CLINICAL PRACTICE ARFER CLlNIGOL
Consultant Paediatrician, Royal Glamorgan Hospital
A 2 year old boy who was referred to the paediatric clinic by his GP with a diagnosis of atypical nappy rash was found to have florid warts in the anal area. Most certainly sexual abuse needed to be considered and ruled out, but what were the other diagnostic possibilities and more importantly what was the best way to approach such a sensitive case?
There appears to be little agreement in the advice given by my colleagues but even greater was the disparity between the view taken by experts in dermatology and genitor-urinary medicine. A literature search was carried out using the key words -anogenital warts, sexual abuse and children. The child was managed using an evidence based approach. However the wide incongruity in the approach suggested by various professionals prompted the conception of this study.
Anogenital warts (AGW) are common in adults (1) and are invariably sexually transmitted. It is not surprising that their presence in a prepubertal child is often thought to indicate sexual abuse. However the relationship between presence of genital warts and diagnosis of sexual abuse is not straightforward. The link between AGW and child sexual abuse requires an understanding of wart transmission and the incubation period to properly interpret their significance. Indeed the presence of AGW alone without supporting clinical, laboratory and social information is not diagnostic of sexual abuse (1). A questionnaire survey was carried out to gauge paediatrian's insight and approach to this condition.
A multiple response (Likert 5 point scale) questionnaire was designed using the actual case of anogenital warts as a template. In order to get impromptu responses from paediatricians with different levels of training and experience it was decided that the questionnaire should be presented to delegates of a paediatric scientific meeting (the Welsh Paediatric Society autumn meeting of 2006 held in Newport). Questionnaires were handed out early in the meeting and collected at close. The data was fed into a Microsoft excel spreadsheet and analysed.
A total of 44 completed questionnaires were received. The paediatric experience of the respondents varied widely (Range 0.5 to 30 years, median 9 years and mean 10.6 years). More than half (52%) had never dealt with a case of anogenital warts.
A quarter (11/44) of the respondents believed that AGW in a child are definite sign of sexual abuse while another eight were ambivalent. A third (15/44) appeared to lack knowledge about peri-natal transmission, which is well-recognised as an important mode of transmission in children younger than 5 years. Even larger numbers did not think that AGW could be transmitted through non-sexual contact. In fact only 43 % (19/44) agreed that routine contact with mother who had common warts could be the source for the child's AGW. At least a third (15/44) considered the presence of genital warts in an adult who had access to the child as a strong evidence identifying him as the perpetrator. Only 17/44 correctly recognised that viral DNA typing from the child and suspected perpetrator was not an infallible tool and was unlikely to help in identifying the perpetrator or indeed that sexual abuse had occurred. Surprisingly 40% (18/44) agreed with the view that AGW are common in children and should not raise concerns about sexual abuse. Another 20% did not feel confident enough to challenge this misleading statement.
When asked to suggest helpful features to make a diagnosis in this difficult case a number of interesting remarks were made including - "ask colleagues with more experience", "ask a community paediatrician" and "talk to the lead doctor for child protection".
The diagnosis of sexual abuse is typically made on the basis of the child's history, ideally supported by objective evidence of sexual abuse when available. Such evidence includes abnormal physical findings noted on physical examination or the presence of a sexually transmitted disease (STD) (2). STDs that are considered definite evidence of sexual abuse or sexual contact are postnatally acquired gonorrhea or syphilis. A positive genital culture for chlamydia or herpes, or a positive wet mount for trichomonas, is evidence of probable sexual abuse (3).
Is the presence of AGW in a prepubescent child evidence of sexual abuse? Should the child be reported to social services? AGW can present a diagnostic dilemma to paediatricians.
The link between AGW and child sexual abuse requires an understanding of wart transmission and the incubation period to properly interpret their significance. Given the serious consequences of sexual abuse, it is crucial that paediatricians recognise sexual abuse in their paediatric patients and appropriately report their concerns. If child sexual abuse is not identified, the abuse may continue, resulting in serious consequences. On the other hand, if sexual abuse is diagnosed in error, there are serious consequences for the child, family, and alleged perpetrator (4).
AGW are one of the most common sexually transmitted diseases of the ano-genital tract in sexually active adults. Approximately 10% of the adult population have clinically apparent AGW, but molecular diagnostic techniques have demonstrated the presence of HPV in 11% to 80% of asymptomatic, sexually active young women. More than 200 types of HPV exist, 30 of which infect mucosal epithelia. Mucosotropic HPV types 6 and 11 are the most common cause of ano-genital condyloma (warts) in adults, adolescents and children (5).
Appearance of warts
The vulvar, vaginal, urethral, and peri-anal areas in girls can be affected by AGW. Boys typically have lesions in the peri-anal area. The clinical appearance of AGW vary from subtle, skin-colored, flat warts to moist, pink to brown, cauliflower-like lesions found particularly in the skin creases and around the vaginal and anal openings (6).
