1. Update on Clinical findings in Anal Examinations
Dr Jo Gifford, September 2017
SARC Paediatric Update, Sterling
With thanks to
Prof Neil Macintosh, Chair of anal signs working group

2. Objectives To be able to correctly identify key anatomical findings :
Acute Anal Signs of Child Sexual Abuse
Non-acute Anal Signs of CSA
To understand the meaning of the absence of findings.
To have an awareness of the evidence base

3. Talk overview Normal anatomy What not to say – 2008 terminology binned
Why have things changed?
Dilatation
Fissures/Laceration
Current terminology & evidence base
What hasn’t changed
Healing of perianal injuries

4. Longitudinal section of ano-rectal area Rectum Pelvic diaphragm
Columns of
Morgagni
Internal anal sphincter
Deep external sphincter sphincter
Dentate line*
Anal canal
Superficial external sphincter
Anal margin/verge
surrounding anus
*also called pectinate line

5. What’s new?

6. What not to say!
Reflex anal dilatation
Fissures

7. The 2008 purple book Dilatation

8. Dilatation – RCPCH definitions 2008
Dilatation – Surprisingly, not defined
Gaping - An anus open/dilated on separation of the buttocks such that a view into the anal canal or rectum is possible. This dilatation remains for the duration of the examination in a fixed or constant way. It is a static sign. Anal gaping is of a greater degree than laxity.
Reflex Anal Dilatation - The dynamic action of the opening of the anus due to relaxation of the external and internal sphincter muscles with minimal buttock retraction

9. Dilatation - UK 2008
Gaping = static phenomenon
RAD = dynamic process

10. American Professional Society on the Abuse of Children - APSAC
Reflex Anal Dilatation - Anal dilatation that occurs upon stroking the buttocks.
“Once considered to be evidence of prior sexual abuse. Relationship to sexual abuse currently unclear.”

11. APSAC
Dilatation – Opening of the anus secondary to relaxation of the external (and possibly the internal) sphincter muscles with minimum traction of the buttocks.
Anal dilatation that occurs within 30 secs (ie a dynamic phenomenon like RAD in UK) and is greater than 20mms A-P diameter with no stool present in the rectal ampulla has been associated with prior anal trauma.

12. Mismatch Reflex Anal Dilatation
UK and USA definitions are clearly different
Significance different
Even accepting this, anal signs are thought by US paediatricians to be much more commonly reported from the UK.
Is anal abuse more common in UK than USA?
Could it be something to do with the examination?
UK - examination in the Left Lateral (LL) position
USA – examination in the Prone Knee Chest (PKC) position – on elbows and knees, head down with bottom in the air.

13. 2015 Purple book APSAC affiliated

14. 2015 RCPCH recommendation
Abandon the term Reflex Anal Dilatation

15. Why not RAD? The only thing in favour: Many things against:
Term used in UK for many years
Many things against:
Not a reflex
It is quite a complex phenomenon
Acknowledged by Hobbs to sometimes be a learnt response
There is a separate genuine anal reflex
Defined by APSAC
This term is a problem in the USA

16. So what, if not RAD
RCPCH Suggest the phenomenon described previously (since even before Cleveland) should now be known as dilatation (in line with APSAC definition) or as dynamic anal dilatation

17. Dilatation in Normal Kids?
McCann et al 1989
267 children aged 2m – 11 years
Prone Knee Chest position for up to 5 minutes
49% dilatation (n=131) of 0.1 – 2.5 cms
30% (n=80) occurred within 30 secs.
Mean time to initial dilatation = 65 secs
mean time to max dilatation = 2m 11secs
Dilatation >20 mms + empty rectum – 1.2% (n=3)
We are not told how many had dilatation >20 mms within 30 seconds

18. Dilatation in Normal Kids?
Berenson et al 1993
89 female infants <18 month old (mean 10.7m)
Supine position with legs extended – (a most unconventional position!)
No child had “anal gaping” – defined as dilatation of > 1 cm

19. Dilatation in Normal Kids?
Myhre et al 2001
305 children aged 5-6 years (276 also examined in Prone Knee Chest)
PKC and LL Examined for no more than 30 secs
Total anal dilatation
Left Lateral M, 2F = 2 (0.7%)
Prone Knee Chest 3M, 10F = 13 (4.7%)

20. Dilatation in Normal Kids?
Sfriso et al 2014
N=230,
117 girls,113 boys; 8d-12.6y [88% <5y]
Inclusion
No suspicion of CSA
A-G examination part of “routine medical”
Exclusion
LATER suspicion of abuse at follow up in those positive for RAD ( Note – there were none with later suspicious histories)
Examined PKC, supine knee chest or LL for no more than 30 secs

