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Normal Anal Examination After Penetration: A Case Report
Brett Slingsby1, Amy Goldberg1
1Department of Pediatrics (Clinical), The Warren Alpert Medical School of Brown University, Hasbro Children's Hospital, Providence, Rhode Island.
Insights
Children may not show physical signs after anal penetration and often delay disclosure. Emergency physicians should consider this in evaluations, especially for suspected child abuse.
Area of Science:
- Pediatric Gastroenterology
- Forensic Pediatrics
Background:
- Physical findings are uncommon following anal penetration in children.
- Children frequently delay disclosure or are reluctant to discuss incidents of anal penetration.
Observation:
- A 12-year-old boy presented with abdominal pain, bloody diarrhea, and anorexia over several weeks.
- Colonoscopy revealed a large rectal foreign body (7 cm x 7 cm) present for at least two weeks.
- The patient initially denied awareness of the object's origin, later admitting self-insertion out of curiosity.
Findings:
- Despite known anal penetration and foreign body removal, a follow-up video colposcopy showed a completely normal anal examination.
- This case highlights that a normal anal examination does not exclude anal penetration in children.
Implications:
- Emergency physicians must recognize that children may present with normal physical exams despite anal penetration.
- Delayed disclosure and normal physical findings are critical considerations in evaluating potential child sexual abuse.
- Referral for a child abuse pediatrics evaluation is recommended when child sexual abuse is suspected, even without definitive disclosure or examination findings.
Background:
Physical findings are rare after anal penetration. Furthermore, children delay in disclosing or are reticent to discuss penetration.
Case Report:
A 12-year-old boy presented to medical care multiple times over a several-week period complaining of abdominal pain, bloody diarrhea, and poor appetite. On colonoscopy, he was found to have a cylindrical foreign body (measuring 7 cm tall and 7 cm in diameter) in his rectum, which had been present for at least 2 weeks. He initially denied knowing how the object got into his rectum and later stated that he inserted it himself out of curiosity. One week after the object was removed, follow-up examination using video colposcopy revealed a completely normal anal examination; the patient had a normal anal examination despite known anal penetration and removal of the object. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Children can have a normal anal examination despite anal penetration, and do not always disclose anal penetration. The aforementioned concepts can be applied to situations related to child sexual abuse in the emergency department, where physical examinations are frequently normal and children delay in disclosing the abuse. When there is concern for sexual abuse, even in the absence of a disclosure or examination findings, patients should be referred for a child abuse pediatrics evaluation if available.
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