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 Table of Contents  
ORIGINAL ARTICLE
Year : 2017  |  Volume : 4  |  Issue : 2  |  Page : 51-54

Possible role of sexual abuse in boys with perianal warts


Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Sohag, Egypt

Date of Web Publication20-Jun-2017

Correspondence Address:
Mohammed Abu El-Hamd
Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, P.O. Box 82524, Sohag
Egypt
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2916.208580

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  Abstract 

Objectives: The objective of this study was to assess the clinical presentations of perianal warts in boys and to evaluate the possible relationship between the presence of perianal warts and the sexual abuse as mode of transmission. Materials and Methods: In a prospective clinical study, it conducted on 16 boys with clinically evident perianal warts at the Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Upper Egypt, between September 2012 and March 2016. A detailed history from the child and his family was taken. All boys underwent full clinical general and local examinations including (1) site, number, size, and the shape of warts in perianal region, (2) physical signs of sexual abuse, (3) warts in other body areas, and (4) signs of other sexually transmitted diseases. Results: The age of boys ranged from 4 to 10 years, with a mean ± standard deviation of 6.4 ± 1.9 years. Fourteen boys (87.5%) presented with multiple moist papules. Eleven boys (68.75%) had a progressive course. Fourteen boys (87.5%) had no symptoms (incidentally discovered) and 2 boys (12.5%) had perianal itching and pain. Thirteen boys (81.25%) had confirmed history of sexual abuse. Fourteen boys (87.5%) had no physical signs of sexual abuse and 2 boys (12.5%) had perianal fissures. Conclusion: Our results suggested that sexual abuse should be considered in every case of boys with perianal warts.

Keywords: Human papillomavirus, perianal warts, sexual abuse


How to cite this article:
El-Hamd MA, Aboeldahab S. Possible role of sexual abuse in boys with perianal warts. J Integr Nephrol Androl 2017;4:51-4

How to cite this URL:
El-Hamd MA, Aboeldahab S. Possible role of sexual abuse in boys with perianal warts. J Integr Nephrol Androl [serial online] 2017 [cited 2017 Nov 20];4:51-4. Available from: http://www.journal-ina.com/text.asp?2017/4/2/51/208580


  Introduction Top


The human papillomaviruses (HPVs) are small DNA viruses of the papovavirus family. The HPVs are the most common infectious agents in humans.[1]

There are more than 200 genotypes of HPV; 30–40 of them can affect the anogenital region. Genital types of HPV are divided into high or low risk depending on their potential for causing anogenital neoplasia, mainly, cervical carcinoma. Low-risk HPV 6 and 11 genotypes are the primary causes of anogenital warts (AGWs).[2]

The average incubation period from sexual HPV exposure to development of AGWs in adolescents and adults is about 3 months, but it is unknown in children.[3]

The main modes of transmission of AGWs in children were autoinoculation, heteroinoculation, and perinatal transmission.[4] Fomite transmission, which requires an inanimate object to carry a pathogen, has also been reported.[5] However, the possibility of sexual abuse must always be in mind.[6]

Anogenital warts are frequently asymptomatic and diagnosed as incidental findings. They may cause itching, burning, or weeping in the affected areas of the skin. AGWs are presenting mainly as papules with the size of a pinhead, up to several centimeters. AGWs are generally whitish, gray-brown, or reddish. AGWs tend to disseminate and become multifocal, occasionally large tumorous masses form and rarely there is a single growth.[7]

In older children and adults, the vulva, perianal region, urethra, shaft of the penis, and more rarely, inguinal and pubic region are known to be preferred sites.[8] Children in the 1st and 2nd year of life are predominantly affected in the perianal region.[5],[9],[10]

Diagnosis of AGWs is generally by clinical examination. The histological, serological, or molecular genetics investigations may be indicated occasionally.[7] In the event of AGWs in childhood, there should be a pediatric gynecological examination in relation to abuse-associated findings and screening for coexistent sexual diseases.[11]

The medical, family, and social histories are essential in the evaluation of a child with AGWs; nonsexual modes of acquisition should be considered.[12]

