Sexually Transmissible Infections in Clinical Practice

35. A Young Girl with Anogenital Lumps

Alexander McMillan1, 2  

(1)

Department of Genitourinary Medicine, NHS Lothian, Edinburgh Royal Infirmary, Edinburgh, Uk

(2)

University of Edinburgh, Edinburgh, Uk

Alexander McMillanFormerly, Consultant Physician, part-time Senior Lecturer

Email: a.amcmm@btinternet.com

Abstract

Claire is a 15-month-old girl who has been brought by her mother to you as her General Practitioner. While bathing Claire, the mother had noted lumps in the anogenital area. When you examine her, you note the presence of anogenital warts (Fig. 35.1).

Claire is a 15-month-old girl who has been brought by her mother to you as her General Practitioner. While bathing Claire, the mother had noted lumps in the anogenital area. When you examine her, you note the presence of anogenital warts (Fig. 35.1).

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Figure 35.1.

Anogenital warts in a young girl.

35.1 How Do You Explain the Presence of Anogenital Warts in a Pre-pubertal Child, and What History Would You Wish to Elicit from the Mother?

The presence of anogenital warts in a pre-pubertal child can be explained in several ways. These include

·               perinatal acquisition of anogenital warts from a clinically or sub-clinically infected mother;

·               inoculation with a common wart virus type on the child's genitals by auto-inoculation or during routine handling by a carer; and

·               infection transmitted during child sexual abuse (CSA).

The most common explanation is perinatal transmission of anogenital warts from mother to child (this includes transplacental transmission). Anogenital warts thus acquired commonly manifest in the first year of life, though their appearance may be delayed for up to 2–3 years after birth. These mothers often, though not invariably, have a past history of anogenital warts. It is possible for wart virus types causing hand warts (e.g., HPV types 1, 2, and 4, etc.) to be transmitted to a child's genitals by auto-inoculation or by carers during routine care, though this is very uncommon. The various HPV types causing warts are generally anatomical site specific, and it is unusual for non-genital wart virus types to infect anogenital skin. Finally, the possibility of child sexual abuse as a potential explanation for anogenital warts in a minor must also always be kept in mind.

The mother should be carefully questioned regarding any personal history of previous genital warts, and especially any history of genital warts during pregnancy. If the child's genital warts appear to be similar to common skin warts, enquiries should be made as to whether the child herself, the mother, or other carers currently have hand warts. If sexual abuse is considered a possibility, details of all adults with responsibility for the child's care should be ascertained.

Where a pre-pubertal child has genital warts, because of the requirement to consider possibility of sexual abuse, General Practitioners faced with this scenario should request specialist involvement.

35.2 What Investigations Might You Consider in This Case, and with Which Agencies Might You Wish to Liase?

Child protection issues arise when a diagnosis of a sexually transmissible infection in a pre-pubertal child is made. A multi-agency approach must be adopted from the outset, and the social work department and community pediatricians involved, as well as consulting Sexual Health physicians. Following discussion with these agencies, it may also be necessary to involve the police.

Where the possibility of sexual abuse has been raised, a careful forensic physical and genital examination of the child must be carried out, looking specifically for signs of abuse. The timing of the forensic examination is important and is dependent upon the time period the alleged abuse. Testing must also be performed for all relevant sexually transmitted infections, using a “chain of evidence” protocol, by a clinician experienced in this field. The timing of the STI screen is also important and is dependent upon the pre-patent period of the STIs, as well as the time period of the alleged abuse. Where appropriate (for example, where the alleged abuse has occurred over a lengthy period) the forensic examination and STI screen can be performed together on a single occasion.

The STI screen in pre-pubertal girls usually includes testing for Chlamydia trachomatis, Neisseria gonorrhoeae, and Trichomonas vaginalis. Where there is definitive evidence or disclosure regarding sexual abuse, consideration must be given to sampling all possible sites of abuse for relevant infections. Where there is only a suspicion of abuse, sampling sites need to be decided on a case-by-case basis, depending on history, symptoms, signs, and the probability of abuse having been perpetrated.

Chlamydia trachomatis can infect the vagina of pre-pubertal girls, as well as the oro-pharynx and rectum, and these sites need to be sampled depending on the abuse history (as discussed above). Urethral sampling is usually avoided due to poor tolerance of minors for this test. In these circumstances, testing a first-voided urine sample should be considered. A sample of vaginal discharge, if present, should be obtained or specimens collected from the posterior wall of the vagina or from the introitus. Care must be taken to avoid the hymen, if present, to prevent unnecessary discomfort to the child. Trans-hymenal swabs can be taken if the size of the hymenal opening allows this. The swabs used for sampling ear, nose, and throat sites should be used for trans-hymenal sampling as they are smaller than the cotton tipped swabs routinely used for STI screening.

Although nucleic acid amplification tests (NAAT) for Chlamydia trachomatis are unlicensed for use on specimens obtained from children, they are now commonly used because of their high sensitivity in adults. A positive NAAT in a child must be confirmed either by culture (preferably, but culture facilities are rarely available in many laboratories) or by a different NAAT to increase result validity for medico-legal purposes. Interpretation of NAAT testing should be done in collaboration with genitourinary medicine specialists and microbiologists, taking into account the anatomical site sampled and local prevalence data which affect the test’s positive and negative predictive values.

Neisseria gonorrhoeae can also infect the vagina, oropharynx, and rectum of pre-pubertal girls and consideration should be given to sampling these sites depending on the history of abuse. Culture remains the gold standard laboratory investigation for N. gonorrhoeae for medico-legal purposes. Nucleic acid amplification tests for N. gonorrhoeae can be undertaken in addition or if urine testing if being performed, but a positive NAAT result will require confirmation by culture.

Vaginal swabs should be taken for microscopy and, if facilities are available, for culture or use of a NAAT for Trichomonas vaginalis. If any vaginal discharge is present, consider microscopy and culture for Candida spp. and bacterial vaginosis. If there is genital ulceration, samples for testing for herpes simplex virus infection by polymerase chain reaction or culture should be obtained.

Serological testing for syphilis, HIV, Hepatitis B, and Hepatitis C should be undertaken, depending on the risk factors. The samples may require to be repeated if initial testing is undertaken within the window period of the infections. Very rarely, depending on the period, timing and type of sexual abuse, and the risk of blood-borne virus infections, vaccination for Hepatitis B and post-exposure prophylaxis for HIV may be appropriate.

35.3 How Would You Treat These Warts?

As anogenital warts will spontaneously regress, treatment should only be considered after a lapse of at least 3 months. When the warts are causing significant symptoms (e.g., bleeding or bacterial superinfection), treatment may need to be initiated earlier.

Antimitotic treatments such as podophyllotoxin and 5-fluorouracil and immune-modulators (imiquimod) are not licensed in children. Occasionally, under specialist guidance, podophyllotoxin can be used in children over the age of 2 years. Anogenital warts in a minor can be treated with cryotherapy, scissor excision, or electrosurgery. These treatments are often very poorly tolerated in young children and may need to be carried out under general anesthesia.