for definitive care of their wounds. In this article, we concentrate upon emergency management of injuries sustained by child victims of acute sexual assault (reports within 72 h of the abuse) provided at a tertiary care pediatric surgical unit. To the best of our knowledge, this is one of the largest series in world literature describing management of major vaginal, rectal, and sphincteric injuries in pediatric sexual trauma victims.
| Material and Methods|| |
It is a prospective study analyzing case details and operative findings of children who fell prey to sexual assault and were referred to our institute for emergency management of their AGI during January
2009-December 2010. There were 16 female and nine male children, who presented with history of vaginal, anal, or anogenital penetration by penis. All children were in the age group of 4-11 years. All the girls were premenarchal. One 11-year-old girl was mentally retarded.
After providing acute emergency care, parental informed consent was obtained for detailed anogenital examination and necessary surgical intervention. All children were examined in the operating room under sedation in supine-frog-leg position for documentation of anatomic findings. , Requisite body swabs were obtained to complete the medicolegal formalities. Details of genital, anorectal, and sphincteric injuries were noted. Photographic evidence was also recorded.  Severity of injuries was judged by perineal tear classification. 
Nine children who had no anogenital injuries (AGI) were excluded from the study. Similarly, eleven other children having first and second degree injuries were managed nonsurgically and were also excluded from the present study.
Five children with more severe injuries, that is, third and fourth degree injuries were managed surgically. The details of their AGI and surgical reconstruction are presented in the current study. Repair  of their injuries was done under general anesthesia  within 4-6 h of presentation to our center. The procedure done was as follows:
- Thorough cleaning using pulse irrigations of 5% providone iodine solution ± debridement
- Urethral catheterization using Foley catheter
- Approximation of torn vaginal muscles using interrupted sutures of 5-0 vicryl
- Vaginal mucosal suturing using 5-0 vicryl, continuous sutures from within (apex) outwards
- Transanal repair of rectal mucosal injuries using 5-0 vicryl from apex to anocutaneous junction 
- Sphincteric reconstruction and repair of the perineal body in layers based on principles of anterior sagittal anorectoplasty (ASARP) ,
- Labial reconstruction
- Diverting colostomy to protect the repair  with thorough on-table irrigation of the distal rectal stump
Oral feeds were started once the colostomy was functioning. All our children and their families underwent psychiatric counseling before discharge from the hospital.
Postoperative care provided to these children constituted:
- Intravenous antibiotics for 7-14 days: Cefotaxime, amikacin, and metronidazole. The child with vaginal vault injury had prolonged postoperative fever and received intravenous cefoperazone and meropenem.
- Close follow-up for signs of wound infection: Charting of fever, hemogram, etc.
- Alternate day operating room examinations under sedation for the initial first week after repair and pulse irrigations with antiseptic solution  to enable optimum cleaning of the operated perineal area ± vaginal lacerations.
- Warm sitz bath twice daily with antiseptic solution started after 7 days of repair.
- Colostomy care.
Continence assessment was done by Kelly's Continence Score  at 6 months following colostomy closure. Along with medical care, reassurance was also provided to the child and family at every follow-up visit.
| Results|| |
Two patients presented within 8-10 h of injury and one after 48 h. Two patients with major injuries were referred within 48-72 h for management of complications after attempted surgical reconstruction.
One girl with vaginal injury presented with life-threatening bleeding and was in shock. Other children had rectal ± vaginal bleeding associated with pain and discomfort. Rectal injury was missed at initial assessment in one girl, whereas one boy was referred with rectum hanging outside the anal orifice. None of them had urethral or nongenital injuries/bite marks.
All five children with third and fourth degree injuries (one male, four female) underwent surgical reconstruction. The nature of surgery performed varied, depending upon timing of presentation after the assault, and repair done earlier. Two children underwent complete anogenital repair with covering colostomy in one stage. One child (case 5) required laparotomy in addition. Their colostomy was closed 8 weeks later after optimal wound healing (second stage). Three children underwent three-stage surgery as detailed in [Table 1].
The hospital stay was variable in these children about 10-15 days in cases 1, 2, and 5; whereas it was significantly prolonged by (10-12 days), that is, 20-22 days in cases 3 and 4.
The cosmetic outcome was excellent in four children who underwent surgical repair. The girl with delayed repair of the perineum had developed scarred perineum by the time definitive repair was done and cosmetic outcome was unsatisfactory.
