Title: Hymenal granulation tissue in a pre-pubertal girl – A case study
Malik S, Wood PL. Kettering General Hospital
Granulation tissue is a recognised sign of chronic inflammation and an unexpected genital tract finding in pre-pubertal girls with no signs of infection or inflammation. We present a case which led us to undertake child sexual abuse investigations with indeterminate verdict.
An 8 year old was referred to our Paediatric Gynaecology clinic with history of recurrent episodes of vaginal discharge. The history of discharge went back 5 years when she presented with similar symptoms to her local hospital. She was seen at the time and swabs were performed which grew Group B Streptococci (GBS). Further investigations included a mid-stream urine which was negative. A diagnosis of juvenile vulvovaginitis with secondary infection was made at the time and she was given a course of antibiotics, which did clear up the discharge. She now presented with a vaginal discharge which varied from a white to a green colour and had a fishy smell to it. Her mother also gave a history of her getting feverish and irritable a day before the discharge recurred.
She was born normally and had 3 brothers aged 18, 17 and 6 years. Her mother, being a social worker, also had fostered other boys who stayed with the family for approximately one year.
On examination, the girl appeared relaxed. Her weight was 31 kg (31st centile) and height 133.5 cm (just below 75th centile). On perineal examination, there was a deep dimple in the natal cleft (at the expected site for a pilonidal sinus). The area was dry but the surrounding skin was slightly reddened and excoriated but not infected. Her introitus was found to be gaping. In view of the above findings an examination under anaesthesia (EUA) and vaginoscopy was arranged. The mother and daughter both signed a consent form. The mother was given information on the nature of swabs to be taken at EUA including chlamydia and gonorrhoea.
A full genital infection screen was done under general anaesthesia with swabs taken from the urethra and vagina. The samples were entered into the chain of evidence book. Some vulval crusting was seen and the introitus was gaping with rolled hymenal edges. Tiny areas of granulation were seen at the 5 and 7 o’clock positions. The vulva and vagina were not inflamed. Microbiopsies were taken from the hymenal tissue. On vaginoscopy, the posterior vaginal wall was found to be thickened. The family was informed of the findings and the safeguarding children team was alerted. The swabs were negative for chlamydia but positive for GBS and anaerobes. The biopsy confirmed active chronic inflammation with granulation tissue. Hemosiderin deposits were also seen. A second opinion was sought from an expert pathologist in forensic pathology who confirmed that the histological pattern was consistent with acute on chronic inflammation and oedema with recent haemorrhage. These findings were not diagnostic of any specific vulvovaginal infection but could be associated with a streptococcal vulvovaginits.
She was interviewed by the child protection and safeguarding team but did not disclose anything suspicious. A few days later the mother sent an e-mail to the child protection team explaining how the child had described “fiddling with her bits” during the summer holidays when she stated that she had inserted her fingers on a number of occasions. The parents felt that she was still a happy and confident child. By the time she was reviewed in the clinic her discharge had settled. There was no itching, smell or bleeding seen. The parents were confident that usual hygiene measures were being followed. A report was prepared for the police. .A thorough investigation was undertaken to attempt to rule out any sexual abuse. A case conference was held where all the evidence was discussed and the case was closed with an indeterminate verdict.
To our knowledge this is the first reported case of confirmed hymenal granulation tissue in a pre-pubertal girl. Granulation tissue is a recognised sign of chronic inflammation but currently there is not much in the literature to suggest its significance the genital tract of young girls. Once histological examination confirmed granulation tissue, a second opinion was sought from a forensic pathologist. Their opinion was that this might be secondary to a streptococcal infection, but that sexual abuse could not be ruled out. The fact that there was no evidence of vulvovaginits on EUA was also of significance. Furthermore despite delicate questioning the girl did not disclose any reference to sexual abuse.
This case highlights the dilemma faced in such cases by the paediatric gynaecology team. It highlights any physical findings have to be corroborated by the history and the child’s disclosure in diagnosing sexual abuse1.
This case also highlights the need for good communication with all interested parties. Communication difficulties that can arise in informing parents and getting their consent for further investigations are further highlighted along with the need for a chain of evidence book. It is difficult for parents to accept that abnormal symptoms and signs might be a potential marker of sexual abuse. However, as a clinician, it is our responsibility to raise issue of sexual abuse with the relevant authorities
A detailed history and the child’s behaviour should form the main basis for diagnosing sexual abuse rather than physical findings alone. In cases of suspected sexual abuse, it is important to take photographic evidence and biopsy of the suspicious area, as well as alerting the child protection team.
- Normal studies are essential for objective medical evaluations of children who may have been sexually abused Adams J.A. Acta Paediatrica, International Journal of Paediatrics, 2003, 92:1378.