PRESENTATIONS AND PRINCIPLES OF MANAGEMENT

STIs in children
and adolescents

had no controls, or used control groups that did not exclude girls
with a history of abuse or who were screened only for current
sexual activity.
Children and adolescents should be seen in the most appropriate site for optimal care. Adolescents are at high risk of pregnancy
and STIs, and may be less compliant with medication and partner
notification. Confidentiality and empathic staff are important in
attracting them to services.

Angela J Robinson

Epidemiology
The risk of contracting an STI depends on several factors
(Figure 2).
In infancy, infection may be related to prolonged colonization
after perinatal acquisition. Uncertainty over incubation periods of
infections prevents the setting of rigid upper age limits after which
abuse is most likely.
In older children with an STI, a history of vaginal/rectal
penetration or apposition of genitals can usually be obtained,
though disclosure may be delayed. In some studies, assessment
to determine whether abuse had occurred was deficient.1 In the
largest epidemiological study of the prevalence of sexually transmitted organisms, findings were reported in 1538 children aged
112 years who were evaluated for possible sexual abuse. Neisseria
gonorrhoeae was found in 41/1469 (2.8%), human papillomavirus
(HPV) causing condylomata acuminata in 28/1538 (1.8%) and
Chlamydia trachomatis in 17/1473 (1.2%).2 The overall prevalence
of definitely sexually transmitted organisms was less than 5%,
consistent with other studies.
In adolescents, consensual sexual activity is more likely to be
the transmission mode, though sexual abuse should be considered.
Data obtained through GUM clinics indicate that adolescents are
at highest risk of STIs. Between 1995 and 2003, rates of diagnoses
of gonorrhoea and chlamydial infection increased by 170% and
242% in women aged 1619 years. Re-infection rates are greatest
in adolescents.3

STIs can affect children at three developmental stages:

during infancy, when mother-to-neonate transmission and
sexual abuse must be considered
prepubertally, as a result of sexual abuse
during adolescence, when sexual activity may be consensual
or abusive.
The presence of any sexually transmitted organism in a child/
adolescent may indicate that sexual abuse has occurred, but
non-sexual transmission of STIs has been reported (Figure 1).
Identification of an STI in a child/adolescent has legal and medical
implications, and its significance requires careful interpretation.
Care is best provided through multidisciplinary teams experienced
in dealing with adolescents and children when sexual abuse is
a possibility. Appropriate training of health-care professionals
undertaking this work is required.

General considerations
There are important anatomical and physiological differences
between the genital organs of adults, adolescents and children.
Hormonal changes influence the microbiological flora of the genital
tract. The presence of some micro-organisms can be considered
normal or potentially pathogenic. Current understanding of the
normal vaginal flora in children is limited. Some studies have
compared children with vulvovaginitis with a control group without addressing the possibility of sexual abuse. Other investigators

Diagnosis
Symptoms such as dysuria, genital discharge, pruritus, soreness
and pain are nonspecific indicators of STI and have many other
causes. Some infections, particularly C. trachomatis and rectal
and/or pharyngeal gonorrhoea, can be asymptomatic.

Angela J Robinson is Consultant in Genitourinary Medicine at the

Mortimer Market Centre, London, UK and Honorary Senior Lecturer at
University College London. Conflicts of interest: none declared.

Modes of transmission of STIs in children

In utero

HIV, syphilis, human papillomavirus, hepatitis B and C

Perinatal

Chlamydia trachomatis, Neisseria gonorrhoeae, herpes simplex

virus, human papillomavirus, HIV, hepatitis B and C

Direct contact
Non-sexual/auto-inoculation

Human papillomavirus, herpes simplex virus

Fomites

?Trichomonas vaginalis

Sexual assault/consensual sex

All STIs

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PRESENTATIONS AND PRINCIPLES OF MANAGEMENT

not been validated in prepubertal children. The latter investigation may be sufficently legally robust, but there have been few
test cases. Ideally, culture confirmation is needed, but culture is
seldom available except in specialist laboratories. NAATs may be
useful as screening tests for Chlamydia and N. gonorrhoeae, but
for evidence in court, confirmation by another NAAT or culture
for Chlamydia and by gonococcal culture is recommended.
The wet preparation for trichomoniasis and clue cells, and the
amine or whiff test are possible only when vaginal discharge is
present. A discharge sample can be taken with a swab and placed
in Amies medium for microscopy and culture.
A clotted blood sample can be taken for syphilis, hepatitis B/C
and HIV serology. Testing should be considered on an individual
basis, depending on the prevalence of these infections in the
population and other risk factors (see below).
Chain of evidence if the presence of infection is used as
evidence in court proceedings, it is essential to follow a chain of
evidence procedure, in which a form is signed as the samples are
handed from one individual to the next. Written protocols should
be agreed between microbiology, paediatric and GUM departments,
to ensure that the correct procedures are followed.

