Dear Lisa,
Can a female abuse victim receive blisters inside her vagina from possibly fondling?
“Hope"
Dear “Hope”,
In most cases it is difficult to tell if a victim was sexually abused based solely on the findings of a physical examination. There are a few reasons for this. Generally a perpetrator who abuses a child does not intend to harm the child physically because of the desire to reengage the child in activities over time. (1) In addition, injuries to the genital area resulting from sexual assault heal very quickly. (2) To complicate matters even more, children tend to not report the abuse immediately because many times they are threatened by the perpetrator or embarrassed and ashamed by the abuse. (1) As a result, abnormalities are typically not found when the child is examined. Research studies have shown that when sexually abused children victims were examined, many of them had normal physical findings. (3)
On the other hand, suspicious physical findings on the examination of a child’s genital area many times turns out to be normal findings for the child’s age. (1) The appearance of the vaginal in the child changes according to their age. In infants the hymen may appear thicker and redundant. These changes are due to maternal hormones which affect the appearance of the vagina for the first few months of life. (4) These findings reappear when a child approaches puberty. In prepubertal girls, the hymen tends to appear more vascular and reddened. (5) In addition, the appearance of the hymen is very variable from one person to the next. All of these normal changes may appear to be abnormal. Because of the many potential variations in appearance, it is necessary for a child who is suspected to have been sexually abused to see a doctor who specializes in this area of medicine. (1)
The victim’s report of the story about what happened is many times the only evidence that can be examined and the most important part of the investigation. It is important to remember that when children report abuse they describe their experience from the developmental perspective of a child who does not have a complete understanding of what is going on. Because of this, they may not report the event as accurately as adults would like them to. (1) Children commonly report that someone “put something inside of them”. This may be interpreted as vaginal penetration to an adult, but to a child this may include contact which is limited to placing “something” in the vaginal area without true penetration. (1) Any type of genital contact is inappropriate, regardless of the degree of penetration, but from a legal standpoint these details become very important.
Children can contract Sexually Transmitted Infections as a result of inappropriate sexual contact. (1) The spread of sexually transmitted diseases occurs when a child comes into contact with infected genital secretions or sexual organs. (1) Therefore the presence of a sexually transmitted infection tells you that the child came into contact with the germ, but it does not tell you exactly what type of contact occurred. For example a child can catch a Sexually Transmitted Disease when they are fondled by a perpetrator whose hands have infected secretions on them. The only scenario where a sexually transmitted infection in a child may not be caused by sexual abuse is in the case of an infant. An infant can catch a Sexually Transmitted Infection from its mother during birth. (6) Sexually transmitted infections can present themselves as lesions, sores, wart like growths, or with pain with urination. In most cases Sexually Transmitted infections are asymptomatic which means that the person does not develop any symptoms at all. (7)
So to answer you question specifically, in most cases no physical evidence of sexual assault is found and a lot of weight falls upon the child’s story and witness accounts. If physical evidence of abuse is found, a child should be examined and the results documented by a doctor who specializes in the area. Since suspicious findings on physical examination of the genital area many times end up being normal, it would be important to have your child examined by a health care professional with experience in that area. What may appear to be blisters to you, may be a normal finding. If the lesions truly are blisters, then screening for Sexually Transmitted Diseases (STD) should be performed. If a child is determined to have an STD this tells you that the child was in contact with the germ, but this does not tell you exactly which type of contact occurred, whether it be fondling or penetration.
All sexual contact with a child, regardless of which type, is considered sexual abuse. Even if there was no physical contact, children exposed to sexual activities via photographs or inappropriate exposure potentially can develops significant psychological problems. (1) These types of activities should be taken very seriously because they may be the perpetrator’s way of preparing a child for future sexual abuse. (1)
The American Academy of Pediatrics recommends the collection of forensic evidence within 72 hours of the sexual abuse. (1) Therefore, if you think your child has been abused, it would be important to contact your Pediatrician for an evaluation and referral to a doctor who specializes in this area. Child Protective Services should be contacted if sexual abuse is suspected. The Child Protective Services case workers are trained to deal with this very sensitive subject and can provide a family with the necessary social support services that are needed.