21. Sfriso et al 2014 - continued
RAD in 14 (6%)
10 girls, 4 boys [med 3y]
11/14 showed at least 1 predisposing factor (6, constipation; 1, suppositories; 3, constipation and enemas; 1, constipation and encopresis)
3/230 (1.3%) had RAD and no predisposing factors (all <5y)

22. Evidence statements dilatation
Gross anal dilatation or dilatation of both internal and external anal sphincters in the absence of stool is associated with anal abuse.
Dynamic dilatation over 30 seconds in the LL position is found in 10-30% of children who allege anal abuse, 1-18% who allege sexual abuse , and in only % selected for non-abuse without predisposing factors.  
There is no published evidence to ascertain whether the presence or absence of stool in the rectum visible via the dilated anal sphincter affects the significance of the finding.
SO - get the child to pass stool and re-examine.

23. (Anal) Laxity - Another term to abandon
Laxity is about tone. It is something you feel, not see – if you think you see it, it is dilatation, so describe it as such.
Rectal Examinations are NOT DONE in cases where there is concern about abuse.
It is subjective requiring a great deal of experience in rectal examinations on both normal and abnormal children.

24. Terms to qualify dilatation
Dynamic anal dilatation – if the dilatation is not present as the buttocks are separated but occurs over the first 30 seconds of observation.
External or total
Note whether the dilatation is intermittent
Note whether stool is visible or not.
Always record the examination position

25. Terms to qualify dilatation
Immediate or static dilatation – use this term ONLY if dilatation is present AS the buttocks are separated AND when there is no change in the dilatation over a period of 30 seconds– qualify with –
External (only the anal canal seen) or total (if rectum, with the columns of Morgagni above the dentate line, is visible).
If dilation is total, estimate the maximal transverse diameter
Note the presence or absence of visible stool.

26. Terms to be abandoned about dilatation
Gaping – instead use dilatation.
Laxity/decreased tone – this is a measure of tension or tone.
Visibly relaxed anus. Abandon this term - it was only ever used by Clayden (1988).
Funneling. Is this external dilatation or what? Unclear.
Winking / twitching.

27. The 2008 purple book Fissures/lacerations

28. Breaks in the skin Abrasions Scratches Grazes Fissures Tears
Lacerations

29. Forensic definitions - UK
Abrasions – partial thickness skin trauma
Brush abrasions – grazes
Linear abrasions – scratches
Fissure – A full thickness split of the skin.
Laceration - A full thickness injury caused by blunt force trauma.

30. 2015 Purple book

31. RCPCH recommendation 2015
All full thickness skin breaks should be called LACERATIONS
fissures

32. The literature - fissures and lacerations
Although assumed distinct, the terms are often used interchangeably.
Evidence in the new purple book:
six studies discuss “fissures”
four discuss “lacerations”
Two discuss “tears “
One discusses “lacerations, fissures and tears”;
One combines “lacerations” and “tears”
Three separately distinguish “fissures” and “lacerations”.

33. These terms have certain implications in the UK
A fissure is more minor than a laceration
Implication 2 (at least in the UK)
a fissure implies trauma from within (ie constipation) and a laceration trauma from outside (eg straddle injury or abuse).
[Though both must have the same mechanism of trauma distending the anus to breaking point]

34. Other implications in the UK
Constipation causes fissures (never lacerations!)
Abuse causes tears or lacerations
Therefore if a minor skin break/fissure is found, there is a tendency to say it is due to constipation.

35. In anal abuse Call all full thickness lesions - LACERATIONS
50%-90% of cases of penetrative anal abuse NO SIGNS
unlikely that abuse causes either a significant tear or no findings, without grades in between
So do we call small “tears” fissures and if so, when is it too big to be called a fissure?
As it is clear that differentiation is both difficult and individual:
Call all full thickness lesions - LACERATIONS

36. Evidence Statement on Anal Lacerations
Have been found in 15% to 20% of children who have been anally abused, 2% to 15% of those sexually abused (with no further details of the abuse) and 1% to 3 % of children selected for non-abuse
2008:
one study suggests that acute and chronic fissures are a frequent finding in anally abused children. A single anal fissure has been reported in the only study of children selected for non-abuse”
“anal lacerations are associated with acute sexual abuse and have not been seen in children selected for non abuse”

37. Summary of changes to anal chapter
Not Reflex Anal Dilatation (RAD) but DILATATION or Dynamic DILATATION
All full thickness perianal skin breaks to be called LACERATIONS – and then describe them in detail.

