Urinary Tract Symptoms Following Sexual Abuse
and
Urinary Tract Infection
Judy L. Klevan, MD, Allan R. De Jong, MD \s=b\ During a routine follow-up visit, 428 victims of sexual abuse and their caretakers were asked about genitourinary complaints. Symptoms elicited included vaginal pain, increased urinary frequency, dysuria, and enuresis. A urinalysis was performed for all victims with symptoms, and those with positive or equivocal urinalysis results had a urine culture done. Urinalysis and urine culture were performed on a control group of 53 consecutive asymptomatic victims. Twenty percent (85/428) of the victims complained of one or more genitourinary symptoms. The
symptom was vaginal pain (51%). Of the symptomatic victims, only 2 most common
had a urinary tract infection. None of the 53 asymptomatic control victims had a urinary tract infection. There was no significant relationship between the presence of genitourinary symptoms and repetitive
abuse, genital trauma, vaginal contact, or gender of the victim. However, patients younger than 6 years of age were more likely to have genitourinary symptoms than older patients. These findings indicate that urinary tract symptoms following sexual abuse are common but that urinary tract infection is quite uncommon. Our study does not support routine screening of children for urinary tract infection solely because they have been sexually abused.
(AJDC. 1990;144:242-244)
Qexual activity
has been associated increased frequency of uri¬ nary tract infection (UTI) in adoles¬ cents and young adults.1,2 Frequent or recurrent UTI has been described as a feature of sexual abuse, but this associ¬ ation has not been well documented. Re¬ cently, a stronger association has been suggested, implying that UTI may be an indicator of sexual abuse.34 Howev¬ er, the study by Reinhart5 found the prevalence of UTI in victims of sexual abuse to be no greater than that in popu¬ lations of healthy schoolchildren. The current study was designed to
with
an
Accepted for publication September 25,1989. From the Department of Pediatrics, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa.
Read in part before the Third National Child Abuse Conference, Philadelphia, Pa, March 16, 1989. Reprint requests to 111S 11th St, Suite 8050 NH, Philadelphia, PA 19107 (Dr De Jong).
questions. First, What is frequency of urinary tract symp¬ toms following sexual abuse? Second, What is the frequency of UTI in sexual¬ ly abused children? answer
two
the
PATIENTS AND METHODS Thomas Jefferson University Hospital (Philadelphia, Pa) is a sexual-assault center for Philadelphia County, Pennsylvania. The sexual-assault center is one of two hospitalbased facilities designated to serve as crisis evaluation and treatment centers for sexual¬
ly abused children. Victims are referred from the police, private physicians, hospital emer¬ gency deparments, social service agencies, and rape-counseling centers throughout the city. Self-referrals are also common. The subjects for the study underwent rou¬ tine initial and follow-up examinations. At the time of the initial complaint of sexual abuse, an initial examination was performed by pediatrie residents and by nurses who are experienced in the examination of abused children. The history obtained included du¬ ration of abuse, alleged perpetrator, and the type of sexual contact. A physical examina¬ tion was performed, evidence was collected, and specimens for bacterial cultures were obtained from oral, anal, and vaginal sites. Serologie tests for syphilis (rapid plasma reagin card test) were also performed. Pres¬ ence or absence of genital trauma—such as vaginal lacerations, scars, or increased hy¬ menal orifice size—was specifically noted. Signs of infection such as vaginal discharge, condylomata, or vesicles were also recorded. Victims were then seen in a follow-up clinic 1 to 3 weeks after the initial report of sexual abuse. During this routine visit, victims and their caretakers were asked about a variety of somatic and behavioral problems, includ¬ ing questions about genitourinary (GU) symptoms. We asked specifically about the following symptoms: vaginal pain, increased urinary frequency, dysuria, and enuresis. All victims symptomatic with GU complaints had a urinalysis performed on a midstream, clean-catch specimen. The urinalysis includ¬ ed a dipstick for nitrites and a microscopic examination. Those with abnormal results of urinalysis (>10 white blood cells [WBCs] per high-power field [hpf] in a spun urine sample, more than 2 bacteria per hpf, or a positive nitrite test) or an equivocal result (between 5 and 10 WBCs per hpf in a spun urine sample, or 2 bacteria or more per hpf) had a urine culture done using a dip-slide method (Uricult, Medical Technology Corp, Somerset,
NJ). A control group was created, because asymptomatic victims rarely had either a uri¬ nalysis or urine culture performed. The con¬ trol group consisted of 53 consecutive asymp¬ tomatic victims. All members of the control group had a urinalysis and a urine culture performed on a midstream, clean-catch spec¬ imen. Data from symptomatic victims were collected from March 1980 to September 1988, while data for the asymptomatic con¬ trol group were collected from March 1987 to September 1988. The asymptomatic control group appeared to be a representative sam¬ ple of all asymptomatic victims. No signifi¬ cant differences were found between the con¬ trol group and all other asymptomatic victims with respect to the victim's age, gen¬ der, relationship to the perpetrator, the fre¬ quency of physical findings, and the type and duration of the abuse. Data were analyzed primarily using descriptive methods, as well as Student's t test for interval data and 2 for comparing categorical data.