References:
(1)Giardino A. Finkel M. Evaluating Child Sexual Abuse. Pediatric Annals. 2005. 34(5):382-393.
(2)McCann J, Voris j. Simon M. Genital injuries resulting from sexual abuse; a longitudinal study. Pediatrics. 1992;89(2):307-317.
(3)Muram D. Medical evaluation of Child victims of sexual abuse. Curr Opin Obstet Gynecol. 1989;1(2):250-258.
(4)Berenson A, heger A, Andrews S. Appearance of the hymen in newborn. Pediatric. 1991;87(4):458-465.
(5)Huffman JW. The Gynecology of Childhood and Adolescence. Philadelphia, PA:WB Saunder; 1969.
(6)Davidson M. Sexually Transmitted Infections. Screening and Counseling. Clinician Reviews. 2006;14(6):56-60.
(7)Fortenberry J. Sexually Transmitted Infections. Pediatric Annals. 2005. 34(10):803-810.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice About Keeping Kids Safe.
Tuesday, October 03, 2006
Monday, October 02, 2006
Chronic Headache
Dear Lisa,
I need your professional opinion. I have a little daughter (13 years old), with a lot of medical problems. She has Hydrocephalus(fourth entrapped ventricle-slit ventricle syndrome), Cerebral Palsy, spastic diplegia, etc. We went to our Neurosurgeon for e check up since she was having a lot of headaches(3 years until now). He said her physical exam was normal and the shunts are ok.(pumping them/without a CT scan). She is double shunted,(programmable valve shunts).His opinion was that headaches caused by her situation of the slit ventricle syndrome and advised to take by her a little dose of acetazolamide(Diamox). If it’s not work he will change the program of the shunts (both shunts). As he said and I have read, when the patient with slit ventricle syndrome lying down he feels better. That doesn’t work in my daughter’s headaches(even she is sleeping with her hand in the front place of her head). When she have a sneeze, or a suddenly movement she touch the front place of her head. Is it really the problem now, the slit ventricle syndrome, or is there a new problem with the fourth entrapped ventricle? Is any relationship between her situation and her oral hydration?(her hydration is about 1350-1500 ml daily winter or summer/her weight is 22kg). Is it possible her headaches caused by the other medical problems?(cerebral palsy-they are not seizures-,osteoarthritis, bad vision, bad and longtime position on the wheelchair).
Thank you for your time.
“Worried about My Daughter’s Headache”,
Dear “Worried About My Daughter’s Headache”,
I hate to hear about anyone who is suffering and in pain, especially when it is a child. It sounds like you have invested a lot of time and energy taking care of her and it must be very frustrating knowing that she’s in pain and not having a answer. Unfortunately children with Hydrocephalus and Slit Ventricle Syndrome tend to experience headaches. As with most chronic medical conditions, children experience symptoms differently. Children with Slit Ventricle Syndrome can present with variations in the type of headaches. Yes there are some that find relief with change of positioning, but others may experience a more cyclical pattern.(1) In general the common symptoms found in Slit Ventricle Syndrome include headache, vomiting and drowsiness.
Just to make things more confusing, these same symptoms occur when there is a shunt malfunction. Shunt malfunction may occur because of chronic or acute inflammation, accumulation of cellular debris or blood, or blockage of one of the ends of the shunt.(2) A child’s growth may also affect the functioning of the shunt. Unfortunately the need for shunt revision occurs at some point in almost all children treated for Hydrocephalus from infancy (2) Therefore, whenever a child experiences symptoms it is important to make sure the shunt is functioning properly.
Many times the functioning of a shunt is checked by measuring the pressure in the skull through Intracranial Pressure ICP monitoring. (1) As you already know the functioning of a shunt is also checked through imaging studies such as a Scan of the head. You mentioned that your Neurosurgeon checked the shunts by pumping them, said they were okay and reported that your daughter's physical examination was normal. These are all good signs. It would be important to follow up with your Doctor if your daughter’s symptoms persist or worsen, in case he may want to order further studies such as a Cat Scan or MRI.