38. Examination position – Good Practice (UK only)
Recommended
Left lateral (as previously recommended)
Supine knee chest (new recommendation)
Prone Knee Chest – may be used to confirm a sign seen in one of the above, BUT SHOULD NOT BE the sole examination position used.

39. Anal signs that haven’t changed

40. Evidence Statement on Anal/perianal Erythema
Anal/perianal erythema, is seen in a small proportion of children who allege sexual abuse and in children selected for non-abuse.
It is more likely to be seen if examined early.
No change

41. Evidence Statement on Perianal venous congestion
Evidence suggests that perianal venous congestion occurs in both children who have been sexually abused and children selected for non-abuse
No change
Practice tip:
observe INITIAL appearance as this will help distinguish bruising from congestion
Review in different positions

42. Evidence Statement on Anal/perianal Bruising
Anal/perianal bruising is found in 1% to 2% of children alleging sexual abuse and in 10% in two studies selected for anal penetration. It is more commonly seen when the examination is early after the abuse.
Anal bruising has not been reported in children selected for non-abuse
2008: “in a small proportion of children selected for sexual abuse”

43. Evidence Statement on Anal Scars and tags
Have been found in up to 32% of children who have been anally abused, only 1% to 2% of those sexually abused (type not specified) but have not been found in children selected for non-abuse
Anal tags outside the midline have only been found in abused children.
2008: “good evidence suggest anal scars are associated with abuse”

44. Healing of perianal injuries

45. Accidental anal trauma new section 2015
Where anal injury is reported following blunt force trauma to the anogenital area, this is usually an extension of genital or perineal trauma
Limited evidence suggests that isolated anal injury most commonly results from penetrative sexual abuse

46. Evidence statement Healing of anal injuries
Evidence from four studies shows that most anal injuries heal without sign of previous trauma. Minor injuries heal quickly and completely while more extensive injuries heal to leave scar tissue and/or skin tags
The presence of scars or perianal skin tags suggests significant lacerations or surgical trauma

47. Lacerations scars and tags 1. Heppenstall-Heger
19 prepubertal children with anal injuries
18 with lacerations (4 accompanied by changes in tone).
Injuries were seen at 6 and 12 o’clock.
Only 3/18 perianal lacerations or surgical trauma healed with anatomic changes:
1 skin tag, 2 with scarring/hyper-pigmentation.
The time interval to these changes is not specified. 

48. 2. McCann
Perianal lacerations in 4 pre-pubertal children after anally penetration.
Initial findings
oedematous thick or flat perianal folds.
Local or general perianal venous congestion in 3 children
2 the external anal sphincter was dilated.
Signs of acute trauma gone by 8 days.
Anal dilatation disappeared in 7-11 days.
Lacerations
Superficial lacerations gone by 1 and 5 days.
A deeper 1st degree laceration - 8 days
A superficial laceration complicated by an infection with Herpes - 11 days.
Deeper (2nd degree) lacerations healed in 1 and 5 weeks with scars, as did the 3rd degree (sutured) laceration.
In the 2 children followed for months, the scars had virtually disappeared.
A small skin tag from the avulsed skin remained at 14 months though became less obvious at puberty.

49. 3. Finkel
Finkel followed 2 children with superficial perianal lacerations to healing.
Complete healing was observed at 7 and 13 days.

50. 4. Boos
Multiple radial perianal lacerations were seen in 2 toddlers who had been run over by motor vehicles at low-speed.
A 16 month-old boy showed radially orientated lacerations at 5, 6 and 10 o’clock:
after 3 days there had been ‘significant’ healing.
A 13- month girl showed perianal lacerations at 5, 6 and 12 o’clock.
It is not indicated how long these took to heal.

51. Anal / perianal injuries: dilatation
Two of 4 children seen by McCann following sexual assault showed a dilated external anal sphincter in the first 24 hours.
In one this had resolved by 7 days
in the other it was still present at 11 days but had resolved by 1 month

52. Healing: Summary and conclusion
 Perianal injuries
The data on healing of anal/perianal lesions are sparse and summarised in a total of 4 studies. 
Most acute injuries to the anal/perianal area resolve rapidly with very little scar tissue. So a perianal scar is of great significance
Ragged lacerations and/or surgery may lead to perianal skin tags which remain, though they become less evident with time.

53. Take home messages Left lateral position to confirm
Explore perianal folds
Get child to pass stool if in doubt
RAD  dynamic total anal dilation
Fissures  lacerations
Injuries heal quickly
Scars are good evidence of significant trauma

54. ?