RESULTS A total of 428 sexual-abuse victims were cared for in the follow-up clinic during the period of the study. The mean age of the victims was 8.6 years (SE 0.18 years). The range of ages was from 1 to 16 years. Eighty-four percent of the victims were female and 67% were black. Eighty-five (20%) of the victims com¬ plained of one or more GU symptoms at the time of the follow-up visit. The most =
commonly reported symptom was vagi¬ nal pain, reported by 51% of the symp¬
tomatic children. Recent onset of diur¬ nal or nocturnal enuresis was reported by 28% of the symptomatic victims. Dysuria and urinary frequency were re¬ ported by 25% and 24% of the symptom¬ atic victims, respectively (Table 1). Fourteen (16%) of the 85 symptomatic victims had two GU symptoms and 5 (6%) symptomatic children reported three symptoms. Fifty-two of the symp¬ tomatic children had become symptom¬ atic since their initial examination; 33 had described symptoms at the time of the initial examination that had persist¬ ed at follow-up. Only two asymptomatic control patients reported symptoms at the initial examination. All symptomatic victims had a urinal¬ ysis but only 32 had a urine culture ob-
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Table 1 .—Genitourinary Tract
Symptoms Reported Among Symptomatic Sexually Abused Children (n 85) =
No. (%) of Symptomatic Victims Reporting
Symptom Vaginal pain
Enuresis
Dysuria
urinary frequency
43 24 21
(51 ) (28) (25)
20
(24)
Increased
tained at the
follow-up
visit. Of the 85
symptomatic victims, only 2 had a UTI as diagnosed by urinalysis or culture. These 2 girls had greater than 10 WBCs per hpf, greater than 2 bacteria per hpf, a positive nitrite test, and a urine cul¬ ture with more than 10° organisms per milliliter of urine. These 2 girls had nei¬ ther prior UTI by history nor evidence of other concurrent GU infection. Fiftythree asymptomatic control patients underwent urinalysis and urine culture, but
none were
found to have
a
UTI
(Figure).