The incidence of sexual abuse in children has been observed in 10%–90% of AGWs patients and this discrepancy is related to the nature of how the sexual abuse assessment was conducted.[13]

It is difficult to know the long-term effects of sexual abuse in the child. The factors affecting the seriousness of the outcome of sexual abuse include the age in which the last molestation occurred, duration and frequency of the molestation, quality of care and experiences with parents in other matters, and assurance from friends and family members that the victim was not to blame. There are several early effects of sexual abuse including anxiety dreams or nightmares and excessive response to stress with helplessness, fright, and psychosomatic symptoms.[14]

There are no reports about the clinical assessment of perianal warts in boys and possible modes of transmissions in Sohag, Upper Egypt.

The objective of this study was to assess the clinical presentations of perianal warts in boys and to evaluate the possible relationship between the presence of perianal warts and the sexual abuse as mode of transmission at Sohag University Hospital, Upper Egypt


  Materials And Methods Top


In a prospective clinical study, it conducted on 16 boys with clinically evident perianal warts at Department of Dermatology, Venereology and Andrology, Faculty of Medicine, Sohag University, Upper Egypt, between September 2012 and March 2016.

These boys came with one or more of their family members either directly or referred from others departments (Pediatric and Surgery) to the Dermatology Department. Informed consent was obtained from parents of the boys to participate in this study. Emotional support and education about nature of the disease, possible modes of transmission, and possible complications had been described to the boys and their families.

A detailed history from the child and his family was taken, including age of the boys, place of residency, socioeconomic level, duration, number and course of perianal warts, and any associated symptoms, any warts in other body areas, or any family history of warts elsewhere in body.

An adequate social history with behavioral and social assessment was done for the child. A detailed carful history about sexual abuse and physical signs of sexual abuse was taken from boys and family members.

All boys underwent full clinical general and local examinations including (1) site, number, size, and the shape of warts in perianal region, (2) physical signs of sexual abuse, (3) warts in other body areas, (4) signs of other sexually transmitted diseases (STDs).

Statistical analysis

Statistical analysis was performed using the IBM Statistical Package for Social Sciences, version 20.0 (SPSS Inc., Chicago, IL, USA). The continuous variables were described as mean ± standard deviation (SD). The categorical variables were presented in terms of their frequencies and proportions.


  Results Top


This study included 16 boys with perianal warts. Four boys (25%) with perianal warts were from rural areas and 12 boys (75%) were from urban areas. Twelve boys (75%) were moderate to high socioeconomic level and 4 boys (25%) were with low socioeconomic level. The age of boys ranged from 4 to 10 years, with a mean ± SD of 6.4 ± 1.9 years. The number of warts ranged from 1 to 11, with a mean ± SD of 5.75 ± 2.66. The duration of warts ranged from 1 to 3 months, with a mean ± SD of 1.75 ± 0.77 months [Table 1].
Table 1: Clinical characteristic of 16 boys with perianal warts

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Fourteen boys (87.5%) presented with multiple moist papules and 2 boys (12.5%) presented with fleshy nodules. Eleven boys (68.75%) had a progressive course and 5 boys (31.25%) had a stationary course. Fourteen boys (87.5%) had no symptoms (incidentally discovered) and 2 boys (12.5%) had perianal itching and pain [Table 1].

Thirteen boys (81.25%) had confirmed history of sexual abuse, 1 boy (6.25%) had possible history of sexual abuse, and 2 boys (12.5%) had no history of sexual abuse. Fourteen boys (87.5%) had no physical signs of sexual abuse and 2 boys (12.5%) had perianal fissures [Table 1].

All boys had no history of warts in other body areas or relatives with warts.