Factors affecting acquisition of STIs

Background prevalence of STI

Maternal infection/mode of delivery
Type of abuse
Time of examination relative to abuse
Trauma
Sexual maturity
Use of barrier contraception
Frequency of sexual activity

Examination recommendations for prepubertal girls are:

supine in the frog-legged position, with the hips flexed and the
soles of the feet touching (kneeelbow prone position may be
preferred by some children)
young children can be held on the carers lap
separation of the labia majora to view the hymenal orifice
gentle traction between the thumb and index finger at the posterior edge of the labia majora to view an unopened hymen.
buttock separation in the left lateral position, using the palms
of both hands, to view the anus.
Boys and peripubertal/pubertal girls are examined as for adults.
Colposcopy has been reported to show minor genital trauma
not otherwise seen, but is unlikely to reveal significant findings of
abuse that would be undetected by an experienced examiner. Its
major advantage is the ability to take photographs for future reference. Any signs of sexual abuse should be recorded (Figure 3).4
Laboratory investigations
Sampling techniques must be specific for the stage of sexual
maturity of the child (the prepubertal vaginal mucosa may be the
site of genital infection with N. gonorrhoeae or C. trachomatis, and
vulval/vaginal swabs suffice).
Sterile, cotton-tipped swabs, moistened if necessary with
sterile water, are recommended for sampling the vulva/vagina
transhymenally or from the posterior fourchette (nasopharyngeal
swabs are ideal). Vulvovaginal washings can be used.
Restrict the number of swabs to the minimum, giving priority to
identification of N. gonorrhoeae, C. trachomatis and Trichomonas
vaginalis. One swab can be used for a Gram-stained slide (if discharge is present) and inoculation of gonococcal medium. Rectal
and oropharyngeal swabs should be taken if clinically indicated.
Obtain a sample for culture of herpes simplex virus (HSV) by
rubbing the lesion vigorously.
Some lesions (e.g. genital warts) may require biopsy. These
specimens can be evaluated using histopathological techniques,
with DNA probe techniques for subtyping.
Diagnostic investigations are listed in Figure 4. Because of the
implications of the presence of an STI in a child, the most sensitive and specific tests available should be used. Most tests for STIs
have been developed and approved only in adults. Culture tests are
most specific and should be used to identify N. gonorrhoeae and
C. trachomatis. If an organism is isolated, it should be preserved in
case further investigation is required for medicolegal purposes.
Direct immunofluorescence, enzyme immunoassays and
nucleic acid amplification tests (NAATs) for C. trachomatis have

MEDICINE 33:9

Vulvovaginitis in prepubertal girls

Vulvovaginitis is a relatively common presentation in prepubertal
girls. In 2575% of cases, no specific pathogen is isolated and
the explanation given is nonspecific irritation related to hygiene,
faecal contamination or use of soaps or bubble baths. Girls with
vulvovaginitis and control groups have similar microbiological
flora, particularly Staphylococcus aureus, streptococci, mixed

Anogenital signs and sexual abuse

Definite evidence of abuse
Evidence of penetrating trauma laceration/scar of hymen
extending into vaginal wall, laceration/healed scar extending
beyond anal mucosa
Presence of sperm
Pregnancy
Some STIs (see text)
Suggestive of abuse
Enlarged hymenal opening
Attenuation of hymen with loss of hymenal tissue
Hymenal notch/cleft extending through more than 50% of the
hymenal rim posterior segment
Scar/fresh laceration of posterior fourchette not involving
hymen
Acute changes (erythema, swelling, bruising, fissures in
genital area)
Bite or suction marks on the genitalia/inner thighs
Anal laxity
Reflex anal dilatation > 2 cm without significant medical history
Source: Heger A et al. Child Abuse Neglect 2002; 26: 64559.

