A developmentally delayed 2-year-old girl had a second surgical repair for congenital heart disease with pulmonary hypertension and was requiring multiple medications. In the postoperative care suite, you were asked to examine her anus because there were ‘concerns of sexual abuse’. The nurse caring for her had noticed perianal bruising (Image 133). She also had some genital redness which was noticed when her urinary catheter was placed for the operation. https://s3-euw1-ap-pe-df-pch-content-public-u.s3.eu-west-1.amazonaws.com/9780429170423/236ca68c-f283-4df8-88b2-3b8ff49bccc9/content/fig133.jpg" xmlns:xlink="https://www.w3.org/1999/xlink"/>

What does the image show?

What are the possible causes for this finding?

This child had significant perianal venous distention which extends anteriorly to the perineum. The incompletely seen posterior commissure of the labia appears slightly erythematous, but no lacerations or other signs of trauma are depicted. Some swelling of the anal folds or rugae is suggested. The child is in the prone position and it is unclear whether her knees are drawn up beneath her.

Given that this finding was not noted during prior procedures and there was no history of sexual abuse provided, these findings were most likely related to the child’s underlying congenital heart disease and effects from anaesthesia. Positive perianal findings are uncommon after child sexual abuse, 1 and chronic pulmonary hypertension with associated increases in pressures in the inferior vena cava may have, over time, chronically enlarged the perianal venous vascular bed. In addition, anaesthetic agents may result in decreased peripheral venous tone. If used, a prone, knee-chest position with resulting increased abdominal pressure (Valsalva) can also increase venous prominence and distention. The genital findings are nonspecific for sexual abuse and may be related to poor hygiene or, in this case, medical procedures.