  Discussion Top


STDs have a considerable morbidity among their victims. This is true even for children. Unfortunately, this aspect has not received good attention and remains a relatively ignored field. Pediatric STDs remain a hidden and neglected problem.[15] Prevalence of childhood HPV infection varies widely in the studies.[16]

There are different methods for evaluation of the circumstances of child sexual abuse which affecting the results. The rate of sexual abuse varied between 2.3% when evaluation was done by judicial system in children aged from 6 months up to 9 years [17] and 22% when associated with social and medical assessment [18] and 71% when applied interdisciplinary research.[19]

In the present study, we found that most of the boys (81.25%) had confirmed history of sexual abuse, one boy (6.25%) had possible history of sexual abuse, and two boys (12.5%) had no history of sexual abuse. This was in agreement with Obalek et al., who reported that the incidence of sexual abuse in children observed in 10%–90% of AGWs patients.[13]

Furthermore, these high results of confirmed history of sexual abuse in boys with perianal warts may be explained by careful and good quality of history taking and this was matched with Gross, who reported that behavioral abnormalities and a carefully elicited history aid clinicians in coming to reliable conclusions and in deciding whether an HPV infection in a child is sexually transmitted and due to sexual abuse.[20] In addition, this was in agreement with data reported by the American Professional Society on the Abuse of Children which confirmed the importance of good history taking in assessment of abused child.[21]

In this study, only two (12.5%) of the boys with perianal warts showed the physical signs of sexual abuse in the form of perianal fissure and lacerations and this result was in agreement with Gilbert et al.,[22] Hornor,[23] and Berenson et al.,[24] who reported that most of confirmed cases of sexually abused child were normal on physical examination or with nonspecific physical findings.

In the present study, the majority (87.5%) of the boys with perianal warts were asymptomatic and only two boys (12.5%) with perianal itching and pain. This was in agreement with Bussen et al.,[7] who reported that AGWs are frequently asymptomatic and only diagnosed as incidental findings.

This study found that the age of presentation of boys with perianal warts ranged between 4 and 10 years. This finding was in agreement with many studies which reported that the average age of presentation of AGWs in prepubertal children was 3.75–4 years [25],[26],[27] and also with Sinclair et al., who reported that children with anogenital warts who were 4–8 years of age and over 8 years were, respectively, 2.9 and 12.1 times more likely to have been abused than children <4 years of age.[12]

In this study, the majority (87.5%) of the boys with perianal warts presented with multiple perianal moist papules. This finding was in agreement with Sinclair et al.[5] and with Bussen et al.,[7] who observed that the clinical appearance of AGWs, in most often, was papules in the size of a pinhead, up to several centimeters in size.

In this study, most of the boys with perianal warts were from urban areas. This may be due to more awareness, higher socioeconomic and educational level than those in rural areas.


  Conclusion Top


To the best of our knowledge, this is the first report assess the clinical features of perianal warts in boys, Upper Egypt. Our results suggested that sexual abuse should be considered in every case of perianal warts in boys. Physicians need to be more attentive with regard to the early diagnosis, as well as communicating with the parents and legal agencies, thus preventing the child from continuing to suffer from abuse.

Acknowledgment

We are grateful to all the faculty and postgraduates in our scientific departments for their invaluable help in conducting this study.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Sterling JC, Handfield-Jones S, Hudson PM; British Association of Dermatologists. Guidelines for the management of cutaneous warts. Br J Dermatol 2001;144:4-11.  Back to cited text no. 1
    
2.
Garland S. Human papillomavirus update with a particular focus on cervical disease. Pathology 2002;34:213-24.  Back to cited text no. 2
    
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Oriel JD. Natural history of genital warts. Br J Vener Dis 1971;47:1-13.  Back to cited text no. 3
    
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Handley J, Hanks E, Armstrong K, Bingham A, Dinsmore W, Swann A, et al. Common association of HPV 2 with anogenital warts in prepubertal children. Pediatr Dermatol 1997;14:339-43.  Back to cited text no. 4
    
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Sinclair KA, Woods CR, Sinal SH. Venereal warts in children. Pediatr Rev 2011;32:115-21.  Back to cited text no. 5
    
6.
Kempe CH. Sexual abuse, another hidden pediatric problem: The 1977 C. Anderson Aldrich lecture. Pediatrics 1978;62:382-9.  Back to cited text no. 6
    
7.
Bussen S, Sütterlin M, Schmidt U, Bussen D. Anogenital warts in childhood –Always a marker for sexual abuse? Geburtshilfe Frauenheilkd 2012;72:43-8.  Back to cited text no. 7
    