All our patients had an uneventful postoperative course except for fever spikes for a long duration in one child. Anxiety and depression were noted in two of our patients but they all responded well to repeated counseling over 4-6 months period by a dedicated child psychologist. No deaths occurred in our study.
Parents of all our patients are satisfied with the cosmetic and functional outcome of repair of their AGI at a follow-up of 2-4 years. The continence results are 100%. None of the female patients have vaginal stenosis or any urinary problems on follow-up.
| Discussion|| |
Traditionally, the management of child rape victims has focused on the forensic, psychosocial and transmissible disease aspects of the attack, but the child with a severe and sometimes life-threatening injury needs to be detected and promptly treated.
Our aim is to manage acute sexual assault victims as any other pediatric trauma cases with added emphasis on management of their psychological aspect. Early optimal treatment of physical injuries of these children was our motto; along with the restoration of genital anatomy and preservation of fecal continence. All children were operated within 4-6 h of presentation to our unit.
We have used the below described perineal tear classification  to grade injuries of children in the present series:
- First degree tear: Laceration is limited to the fourchette and superficial perineal skin or vaginal mucosa. Perineal body intact.
- Second degree tear: Laceration extends beyond fourchette, perineal skin, and vaginal mucosa to perineal muscles and fascia; but not the anal sphincter. Perineal body involved.
- Third degree tear: Fourchette, perineal skin, vaginal mucosa, muscles, and anal sphincter are torn.
- Partial tear of the external anal sphincter involving less than 50% thickness
- >50% of external anal sphincter thickness torn
- Internal anal sphincter torn
- Fourth degree tear: Fourchette, perineal skin, vaginal mucosa, muscles, anal sphincter, and anorectal mucosa are torn.
This classification does not take into account associated injuries like very high vaginal (eg., vaginal vault) tears, high rectal lacerations, or breach of the pelvic peritoneum. For obvious reasons, there are limitations to application of this classification in male patients. However, since no other classification system exists at present, to classify injuries resulting from sexual trauma in children, we have extrapolated above classification and utilized the same to guide initial line of management in our patients. In male patients, injury to anal mucosa was taken as grade 1 injury. Involvement of perineal body was taken as grade 2 injury. Major avulsion of the rectum (damage to anorectal mucosa) with sphincteric damage was taken as grade 4 injury (case 4).
The patterns of injuries noted by us were as follows. All girls with third and fourth degree injuries had two lateral vaginal tears each, one between 4 to 5 O'clock position and another between 7 to 8 O'clock positions [Figure 1]a. They also had long anterior wall anorectal tears and varying degrees of damage of anterior portion of the external as well as internal anal sphincter [Figure 3]. Dubowitz and Lane  have described complete transection of posterior hymen to the base, that is, hymenal tears between 4 to 8 O'clock position to be diagnostic of sexual trauma on girls. Similarly, fourchette and posterior commissure injuries are described in nubile virgins if violence used is great. 
|Figure 1: (a) Extensive vaginal lacerations at 5 and 8 O'clock position in female victim. Also note damage to the perineal body and anterior part of anorectum (b) Active vaginal bleeding in the female victim with brutally torn vagina|
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|Figure 2: Rectum hanging outside the anal canal in male victim of sodomy|
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Vaginal tear in one girl (case 5) was quite extensive and was extending intraperitoneally into the vaginal vault (colporrhexis) causing life-threatening active bleeding [Figure 1]b and massive hematoma in the right iliac fossa. Short length of vagina in a 4-year-old girl and forceful penetration by rigid erect penis might have caused such extensive tear of the vaginal vault. Narayan Reddy has described mechanism of vaginal injury in detail. He has noted lacerations or rupture of vagina more commonly in the right fornix or extending across the posterior fornix, sometimes causing tear in the vault. He has therefore stressed upon bimanual examination under anesthesia.  In our case too, the tear in the right fornix of vagina, extending into the vault was detected on bimanual examination under anesthesia.
One boy (case 4) had near complete circumferential tear of the rectosigmoid, about 5-6" above the dentate line. The rectum was hanging outside the anal opening [Figure 2], held above by its intact wall between 2 to 6 O'clock positions only. He had damage to the external and internal anal sphincter.
In the study of 11 sexually assaulted girls described by Jones et al, the injuries of 9 children (82%) involved the hymen, vagina, anus, or rectum. Injuries due to sexual assault in this study group had an average injury severity score of 2.1 , whereas the average injury severity score in our study is ~17 [Table 1].