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Management antibiotic treatment is based on the local sensitivity of N. gonorrhoeae. Recently, gonorrhoea has become resistant
to fluoroquinolones, and third-generation cephalosporins are now
recommended in adults.

Investigations for STIs in sexually abused children

Gram-stain of any genital or anal discharge

Culture for Neisseria gonorrhoeae and Chlamydia trachomatis
Vaginal culture for Trichomonas vaginalis (girls)
Wet preparation for trichomonads and clue cells (girls)
if vaginal discharge present
Cultures of lesions for herpes simplex virus
Frozen serum sample
Serological tests for syphilis1
Hepatitis B surface antigen1
HIV antibody1

C. trachomatis: the risk of neonatal C. trachomatis infection is

5070% in infants born to infected mothers. The major clinical
manifestation is neonatal ophthalmia, but C. trachomatis also
causes pneumonia. Asymptomatic infection of the vagina and
rectum occurs in up to 15% of infants born to infected women.
Perinatally acquired chlamydial infection can persist for up to
3 years and therefore must be considered in abuse cases. C. trachomatis infection has been identified in 0.4211%of sexually abused
children when rectogenital specimens were routinely cultured.
The greatest prevalences of C. trachomatis infection have been
reported in adolescent populations. In 2004, the rate of diagnoses in
1619-year-old women was reported as 1.3% (1334/100,000). The
prevalence is lower in boys; the Chlamydia screening programme
reported 1.5% in boys under 16 years of age compared with 7.5%
in girls, and 10% in boys aged 1619 years compared with 12.1%
in girls.
Clinical features both boys and girls are often asymptomatic.
Most girls with cervicovaginal chlamydial infection have no symptoms. Nonspecific symptoms are often ignored or misdiagnosed.
Adolescent girls are more likely to suffer pelvic infection as a
complication of the infection.
Management in neonates, topical antibiotic therapy alone
is inadequate; systemic treatment is required. The recommended
regimen is erythromycin, 15 mg/kg/day p.o. in four divided doses
for 1014 days. The mother and mothers sex partner should be
tested and treated. In children over 8 years of age, when dentition is complete, doxycycline, tetracycline or erythromycin can be
used. In adolescents, azithromycin, 1 g single dose, has advantages
regarding compliance and can be directly observed.

If supportive epidemiological evidence

anaerobes and Escherichia coli. Candida is not usually isolated

in prepubertal girls, but can be found in girls with predisposing
factors. Other causes include sexually transmitted organisms
and threadworms. Microbiological investigations for sexually
transmitted organisms should be undertaken to try to establish
a diagnosis. If sexually transmitted organisms are identified, a
systematic assessment by an experienced professional in sexual
abuse is needed.

Sexually transmitted organisms

Gonorrhoea: in 13 surveys of children evaluated for known or
suspected sexual abuse since 1988, the prevalence of gonorrhoea
is 14.6%. It is greater in those who have suffered multiple episodes of abuse. Isolation of N. gonorrhoeae from any site in a child
with no prior peer sexual activity strongly suggests sexual abuse.
Evidence suggests that gonorrhoea in children over 1 year old is
sexually transmitted, and a diagnosis of gonococcal infection is
highly suggestive of abuse. In children under 1 year, infection
usually results from ocular contamination through mother-to-child
transmission, though abuse may still have to be considered.
Gonococci have been shown to survive for 224 hours on
toilet seats and for up to 72 hours on other materials (wooden
spatulae, cardboard and cotton-tipped swabs), but transmission
of infection from toilet seats has not been reported. Acquisition of
gonorrhoea by non-sexual means (e.g. close non-sexual contact,
infected underwear or linen) is not considered in adults.
Reports of non-sexual transmission in children highlight overcrowded living conditions. Household contacts of infected children
should also be evaluated; 1550% have been shown to have the
infection.
Clinical features and diagnosis infection may occur in the
urethra, endocervix, conjunctiva, oropharynx, prepubertal vagina
and rectum. The most common symptom is vaginal discharge, but
up to 45% of children infected with N. gonorrhoeae are asymptomatic. Definitive diagnosis depends on culture of the organism
and confirmation using at least two laboratory tests of different
biological principles. Inadequate characterization of Neisseria spp.
may result in incorrect diagnosis and has resulted in false allegations of abuse.