Your daughter’s complaints of pain at night and with movement or activity are typically considered warning signs for a problem that originates in the brain. Headache that awaken a child or present when the child first awakes in the morning are classic symptoms of increased intracranial pressure. (3) In particular pain in the occipital area (back of head) and the inability of the patient to describe the quality of the head pain are associated with problems inside the skull such as a shunt malfunction.(3)
Your daughter's Neurosurgeon knows her medical history, findings from her physical examination and results of tests done so far. He is in the best position to advise you regarding the most beneficial course of treatment. It seems that your child’s Neurosurgeon has pin pointed Ventricular Slit Syndrome as the cause of your child’s headaches. Accepting a chronic condition as the reason for a longstanding painful symptom in your child is very difficult and normally results in a lot of questioning and doubt. It is also very common to want to rule out other causes of a headache since headaches can be caused by many factors. This is a very thorough and reasonable approach, especially when it comes to the health of your child.
Whenever a parent has a chronically ill child, so much time is spent at specialist’s office that sometimes the value of the primary care physician or Pediatrician is overlooked. It is through your daughter’s Pediatrician that other causes for a headache can be investigated. This is not only a very essential part of her overall care, but it will reassure you all areas were investigated. Headaches in children have many causes and an evaluation by your daughter’s Pediatrician can guide you in the right direction.
Cervical spine abnormalities can present with musculoskeletal headaches and also with headaches compatible with migraines.(4) You mentioned that your daughter has Cerebral Palsy, Osteoarthritis and is wheelchair bound. All three of these conditions may cause or contribute to an abnormality in her cervical spine which could lead to chronic headaches. This may be an area that you want to investigate.
Chronic Sinusitis is another condition that is commonly associated with headaches. (4) Your pediatrician will be able to ascertain if your daughter’s symptoms are caused s by chronic Sinusitis. Sometimes a child can have a chronic headache and Sinusitis at the same time. If this occurs, the Sinus infection can make the chronic headaches worse and more difficult to control. Once a Sinus infection is treated, the chronic headaches are much easier to treat. (4)
Another consideration is Temporomandibular Joint problems or TMJ which can also present with a chronic daily headache. TMJ is often associated with clicking or popping and problems moving the jaw. Other dental conditions such as malocclusion or an uneven bite, chronic gum infections and abscesses can lead to chronic headaches.(4) An evaluation by a dentist can identify and address these issues if necessary.
You mentioned that your daughter has bad vision. Bad vision is usually not the cause of the type of chronic headaches that you are describing. But your daughter’s health condition can affect her vision. Eye problems are often found when a child is initially diagnosed with Hydrocephalus, as well as in children with functioning shunts and controlled Hydrocephalus. (2) The increased intracranial pressure that children develop with Hydrocephalus can causes changes in their eye examination. Because of this yearly visits with a Pediatric Ophthalmologist are typically recommended.(2)
Your child’s evaluation at the Pediatrician’s Office can rule out any other possible causes headaches that may apply to your daughter. Many times a head ache evaluation includes blood work and a headache diary. The Headache diary is a record that is taken over the span of 1 to 2 weeks and includes information such as the intensity of pain on a scale of 1 to 10, the location of the pain, other associated symptoms such as vomiting or visual disturbances, the time of day that the pain occurs, the duration of the pain, any association between the pain and activities, its relation to food and the time of the month. I’m not sure if your daughter is able to eat food or if the fluids she is taking is a nutritional supplement. It would be important to report any changes in her dietary intake and use of medications and herbal supplements. In some cases certain foods or herbal remedies cause headaches.(5)
I wish you and your daughter a speedy resolution to this problem. If she continues to have pain you should bring her back to the Neurosurgeon’s office in order to discuss other treatment options. In some cases an adjustment in the medication or the addition of a new type of medication is all that is needed.
For more information about Split Ventricle Syndrome; log on to:
The International Federation for Spina Bifida and Hydrocephalus.
References:
(1)The International Federation for Spina Bifida and Hydrocephalus. Split Ventricle Syndrome. Available at: http://www.ifglobal.org/hydrocephalus.asp?lang=1&main=7&sub=1#Slit_Ventricle_Syndrome. Accessed September 2006.