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Ashiru JO, Ogunbanjo BO, Rotowa NA, Adeyemi-Doro FA, Osoba AO. Intraoral condylomata acuminata. A case report. Br J Vener Dis 1983;59:325-6.  Back to cited text no. 8
    
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Mammas IN, Sourvinos G, Spandidos DA. Human papilloma virus (HPV) infection in children and adolescents. Eur J Pediatr 2009;168:267-73.  Back to cited text no. 9
    
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Kaplan R, Adams JA, Starling SP, Giardino AP: Medical response to child sexual abuse. A resource for professionals working with children and families. St. Louis: STM Learning 2011.p. 180-7.  Back to cited text no. 11
    
12.
Sinclair KA, Woods CR, Kirse DJ, Sinal SH. Anogenital and respiratory tract human papillomavirus infections among children: Age, gender, and potential transmission through sexual abuse. Pediatrics 2005;116:815-25.  Back to cited text no. 12
    
13.
Obalek S, Misiewicz J, Jablonska S, Favre M, Orth G. Childhood condyloma acuminatum: Association with genital and cutaneous human papillomaviruses. Pediatr Dermatol 1993;10:101-6.  Back to cited text no. 13
    
14.
Herbert CP. Sexual abuse of children. Can Fam Physician 1982;28:1173-8.  Back to cited text no. 14
    
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Pandhi D, Kumar S, Reddy BS. Sexually transmitted diseases in children. J Dermatol 2003;30:314-20.  Back to cited text no. 15
    
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Syrjanen S. HPV infections in children. Papillomavirus Rep 2003;14:93-110.  Back to cited text no. 16
    
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Jones V, Smith SJ, Omar HA. Nonsexual transmission of anogenital warts in children: A retrospective analysis. ScientificWorldJournal 2007;7:1896-9.  Back to cited text no. 17
    
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de Jesus LE, Cirne Neto OL, Monteiro do Nascimento LM, Costa Araújo R, Agostinho Baptista A. Anogenital warts in children: Sexual abuse or unintentional contamination? Cad Saude Publica 2001;17:1383-91.  Back to cited text no. 19
    
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Gross G. Condylomata acuminata in childhood – pointing to sexual abuse. Hautarzt 1992;43:120-5.  Back to cited text no. 20
    
21.
American Professional Society on the Abuse of Children. Sexual abuse of children. In: Myers J, Berliner L, Briere J, Hendrix C, Jenny C, Reid T, editors. The APSAC Handbook on Child Maltreatment. 2nd ed. London- New Delhi: Thousand Oaks Sage; 2001. p. 55-78.  Back to cited text no. 21
    
22.
Gilbert R, Widom CS, Browne K, Fergusson D, Webb E, Janson S. Burden and consequences of child maltreatment in high-income countries. Lancet 2009;373:68-81.  Back to cited text no. 22
    
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Hornor G. Ano-genital warts in children: Sexual abuse or not? J Pediatr Health Care 2004;18:165-70.  Back to cited text no. 23
    
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Berenson AB, Chacko MR, Wiemann CM, Mishaw CO, Friedrich WN, Grady JJ. A case-control study of anatomic changes resulting from sexual abuse. Am J Obstet Gynecol 2000;182:820-31.  Back to cited text no. 24
    
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Obalek S, Jablonska S, Favre M, Walczak L, Orth G. Condylomata acuminate in children; frequent association with human papillomaviruses responsible for cutaneous warts. J Am Acad Dermatol 1990;23:205-13.  Back to cited text no. 25
    
26.
Obalek S, Jablonska S, Orth G. Anogenital warts in children. Clin Dermatol 1997;15:369-76.  Back to cited text no. 26
    
27.
Marcoux D, Nadeau K, McCuaig C, Powell J, Oligny LL. Pediatric anogenital warts: A 7-year review of children referred to a tertiary-care hospital in Montreal, Canada. Pediatr Dermatol 2006;23:199-207.  Back to cited text no. 27
    



 
 
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