MEDICINE 33:9

Syphilis: early infectious syphilis in children is very rare in the

UK, though congenital syphilis may become more common as a
consequence of recent syphilis outbreaks. Cases have been reported
in sexually abused children in the world literature. Congenitally
acquired syphilis should be excluded. The organism responsible
is Treponema pallidum, which can be transmitted transplacentally
and through sexual contact. Prepubertal children with early infectious syphilis should be presumed to be victims of sexual abuse.
Clinical features and diagnosis children may present
symptomatically with primary or secondary syphilis. Positive
serological tests have been recorded in some abused children.
Venous blood should be taken for syphilis serology immediately
and after 3 months, if there may be a risk of syphilis following
sexual exposure. Dark-ground microscopy should be performed
on appropriate specimens when lesions of primary or secondary
syphilis are suspected.
T. vaginalis: neonatal transmission of T. vaginalis may occur at
delivery. The organism may persist for 36 weeks in the neonatal
vagina, which is oestrogenized, and can reside in the urinary tract
after disappearance from the vagina.
After the neonatal period, T. vaginalis is transmitted almost
exclusively by sexual intercourse. Isolation of T. vaginalis in
children beyond the first year of life suggests sexual contact and
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warrants evaluation for sexual abuse and investigation for other

STIs. T. vaginalis does not usually survive for long in the alkaline
environment of the prepubertal vagina, and its presence suggests
recent abuse.
Non-sexual transmission is believed to be rare, but is theoretically possible. T. vaginalis has been found in urine and semen
specimens after several hours exposure to air, and the organism
can survive for up to 20 minutes in the toilet pan and for hours
on damp towels and clothing used by infected women.
Clinical features and diagnosis vulvovaginitis is usually
present in infected adolescents, though asymptomatic infection
can occur. T. vaginalis in children is diagnosed as in adults, but
the sensitivity and specificity of wet preparation and culture are
not documented for children.
Management the dose of metronidazole used for treatment
is age dependent.

abused was 42% (range 3.3100%). The risk of genital warts following abuse is difficult to assess, because of lack of long-term
follow-up data after diagnosis of sexual abuse.
The peak age of incidence is between birth and 4 years. Reports
of anogenital warts in girls are twice as common as those in
boys.
Clinical features and diagnosis condylomatous, papular
and flat warts are seen in children. They may be asymptomatic
or may cause soreness, irritation and bleeding. Anogenital warts
are usually found around the vaginal introitus, on the perineum
and around the anus in girls. In boys, they are most common on
the perianal and perigenital areas. Penile condylomata are rare.
Diagnosis is clinical and can be confirmed by biopsy. DNA
subtyping of HPV is of limited value, but should be considered
to indicate whether the wart is of genital or non-genital type.
However, genital HPV types can be transmitted vertically, and
non-genital wart types can be transmitted by abuse (e.g.fondling/
digital penetration). Examination of parents/carers and siblings
for evidence of infection may provide useful information and is
recommended, as is long-term follow-up in view of the risk of
subsequent anogenital neoplasia.
Management options include a period of observation; many
cases resolve spontaneously. Location, severity, age of the child
and the potential discomfort of the procedure should be considered when deciding treatment. Physician-applied or parentapplied podophyllotoxin, cryotherapy or surgical removal under
general anaesthesia can be used, but their adequacy is uncertain
because there are few large studies. Long-term follow-up is often
lacking.
Appropriate tests should be undertaken to exclude other
STIs.