(2)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:304-305.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006;35(5)345-354.
(4)Linder S .Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005;34(6):442-446.
(5)Lewis D, Yonker M, Winner P, Sowell M. The Treatment of Pediatric Migraine. 2005;34(6):449-460.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice About Sick Kids
I need your professional opinion. I have a little daughter (13 years old), with a lot of medical problems. She has Hydrocephalus(fourth entrapped ventricle-slit ventricle syndrome), Cerebral Palsy, spastic diplegia, etc. We went to our Neurosurgeon for e check up since she was having a lot of headaches(3 years until now). He said her physical exam was normal and the shunts are ok.(pumping them/without a CT scan). She is double shunted,(programmable valve shunts).His opinion was that headaches caused by her situation of the slit ventricle syndrome and advised to take by her a little dose of acetazolamide(Diamox). If it’s not work he will change the program of the shunts (both shunts). As he said and I have read, when the patient with slit ventricle syndrome lying down he feels better. That doesn’t work in my daughter’s headaches(even she is sleeping with her hand in the front place of her head). When she have a sneeze, or a suddenly movement she touch the front place of her head. Is it really the problem now, the slit ventricle syndrome, or is there a new problem with the fourth entrapped ventricle? Is any relationship between her situation and her oral hydration?(her hydration is about 1350-1500 ml daily winter or summer/her weight is 22kg). Is it possible her headaches caused by the other medical problems?(cerebral palsy-they are not seizures-,osteoarthritis, bad vision, bad and longtime position on the wheelchair).
Thank you for your time.
“Worried about My Daughter’s Headache”,
Dear “Worried About My Daughter’s Headache”,
I hate to hear about anyone who is suffering and in pain, especially when it is a child. It sounds like you have invested a lot of time and energy taking care of her and it must be very frustrating knowing that she’s in pain and not having a answer. Unfortunately children with Hydrocephalus and Slit Ventricle Syndrome tend to experience headaches. As with most chronic medical conditions, children experience symptoms differently. Children with Slit Ventricle Syndrome can present with variations in the type of headaches. Yes there are some that find relief with change of positioning, but others may experience a more cyclical pattern.(1) In general the common symptoms found in Slit Ventricle Syndrome include headache, vomiting and drowsiness.
Just to make things more confusing, these same symptoms occur when there is a shunt malfunction. Shunt malfunction may occur because of chronic or acute inflammation, accumulation of cellular debris or blood, or blockage of one of the ends of the shunt.(2) A child’s growth may also affect the functioning of the shunt. Unfortunately the need for shunt revision occurs at some point in almost all children treated for Hydrocephalus from infancy (2) Therefore, whenever a child experiences symptoms it is important to make sure the shunt is functioning properly.
Many times the functioning of a shunt is checked by measuring the pressure in the skull through Intracranial Pressure ICP monitoring. (1) As you already know the functioning of a shunt is also checked through imaging studies such as a Scan of the head. You mentioned that your Neurosurgeon checked the shunts by pumping them, said they were okay and reported that your daughter's physical examination was normal. These are all good signs. It would be important to follow up with your Doctor if your daughter’s symptoms persist or worsen, in case he may want to order further studies such as a Cat Scan or MRI.
Your daughter’s complaints of pain at night and with movement or activity are typically considered warning signs for a problem that originates in the brain. Headache that awaken a child or present when the child first awakes in the morning are classic symptoms of increased intracranial pressure. (3) In particular pain in the occipital area (back of head) and the inability of the patient to describe the quality of the head pain are associated with problems inside the skull such as a shunt malfunction.(3)
Your daughter's Neurosurgeon knows her medical history, findings from her physical examination and results of tests done so far. He is in the best position to advise you regarding the most beneficial course of treatment. It seems that your child’s Neurosurgeon has pin pointed Ventricular Slit Syndrome as the cause of your child’s headaches. Accepting a chronic condition as the reason for a longstanding painful symptom in your child is very difficult and normally results in a lot of questioning and doubt. It is also very common to want to rule out other causes of a headache since headaches can be caused by many factors. This is a very thorough and reasonable approach, especially when it comes to the health of your child.