Factors that might be related to the reporting of symptoms such as genital trauma (including genital infection), a history of vaginal contact, or repetitive abuse were analyzed. 2 analysis did not show a significant relationship be¬ tween the presence of genital trauma and the presence of GU symptoms. Sim¬
ilarly, a significant relationship was not found between a history of vaginal con¬ tact or repetitive abuse and the pres¬
of GU symptoms (Table 2). Be¬ vaginal pain was the most commonly reported symptom, female subjects were more likely to be symp¬ tomatic. However, when the genderspecific symptom of vaginal pain was removed from the analysis, the propor¬ tion of female subjects who were symp¬ tomatic was not different from the pro¬ portion of male subjects who reported symptoms. When the effect of age on the presence of GU symptoms was ex¬ amined, we found that victims younger than 6 years old were significantly more likely to complain of GU symptoms than older victims (Table 2). Furthermore, the mean age of symptomatic victims was 6.9 years, significantly less than the mean age of 9.0 years of all asymptomat¬ ic victims (t test = 4.75, P
and
Urinary Tract Infection
Judy L. Klevan, MD, Allan R. De Jong, MD \s=b\ During a routine follow-up visit, 428 victims of sexual abuse and their caretakers were asked about genitourinary complaints. Symptoms elicited included vaginal pain, increased urinary frequency, dysuria, and enuresis. A urinalysis was performed for all victims with symptoms, and those with positive or equivocal urinalysis results had a urine culture done. Urinalysis and urine culture were performed on a control group of 53 consecutive asymptomatic victims. Twenty percent (85/428) of the victims complained of one or more genitourinary symptoms. The
symptom was vaginal pain (51%). Of the symptomatic victims, only 2 most common
had a urinary tract infection. None of the 53 asymptomatic control victims had a urinary tract infection. There was no significant relationship between the presence of genitourinary symptoms and repetitive
abuse, genital trauma, vaginal contact, or gender of the victim. However, patients younger than 6 years of age were more likely to have genitourinary symptoms than older patients. These findings indicate that urinary tract symptoms following sexual abuse are common but that urinary tract infection is quite uncommon. Our study does not support routine screening of children for urinary tract infection solely because they have been sexually abused.
(AJDC. 1990;144:242-244)
Qexual activity
has been associated increased frequency of uri¬ nary tract infection (UTI) in adoles¬ cents and young adults.1,2 Frequent or recurrent UTI has been described as a feature of sexual abuse, but this associ¬ ation has not been well documented. Re¬ cently, a stronger association has been suggested, implying that UTI may be an indicator of sexual abuse.34 Howev¬ er, the study by Reinhart5 found the prevalence of UTI in victims of sexual abuse to be no greater than that in popu¬ lations of healthy schoolchildren. The current study was designed to
with
an
Accepted for publication September 25,1989. From the Department of Pediatrics, Jefferson Medical College of Thomas Jefferson University, Philadelphia, Pa.
Read in part before the Third National Child Abuse Conference, Philadelphia, Pa, March 16, 1989. Reprint requests to 111S 11th St, Suite 8050 NH, Philadelphia, PA 19107 (Dr De Jong).
questions. First, What is frequency of urinary tract symp¬ toms following sexual abuse? Second, What is the frequency of UTI in sexual¬ ly abused children? answer
two
the
PATIENTS AND METHODS Thomas Jefferson University Hospital (Philadelphia, Pa) is a sexual-assault center for Philadelphia County, Pennsylvania. The sexual-assault center is one of two hospitalbased facilities designated to serve as crisis evaluation and treatment centers for sexual¬
ly abused children. Victims are referred from the police, private physicians, hospital emer¬ gency deparments, social service agencies, and rape-counseling centers throughout the city. Self-referrals are also common. The subjects for the study underwent rou¬ tine initial and follow-up examinations. At the time of the initial complaint of sexual abuse, an initial examination was performed by pediatrie residents and by nurses who are experienced in the examination of abused children. The history obtained included du¬ ration of abuse, alleged perpetrator, and the type of sexual contact. A physical examina¬ tion was performed, evidence was collected, and specimens for bacterial cultures were obtained from oral, anal, and vaginal sites. Serologie tests for syphilis (rapid plasma reagin card test) were also performed. Pres¬ ence or absence of genital trauma—such as vaginal lacerations, scars, or increased hy¬ menal orifice size—was specifically noted. Signs of infection such as vaginal discharge, condylomata, or vesicles were also recorded. Victims were then seen in a follow-up clinic 1 to 3 weeks after the initial report of sexual abuse. During this routine visit, victims and their caretakers were asked about a variety of somatic and behavioral problems, includ¬ ing questions about genitourinary (GU) symptoms. We asked specifically about the following symptoms: vaginal pain, increased urinary frequency, dysuria, and enuresis. All victims symptomatic with GU complaints had a urinalysis performed on a midstream, clean-catch specimen. The urinalysis includ¬ ed a dipstick for nitrites and a microscopic examination. Those with abnormal results of urinalysis (>10 white blood cells [WBCs] per high-power field [hpf] in a spun urine sample, more than 2 bacteria per hpf, or a positive nitrite test) or an equivocal result (between 5 and 10 WBCs per hpf in a spun urine sample, or 2 bacteria or more per hpf) had a urine culture done using a dip-slide method (Uricult, Medical Technology Corp, Somerset,
NJ). A control group was created, because asymptomatic victims rarely had either a uri¬ nalysis or urine culture performed. The con¬ trol group consisted of 53 consecutive asymp¬ tomatic victims. All members of the control group had a urinalysis and a urine culture performed on a midstream, clean-catch spec¬ imen. Data from symptomatic victims were collected from March 1980 to September 1988, while data for the asymptomatic con¬ trol group were collected from March 1987 to September 1988. The asymptomatic control group appeared to be a representative sam¬ ple of all asymptomatic victims. No signifi¬ cant differences were found between the con¬ trol group and all other asymptomatic victims with respect to the victim's age, gen¬ der, relationship to the perpetrator, the fre¬ quency of physical findings, and the type and duration of the abuse. Data were analyzed primarily using descriptive methods, as well as Student's t test for interval data and 2 for comparing categorical data.