Other vaginal organisms

Gardnerella vaginalis may be part of the normal vaginal flora
in children as in adults (414%) and should not be considered
strong evidence for sexual abuse. Cultures should not be taken for
this organism; positive results are unhelpful. Bacterial vaginosis
has been identified in some studies of sexually abused children.
The prevalence of bacterial vaginosis in adolescent girls
increases with the number of sexual partners. The condition may
cause an odorous vaginal discharge, but can be asymptomatic.
The prepubertal vagina is alkaline, so pH is unhelpful in diagnosis;
Gram-staining of a vaginal sample is the most useful investigation.
Metronidazole can be prescribed for treatment if necessary.
In adults, vaginal colonization with Mycoplasma hominis and
Ureaplasma urealyticum is strongly correlated with sexual activity, race and hormonal status. Vaginal colonization in prepubertal
children may relate to vertical transmission. Using the presence of
mycoplasmas as a marker of sexual abuse remains controversial,
and the value of identifying them is doubtful. Colonization may
produce no symptoms, but there have been reports of vaginal
discharge. When mycoplasmas are the only identified organisms, a
trial of tetracycline can be given in children over the age of 8 years.
Metronidazole may also be used.

HSV types 1 and 2 can both cause herpetic clinical syndromes. In

the UK, HSV-1 causes about one-half of cases of genital herpes.
Isolation of HSV-2 from a genital ulcer in a child cannot prove
or exclude sexual contact as a means of transmission, but the
genitals are a more likely source because HSV-2 is not a common
cause of orolabial herpes. The exact prevalence of genital herpes
in prepubertal children is unknown, but it is uncommon. Primary
genital herpes is rarely reported following assault. Diagnosis of
HSV in 1619-year-olds increased by 10% between 1999 and
2003.
The virus is transmitted by close contact, including mouthto-mouth, genital-to-genital, orogenital and anogenital. In some
outbreaks of HSV attributed to spread by fomites, a common-source
contact may be a more likely explanation than inanimate objects.
Other methods of transmission include auto-inoculation from an
oral infection to the genital area, but this is rare in adults. Transmission from the recurrent whitlow on a mothers hand to her child,
causing primary herpetic vulvovaginitis, has been reported.
Clinical features and diagnosis the clinical features of HSV
infection in children are similar to those in adults. Asymptomatic infection may occur in children, but no studies have been
published.
Diagnosis is by culture of HSV. Typing may be valuable for
epidemiological studies and when possible perpetrators of sexual
abuse are identified. The availability of restriction enzyme technology to demonstrate the uniqueness of HSV isolates may be
helpful; if isolates from a possibly abused child and those from an

Anogenital warts in adults are most commonly associated with

HPV types 6, 11, 16 and 18, with partial site specificity. HPV can
be vertically transmitted at birth or, rarely, in utero; the incubation
period is several months to years. HPV types 6 and, particularly, 11
occur in laryngeal papillomas; types 1 and 2 have been reported
in anogenital warts in children.
Anogenital warts may arise through non-sexual contact or autoinoculation. HPV type 2 is the most common type in cutaneous
warts, suggesting that auto-inoculation occurs by handling or
scratching of the anogenital region. How often anogenital warts
in children arise from non-sexual contact is uncertain, but when
carers have palmar warts transmission is likely to be attributed to
non-sexual transmission in reported studies.
It is difficult to satisfactorily exclude abuse in children with
anogenital warts. Referral patterns may give biased results; some
authors argue that sexual abuse is a more common cause of anogenital warts in children than vertical transmission. In surveys of
children with STIs published between 1988 and 1996, of those
with genital warts, the median proportion reported to have been

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alleged perpetrator were shown to be identical by the technique,

this would constitute strong evidence of sexual abuse.
Type-specific serological assays for IgM and IgG antibodies
available through reference laboratories may help to determine
the mode of acquisition in a child, particularly when there is no
obvious source of herpetic infection and blood samples are available from parents or possible perpetrators. HSV viral typing of the
culture from the child is a prerequisite.
Differential diagnoses of genital ulcers include other viral infections, trauma, Behets syndrome, drug reactions, lichen sclerosus,
chancroid and syphilis.
Management in children under 2 years of age, one-half of the
adult dose of aciclovir should be used. The adult dose is satisfactory in children over this age.

(2004). The latter may have significant impact on requirement to

share information and hence on confidentiality.
Clinicians must be aware of their responsibilities established
by the General Medical Council in relation to confidentiality and
consent (see MEDICINE 33:2), balancing the needs and rights of
young people for confidential and appropriate medical care with
child protection issues. Clinicians must document their findings
carefully and ensure follow-up, because disclosure of sexual abuse
may emerge at a later consultation. When abuse is suspected,
further examination may be required if the incubation periods of
bacterial sexually transmitted organisms have not been covered.
Prophylactic antibiotics can be considered, but need not be given
if the clinician has confidence in the laboratory service.