Various authors have described delayed presentation of victims of sexual assault, whereas in our study, two children presented within 8-10 h of the insult (acute sexual assault). One child presented after 48 h. In the remaining two cases, the delay, mainly because of prior surgical intervention led to significant morbidity in terms of added surgery and significantly prolonged hospital stay in these unfortunate children.
Fecal leak from vagina (rectovaginal fistula) was noted in one child (case 3) on postoperative day 3 as against a rather late presentation at 2 weeks as described by Ekenze et al.  The above authors had to perform posterior sagittal anorectoplasty (PSARP) for repair of the fistula; whereas in our case, it healed spontaneously after complete fecal diversion and thorough on-table irrigation of the distal rectal stump.
Healing was very good in majority of children, despite heavy contamination, probably because of really thorough local cleaning using antiseptic solution and cover of intravenous broad spectrum antibiotics. The wound healing after delayed repair of the perineum in one girl was suboptimal.
Small tears of the hymen, vagina, or the anorectal mucosa are universally managed conservatively.  However, controversy exists about management of rectal trauma. Though some rectal injuries may be repaired primarily, the risk of a bad result producing fecal incontinence hardly seems justified. Hence, diverting colostomy is often performed for management of penetrating rectal injuries. , Extensive perianal lacerations are repaired at the same time to reapproximate the sphincter muscle mechanism as much as possible. Otherwise, there is eminent danger of the sphincter muscle fibers getting retracted or being devascularized with healing by fibrosis and suboptimal results of delayed repairs. Oztürk et al.,  have described relative risk > 2 of developing a postoperative septic complication for patients with injury severity score ISS > 15. No major septic complications (other than fever) occurred in our study though the average ISS of our study population was 17; probably because of thorough on-table distal loop washouts and regime of postoperative wound irrigations under sedation using antiseptic solution. Ashcraft  has described two incidents of rectal trauma resulting from sexual assault, causing laceration of the pelvic peritoneum and resultant peritonitis leading to death of one patient. Similarly, Ameh has described death of a girl child from missed intraperitoneal rectal injury.  No deaths occurred in our study, although all five of our patients had major life-threatening injuries with eminent danger of peritonitis [Table 1]. No similar study was found on thorough literature search, describing surgical repair of vaginal, rectal, and sphincteric injuries in pediatric sexual trauma victims for comparison of our results. Present study is probably the largest series of surgical reconstruction in this subset of population.
The psychological problems described in childhood sexual assault victims are anxiety, depression, low self-esteem, posttraumatic stress disorder (PTSD), and suicidal tendencies among adolescents.  Similarly nonspecific behavioral changes like social withdrawal, acting out, increased clinginess, distractibility, learning difficulties, regression in developmental milestones, and new onset bedwetting/encopresis may also be noted in adolescent victims of sexual assault.  Various authors have described interview of the child by an expert and combination of human figure drawing, use of anatomical dolls, , etc. as part of psychological assessment and counseling of a child with suspected sexual abuse. Each of the above methods has different specificity in picking up abuse. We have used child interview, behavioral assessment, sentence completion test, and human figure drawing in our children. Anxiety, depression, and fearfulness were noted in two of our patients; but they all responded well to repeated counseling sessions by a child psychologist. Our patients are on regular follow-up to assess long term psychological effects of sexual trauma in childhood.
In all our children, staged surgical approach gave excellent results. Based on this experience, we conclude that injuries in acute pediatric sexual assault victims should be assessed at the earliest and severe injuries primarily repaired by an expert. Primary repair offers best results in terms of functional as well as cosmetic outcome for these children. A temporary diverting colostomy protects the repair and should always be constructed without hesitation. Early judicial proceedings of such cases, execution of maximum and early punishment to the criminal, community education about sexual assault prevention, and measures of child safety would probably go a long way to reduce such ghastly incidents in future. As part of our social responsibility towards primary prevention of child sexual abuse, we have launched an ongoing educational activity for parents of school-going children in our city, the leaflet of which is attached [Annexure 1].
| Acknowledgement|| |
We acknowledge colleagues from Departments of Surgery and Gynecology (OBGY) for entrusting the management of pediatric sexual trauma victims onto us. Colleagues from Departments of Anesthesia and Pediatrics gave invaluable help peri- and postoperatively. We are indebted to all our residents without whose help it would have been impossible to manage these unfortunate children.