Whenever a parent has a chronically ill child, so much time is spent at specialist’s office that sometimes the value of the primary care physician or Pediatrician is overlooked. It is through your daughter’s Pediatrician that other causes for a headache can be investigated. This is not only a very essential part of her overall care, but it will reassure you all areas were investigated. Headaches in children have many causes and an evaluation by your daughter’s Pediatrician can guide you in the right direction.
Cervical spine abnormalities can present with musculoskeletal headaches and also with headaches compatible with migraines.(4) You mentioned that your daughter has Cerebral Palsy, Osteoarthritis and is wheelchair bound. All three of these conditions may cause or contribute to an abnormality in her cervical spine which could lead to chronic headaches. This may be an area that you want to investigate.
Chronic Sinusitis is another condition that is commonly associated with headaches. (4) Your pediatrician will be able to ascertain if your daughter’s symptoms are caused s by chronic Sinusitis. Sometimes a child can have a chronic headache and Sinusitis at the same time. If this occurs, the Sinus infection can make the chronic headaches worse and more difficult to control. Once a Sinus infection is treated, the chronic headaches are much easier to treat. (4)
Another consideration is Temporomandibular Joint problems or TMJ which can also present with a chronic daily headache. TMJ is often associated with clicking or popping and problems moving the jaw. Other dental conditions such as malocclusion or an uneven bite, chronic gum infections and abscesses can lead to chronic headaches.(4) An evaluation by a dentist can identify and address these issues if necessary.
You mentioned that your daughter has bad vision. Bad vision is usually not the cause of the type of chronic headaches that you are describing. But your daughter’s health condition can affect her vision. Eye problems are often found when a child is initially diagnosed with Hydrocephalus, as well as in children with functioning shunts and controlled Hydrocephalus. (2) The increased intracranial pressure that children develop with Hydrocephalus can causes changes in their eye examination. Because of this yearly visits with a Pediatric Ophthalmologist are typically recommended.(2)
Your child’s evaluation at the Pediatrician’s Office can rule out any other possible causes headaches that may apply to your daughter. Many times a head ache evaluation includes blood work and a headache diary. The Headache diary is a record that is taken over the span of 1 to 2 weeks and includes information such as the intensity of pain on a scale of 1 to 10, the location of the pain, other associated symptoms such as vomiting or visual disturbances, the time of day that the pain occurs, the duration of the pain, any association between the pain and activities, its relation to food and the time of the month. I’m not sure if your daughter is able to eat food or if the fluids she is taking is a nutritional supplement. It would be important to report any changes in her dietary intake and use of medications and herbal supplements. In some cases certain foods or herbal remedies cause headaches.(5)
I wish you and your daughter a speedy resolution to this problem. If she continues to have pain you should bring her back to the Neurosurgeon’s office in order to discuss other treatment options. In some cases an adjustment in the medication or the addition of a new type of medication is all that is needed.
For more information about Split Ventricle Syndrome; log on to:
The International Federation for Spina Bifida and Hydrocephalus.
References:
(1)The International Federation for Spina Bifida and Hydrocephalus. Split Ventricle Syndrome. Available at: http://www.ifglobal.org/hydrocephalus.asp?lang=1&main=7&sub=1#Slit_Ventricle_Syndrome. Accessed September 2006.
(2)Jackson P, Vessey J. Primary Care of the Child with a Chronic Condition. St. Louis Missouri: Mosby –Yearbook, Inc. 1992:304-305.
(3)Rubin D, Suecoff S, Knupp K. Headaches in Children. Pediatric Annals. 2006;35(5)345-354.
(4)Linder S .Understanding the Comprehensive Pediatric Headache Examination. Pediatric Annals. 2005;34(6):442-446.
(5)Lewis D, Yonker M, Winner P, Sowell M. The Treatment of Pediatric Migraine. 2005;34(6):449-460.
Lisa-ann Kelly R.N., P.N.P.,C.
Certified Pediatric Nurse Practitioner
Pediatric Advice About Sick Kids
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