HIV: most children infected with HIV are presumed to have

acquired it though maternal transmission, intravenous drug use,
blood products or voluntary sexual activity. However, transmission through sexual assault has been reported and is likely to
increase.
Consider screening for HIV infection (with appropriate discussion with the family and the child, if feasible) in cases of abuse
when:
the assailant is HIV positive
the assailant is at high risk of HIV infection
there were multiple assailants
the victim has a high-risk behavioural profile (e.g. prostitute,
drug misuse)
the victim has a clinical profile consistent with AIDS or symptomatic HIV disease.
Some physicians in the USA screen all sexually abused children
for HIV, because sexual abuse may be an epidemiological marker
for HIV infection in some populations. Venous blood for HIV
antibody testing should theoretically be taken at the time of
examination, and at 3 and 6 months. The blood samples taken
at the initial examination may be stored for HIV testing later if
symptoms develop. In the UK, this may be important with regard
to Criminal Injuries Compensation. When the test result is positive,
maternal HIV antibody status should be ascertained to exclude
vertical transmission.

REFERENCES
1 Beck- Sague C M, Solomon F. Sexually transmitted diseases in abused
children and adolescent and adult victims of rape: review of selected
literature. Clin Infect Dis 1999; 28: (Suppl. 1): S7483.
2 Ingram D L, Everett D, Lyna P et al. Epidemiology of adult sexually
transmitted disease agents in children being evaluated for sexual
abuse. Pediatr Infect Dis 1992; 11: 94550.
3 Health Protection Agency. Focus on prevention. London: Health
Protection Agency, 2004.
4 Heger A, Ticson L, Velasquez O et al. Children referred for possible
sexual abuse: medical findings in 2384 children. Child Abuse Neglect
2002; 26: 64559.
FURTHER READING
British Medical Association. Consent, rights and choices in health care
for children and young people. London: BMA, 2000.
Department of Health. Working together. The Children Act 1989. A guide
to arrangements for interagency cooperation for the protection of
children from abuse. London: HMSO, 1990.
Hay P E. The diagnosis and management of vaginal discharge. In:
Barton S E, Hay P E, eds. Handbook of genitourinary medicine.
London: Arnold, 2000: 849.
Heger A, Jean Emans S, eds. Evaluation of the sexually abused child.
2nd ed. New York: Oxford University Press, 2000.
Joishy M, Ashtekar C S, Jain A et al. Do we need to treat vulvovaginitis in
pre-pubertal girls? BMJ 2005; 330: 1868.
Robinson A J. The clinical examination and how to obtain specimens.
In: Barton S E, Hay P E, eds. Handbook of genitourinary medicine.
London: Arnold, 2000: 1617.
Robinson A J, Ridgway G L. Sexually transmitted diseases in children:
non-viral including bacterial vaginosis, Gardnerella vaginalis,
mycoplasmas, Trichomonas vaginalis, Candida albicans, scabies and
pubic lice. Genitourin Med 1994; 70: 20814.
Royal College of Physicians. Physical signs in child sexual abuse. 2nd ed.
London: Royal College of Physicians, 1997.
Thomas A, Forster G, Robinson A et al. National guideline on the
management of suspected sexually transmitted infections in children
and young people. Sex Transm Infect 2002; 78: 32431. www.bashh.
org/guidelines

Children, adolescents and the UK legal framework

Confidentiality is vital in ensuring that adolescents access sexual
health services. Young people are entitled to the same degree of
confidentiality as adults, even when aged under 16 years and
having sexual intercourse. According to the law, sexual activity
maybe defined as unlawful through age, age of the partner or
involvement in prostitution. Under-16s must be assessed for Fraser
competence. If there is any concern about the nature of sexual
activity, the doctor has a duty of care to ensure that children do
not suffer significant harm. The childs welfare is paramount.
The sexual offences reform bill has clarified that under-13s are
incapable of consenting to sexual activity, requiring referral to
child protection services or the police.
In the UK, the care of children and young people is guided by
standards established in the statute for sexually transmitted disease
services, the European Convention on Human Rights, the Human
Rights Act, the Sexual Offences Act (2003) and the Children Act

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