| References|| |
|1.||Kellogg N. American Academy of Pediatrics Committee on Child Abuse and Neglect. The evaluation of sexual abuse in children. Pediatrics 2005;116:506-12. |
|2.||Narayan Reddy KS. Sexual offences. In: Narayan Reddy KS, editor. The Essentials of Forensic Medicine and Toxicology. 2004. p. 331-49. |
|3.||Dutta DC. Injuries to the birth canal. In: Konar H, editor. Textbook of Obstetrics. Calcutta, Central; 2004. p. 423-4. |
|4.||Oztürk H, Onen A, Dokucu AI, Otçu S, Yaðmur Y, Yucesan S. Management of anorectal injuries in children: An eighteen-year experience. Eur J Pediatr Surg 2003;13:249-55. |
|5.||Levine JH, Longo WE, Pruitt C, Mazuski JE, Shapiro MJ, Durham RM. Management of selected rectal injuries by primary repair. Am J Surg 1996;172:575-8. |
|6.||Okada A, Kamata S, Imura K, Fukuzawa M, Kubota A, Yagi M, et al. Anterior sagittal anorectoplasty for rectovestibular and anovestibular fistula. J Pediatr Surg 1992;27:85-8. |
|7.||Wakhlu A, Pandey A, Prasad A, Kureel SN, Tandon RK, Wakhlu AK. Anterior sagittal anorectoplasty for anorectal malformations and perineal trauma in the female child. J Pediatr Surg 1996;31:1236-40. |
|8.||Kudsk KA, Hanna MK. Management of complex perineal injuries. World J Surg 2003;27:895-900. |
|9.||Bhatnagar V. Assessment of postoperative results in anorectal malformations. J Indian Assoc Pediatr Surg 2005;10:80-5. |
|10.||Dubowitz HD, Lane WG. Abused and Neglected children. In: Kliegman, Stanton, Geme ST, Schor, Behrman, editors. Nelson Textbook of Pediatrics. Philadelphia: Saunders; 2011. p. 142-6. |
|11.||Dikshit PC. Sexual offences. In: Dikshit PC, editor. Textbook of Forensic Medicine and Toxicology. New Delhi: Peepee; 2007. p. 378-40. |
|12.||Jones JG, Worthington T. Genital and anal injuries requiring surgical repair in females less than 21 years of age. J Pediatr Adolesc Gynecol 2008;21:207-11. |
|13.||Baker SP, O'Neill B, Haddon W Jr, Long WB. The injury severity score: A method for describing patients with multiple injuries and evaluating emergency care. J Trauma 1974;14:187-96. |
|14.||Ekenze SO, Nwagha UI, Ezomike UO, Obasi AA, Okafor DC, Nwankwo EP. Management of sexual assault-related large rectovaginal fistula in an eight-year-old. J Pediatr Adolesc Gynecol 2011;24:e39-41. |
|15.||Heppenstall-Heger A, McConnell G, Ticson L, Guerra L, Lister J, Zaragoza T. Healing patterns in anogenital injuries: A longitudinal study of injuries associated with sexual abuse, accidental injuries, or genital surgery in the preadolescent child. Pediatrics 2003;112:829-37. |
|16.||Ashcraft KW. Acquired anorectal disorders. In: Ashcraft KW, Murphy JP, Sharp RJ, Sigalet DL, Snyder CL, editors. Pediatric Surgery. Philadelphia: WB Saunders; 2000. p. 511-7. |
|17.||Ameh EA. Anorectal injuries in children. Pediatr Surg Int 2000;16:388-91. |
|18.||Glaser Danya. Child sexual abuse. In: Rutter M., Taylor E, editors. Child and Adolescent Psychiatry. Berlin: Blackwell Science; 2002. p. 346. |
|19.||Barron CE, Felice ME. Adolescent rape. In: Kliegman, Stanton, Geme St, Schor, Behrman, editors. Nelson Textbook of Pediatrics. Philadelphia: Saunders; 2011. p. 702-5. |
|20.||Leventhal JM, Hamilton J, Rekedal S, Tebano-Micci A, Eyster C. Anatomically correct dolls used in interviews of young children suspected of having been sexually abused. Pediatrics 1989;84:900-6. |
[Figure 1], [Figure 2], [Figure 3]