The index case was the case of sexual assault at the age of three months. She sustained perineo-genital injuries which were initially repaired at a secondary health centre. However, the primary repair broke down and there was associated incontinence of faeces. This condition required a diverting colostomy, sphincteric repair and vaginoplasty.

This is a case of perineal and genital injuries in a 3-month old female child who was brought to the paediatric surgical outpatient (PSOP) clinic with complaints of anal and vaginal injuries from a sexual assault at the age of 3 months by a 21-year old tailor apprentice.

The incident was said to have occurred when the patient was kept alone in the house while her mother went outside their living room to spread washed clothes in the compound. She also had injuries around the anus and vagina which was associated with significant blood loss. Following this incident, she was rushed to a General Hospital, where a primary repair was done but this later broke down. As a result of the wound breakdown and the uncontrolled passage of faeces from the anal orifice, she was   referred   to   our  health  facility  (Olabisi  Onabanjo University Teaching Hospital, OOUTH) for expert management.

At the OOUTH, relevant history surrounding her presentation as mentioned earlier was obtained and documented. Physical examination revealed a female infant, afebrile, not pale, anicteric and well hydrated with normal vital signs. Vaginal inspection showed distorted vulva with faecal matter around the vaginal orifice. Rectal examination showed disruption of the anal orifice which was in open communication with the vaginal opening (Figure 1). A provisional diagnosis of recto-vaginal fistula secondary to sexual assault was made.

She was prepared for examination under anaesthesia (EUA) and the intra-operative findings were widespread erythematous perineal skin, faecal effluent on the vulva, vestibule and vagina, torn hymen, severe disruption of the anal sphincter and vaginal mucosa appearing normal. A definitive diagnosis of faecal incontinence secondary to anal sphincteric injury from sexual assault was made.  A second procedure (colostomy) (Figure 2) was carried out one week after examination under anaesthesia to divert faecal matter from the perineal wounds and the urogenital system. Following an uneventful postoperative period, she was discharged to the paediatric surgical out-patient clinic to await repair of the genital and perineal injuries (Figure 3).

The index case involved a three month old female child who was sexually assaulted while the parents were absent from home.

Genital injuries are common in adolescent and children. Sexual assault is the most common cause of genital injuries in developed  countries  while  accidents  account for majority of the cases in underdeveloped and developing countries (John and Joan, 1993).

Controversy persists regarding the causes of and the morbidity associated with blunt perineal injuires in children (Hashish, 2011). The mechanism and extent of perineal injury, surgical repair and associated injuries are important considerations when dealing with children who sustained perineal and genital injuries. Motor vehicular crashes account for most of the perineal injuries in children aged 10 to 16 years while falls and bicycle-related injuries were significantly more prevalent in children less than 9 years of age and sexual assaults in children 0 to 4 years.  Head trauma is usually the most common associated injuries in children less than 15 years of age (Hashish, 2011; Kaplanoglu et al., 2014).

Goals of management of children with genital and perineal injuries include acute phase management of injuries which involves adequate history taking, thorough physical examination of the entire system and the perineum. Visual examination of the perineum often yield satisfactory findings and information about the type and extent of these injuries but this could be improved by using magnifying aids, examination under sedation or general anaesthesia. Other important steps in managing these patients are prevention of transmissible diseases and pregnancy, collection of forensic evidence, management of social circumstances, physical and psychosocial rehabilitation (Graeme, 2004).

The index case was initially attended to by a general practitioner where history of injury and findings on physical examination were documented and followed by emergency care.  At our facility, she was first taken to the of treatment and medicol-legal situations (Campbell et al., 2010). Pediatric trauma involving the perineal region is rare in pre-pubertal girls with a reported incidence of 4 to 6%. Targets of sexual abuse are children less than 10 years of age and below with the 4 to 6 years old at the highest risk. Most of the victims suffer perineo-genital or perineal injuries (Vishrut et al., 2016; Martin, 1989).

The incidence occurs across different countries and continents in the world. There are antecedent conditions that identify the children at risk, recognize local pattern of victim-assailant relationship in every environment and to attempt to determine the incidence of complications, including pregnancy, transmission of infectious diseases such as HIV, gonorrhea, hepatitis and physical trauma. Sexual abuse inflicts both physical and post-assault emotional trauma for the victim and the family (Nancy, 2005; Asindi et al., 1989).

Perineal injuries following trauma are associated with a significant degree of tissue tear, which is due to rapid and excessive stretching of the tissues against fixed bone structure of the pelvis. The extent of stretching determines the depth and extent of laceration and may involve the genital tract, urinary tract, GIT or a combination of the three (Hashish, 2011).

Quick evaluation and documentation of the injury type should be done and decision taken regarding mode of management in order to achieve a favorable outcome. Injuries vary from simple anal laceration, perineal gyneacology unit where physical examination and examination under general anaesthesia were carried out and their findings documented. When this patient finally got to us, we prepared her for repeat  examination  under anaesthesia and establishment of a defunctioning colostomy.   

Female genitalia is more fragile in prepubertal period because of low levels of estrogen perineal and genital injuries in this age-group tend to be severe and may require repair more often than older children where the genitalia is more resistant to injury. Furthermore, perineal injuries in children under 4 years should raise the suspicion of abuse. Incidence of genital injuries after rape and sexual assault ranges from 50 to 90%. Abuse against the child and adolescent is a public health issue of great social and family impact and may have different consequences. Intra-familial sexual abuse is difficult to document and manage because the child must be protected from additional abuse and coercion not to reveal or deny the abuse in order to preserve the family unit (Michael et al., 2000; Jones and Bassy, 1991).

Pattern of injury includes first degree (muscles intact), second degree (muscles torn) and third degree (extending into the rectum). Bruising, laceration or penetration will depend on the nature of the object inflicting the injury. The index case sustained second degree perineal and genital injuries which broke down after an initial attempt at repair by a general practitioner. However, combined management by the gyneacological and paediatric surgical units of our hospital yielded a satisfactory outcome. Evaluation under anesthesia to identify and document severity of injury is important and immediate local repair with diversion stoma and secondary repair gives excellent cosmetic and continence results (Bakal et al., 2016; Nancy et al., 1998).

Perineal injuries in children occur worldwide and often result from road traffic accidents, falls and sexual assault. Reports on these injuries especially those resulting from sexual assaults are not common, hence the need to report this case to show the steps involved in managing these patients and to disseminate information on the rising incidence of this type of injury in our society. 

The authors have not declared any conflict of interests.