RESULTS A total of 428 sexual-abuse victims were cared for in the follow-up clinic during the period of the study. The mean age of the victims was 8.6 years (SE 0.18 years). The range of ages was from 1 to 16 years. Eighty-four percent of the victims were female and 67% were black. Eighty-five (20%) of the victims com¬ plained of one or more GU symptoms at the time of the follow-up visit. The most =
commonly reported symptom was vagi¬ nal pain, reported by 51% of the symp¬
tomatic children. Recent onset of diur¬ nal or nocturnal enuresis was reported by 28% of the symptomatic victims. Dysuria and urinary frequency were re¬ ported by 25% and 24% of the symptom¬ atic victims, respectively (Table 1). Fourteen (16%) of the 85 symptomatic victims had two GU symptoms and 5 (6%) symptomatic children reported three symptoms. Fifty-two of the symp¬ tomatic children had become symptom¬ atic since their initial examination; 33 had described symptoms at the time of the initial examination that had persist¬ ed at follow-up. Only two asymptomatic control patients reported symptoms at the initial examination. All symptomatic victims had a urinal¬ ysis but only 32 had a urine culture ob-
Downloaded From: http://archpedi.jamanetwork.com/ by a Monash University Library User on 06/15/2015
Table 1 .—Genitourinary Tract
Symptoms Reported Among Symptomatic Sexually Abused Children (n 85) =
No. (%) of Symptomatic Victims Reporting
Symptom Vaginal pain
Enuresis
Dysuria
urinary frequency
43 24 21
(51 ) (28) (25)
20
(24)
Increased
tained at the
follow-up
visit. Of the 85
symptomatic victims, only 2 had a UTI as diagnosed by urinalysis or culture. These 2 girls had greater than 10 WBCs per hpf, greater than 2 bacteria per hpf, a positive nitrite test, and a urine cul¬ ture with more than 10° organisms per milliliter of urine. These 2 girls had nei¬ ther prior UTI by history nor evidence of other concurrent GU infection. Fiftythree asymptomatic control patients underwent urinalysis and urine culture, but
none were
found to have
a
UTI
(Figure).
Factors that might be related to the reporting of symptoms such as genital trauma (including genital infection), a history of vaginal contact, or repetitive abuse were analyzed. 2 analysis did not show a significant relationship be¬ tween the presence of genital trauma and the presence of GU symptoms. Sim¬
ilarly, a significant relationship was not found between a history of vaginal con¬ tact or repetitive abuse and the pres¬
of GU symptoms (Table 2). Be¬ vaginal pain was the most commonly reported symptom, female subjects were more likely to be symp¬ tomatic. However, when the genderspecific symptom of vaginal pain was removed from the analysis, the propor¬ tion of female subjects who were symp¬ tomatic was not different from the pro¬ portion of male subjects who reported symptoms. When the effect of age on the presence of GU symptoms was ex¬ amined, we found that victims younger than 6 years old were significantly more likely to complain of GU symptoms than older victims (Table 2). Furthermore, the mean age of symptomatic victims was 6.9 years, significantly less than the mean age of 9.0 years of all asymptomat¬ ic victims (t test = 4.75, P