Mode of Transmission of HPV
In adults, genital HPV infections are primarily sexually transmitted. In children, the mode of transmission of HPV infection is not as straightforward. Sexual transmission is recognised as a possibility in children, but other possible modes of transmission have been documented (7).
Vertical transmission of the HPV virus from infected mother to her infant can occur. Vertical transmission can occur through the bloodstream prior to birth, or at the time of birth, as the infant passes through the infected birth canal (8). Delivery via caesarean section does not eliminate the possibility of vertical transmission of HPV(9). Vertical transmission of the HPV virus does not mean that warts must be present at birth or shortly after birth. HPV is a latent virus and can reside in the skin and mucous membranes without causing warts. The warts may not appear until months or even years after birth.
The absence of visible AGW in the mother during pregnancy does not eliminate the possibility of vertical transmission to the child. HPV can cause subclinical infection, meaning the virus can be present on the cervix or in the vagina without causing warts (8).
AGW also can be transmitted via autoinoculation (1). Children with a common wart on their hands or elsewhere on their body can transmit the virus by touching their warts and then touching their own genitals. HPV can be transmitted nonsexually from direct contact with caretaker contaminated with genital HPV or common warts. HPV transmission via contact with contaminated objects or surfaces is possible (10).
Sexual transmission indicating sexual abuse is of course well-recognised (11). Many forms of sexual abuse can result in transmission of HPV, including genital-genital contact, genital-anal contact, oral-genital contact, fondling, and digital anal/genital penetration.
Incubation Period of HPV
Disagreement exists regarding the incubation period of HPV. Studies have indicated that HPV can remain dormant for up to 5 years without causing lesions if transmitted vertically(12). However, other professionals have concluded that 2 years is the longest period that the HPV virus lays dormant following vertical transmission (8). The long incubation period for HPV is important to understand when treating a child with AGW.
Viral Typing of HPV
Viral typing of the ano-genital wart does not help in determining if the lesions are sexually or vertically transmitted or even in establishing that transmission of virus has occurred between two individuals (1). For example, HPV types 1 and 2 cause hand, foot, and body warts but is also be found in the ano-genital area. If HPV type 1 or 2 is detected from both the child with AGW and a carer the following possibilities exist-
- Transmission of the warts by autoinoculation
- Non-sexual transmission to the child by direct contact with a caretaker with warts
- sexual abuse involving fondling or digital penetration
Therefore, viral typing is not routinely recommended.
Clinical Relevance of AGW
AGW in children have serious clinical implications. The immediate concern is to differentiate between possible sexual abuse and vertical transmission from the mother. To a lesser extent there may be concern regarding the potential for the future development of ano-genital malignancies.
Any child with AGW requires a complete medical examination, including a careful examination of the anus and genitalia for possible signs of sexual abuse. An oral examination for warts also should be conducted. All AGW should be documented and photographed. Testing for other sexually transmitted diseases should be done. This includes testing for syphilis, gonorrhoea and chlamydia. Advice from genito-urinary experts may be taken in this regard.
A maternal and paternal history of common warts, AGW and STDs should be obtained. It should be checked if the mother has had a recent cervical smear as it may show evidence of HPV infection. Routine Pap smears have a low sensitivity for HPV(13). Therefore if maternal transmission appears to be the most likely mode of transmission for the HPV, more sensitive testing for HPV should be recommended to the mother such as HPV DNA.
A complete social history must be obtained, including details of all persons living in the home with the child. Previous involvement with social services including any concerns regarding child abuse/neglect should be inquired about. The child's carers should be asked about any past or present concerns regarding sexual abuse of any family member, especially the child with AGW. A behavioral history of the child, particularly any sexual acting out behaviors, should be obtained.
Social services should be notified of concerns of possible sexual abuse when AGW are diagnosed in any child older than 3 years. For children younger than 3 years, social services should be notified if other risk factors are noted during assessment, such as an abnormal genital examination, the presence of another sexually transmitted disease, or social information that requires further investigation (3).
Treatment of children with AGW also is controversial. Without treatment, the rate for spontaneous remission of HPV may be as high as 67% (8). Some clinicians opt not to treat the warts because of the high rate of spontaneous remission. Treatment failure rates for HPV can be from 25% to 50% (8). Treatment options are based on the location and extent of the lesions and include burning, freezing, laser treatment, surgery, and chemical treatment. The best course of action is to make a referral to a dermatologist for proper treatment and follow-up.
Do AGW indicate sexual abuse? The answer is not straight forward. It requires careful piecing together of clues in each case to be able to see the whole picture. The clinician should attempt to answer this challenging question based on the following
1. Detailed history including age & social factors.
2. Anogenital examination for signs of sexual abuse.
3. Investigations for other sexually transmitted infections.
4 . Physical examination of parents and siblings for warts.
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