|Year : 2020 | Volume
| Issue : 2 | Page : 132-135
Impacted corncob in the anus: An unusual presentation of child sexual abuse
Maria Ahuoiza Garba, Lawal Waisu Umar, Sani Musa, Hauwa Umaru Makarfi
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna, Nigeria
|Date of Submission||04-Jul-2018|
|Date of Decision||20-Aug-2018|
|Date of Acceptance||30-Oct-2018|
|Date of Web Publication||10-Jul-2020|
Dr. Maria Ahuoiza Garba
Department of Paediatrics, Ahmadu Bello University Teaching Hospital, Shika-Zaria, Kaduna
Source of Support: None, Conflict of Interest: None
Child sexual assault has gained global attention as a medico-social problem with significant immediate and long-term impact on victims, their families and society. This abhorrent deviant act may present with bizarre manifestations including various objects inserted into body orifices of victims. We report a bizarre case of anal impaction of an organic foreign body in a 9-year old boy. He had been serially abused over a two-year period by an adult male who lures him with candies and inserts a corncob into his anus before having penetrative anal sex intercourse with him. The abuse came to light following impaction of the corncob in the anus with consequent development of sepsis. Fragments of the cob were manually retrieved from the anal canal. He did well on antibiotics and was discharged to the social welfare services and psychotherapist for continued care. This report highlights the bizarre presentations of sexual assault in children. Childcare practitioners should be wary of the possibility of foreign bodies insertion in victims, which may lead to severe complications.
Keywords: Anal, child, corncob, foreign body, sexual abuse
|How to cite this article:|
Garba MA, Umar LW, Musa S, Makarfi HU. Impacted corncob in the anus: An unusual presentation of child sexual abuse. Sahel Med J 2020;23:132-5
| Introduction|| |
Child sexual abuse (CSA) is a worldwide medico-social problem which leaves in its trail, significant immediate and long-term impact on victims, their families, and the society. Male children as victims of CSA, although underreported in African settings, have been widely documented in the literature. Its disclosure is, however, restricted due to fear instilled on the victim by the perpetrator and fear of accompanying societal stigma against the entire victim's family.,, Nonetheless, its impact is as devastating as it is with female victims of CSA. Abuse may go undetected for prolonged periods only to be brought to light when complications arise.,
We report a rare case of anal foreign object impaction in a boy following serial anal sexual assault.
| Case Report|| |
A 9-year-old primary two pupil was brought to the Emergency Pediatric Unit (EPU) with a 4-week history of diarrhea, purulent anal discharge and a 5-day history of constipation along with anorexia, fever and severe anal pain. He initially had a stooling frequency of 10–15 times a day, described as scanty and whitish. There was no vomiting or abdominal distension. Following the administration of several medications including antibiotics obtained from a patent medicine vendor (PMV), the frequency of stooling decreased gradually. Five days before presentation, he developed constipation with marked anorexia, high-grade intermittent fever, and severe anal pains with inability to sit. He was noticed to be persistently emitting a discharge with putrid odor around the perianal region, which led to a suspicion of sexual abuse by the PMV and the parents, following which on inquiry, the child admitted to having been sexually abused serially by an adult stranger. The assailant inserts a corncob into his anus following which he had penetrative penile–anal intercourse on him. The first encounter happened about 2 years before presentation when he was sent to cut fodder for cattle. The assailant had lured him with a “candy” into a bush and threatened to kill him if he revealed the encounter to anyone. Subsequently, the assailant had met with the boy severally over the past 2 years usually on market days, lured him with gifts into a farm for the same pattern of sexual assault, the last episode of which occurred 5 weeks before presentation.
He was the seventh of nine children born to parents who both only have primary school education. The father is a stone crusher while his mother is a petty trader. His school performance had worsened in the past year, but no change in behavior had been observed by the parents to warrant suspicion in that time.
On examination, he was acutely ill, groaning in pains and was febrile, with an offensive foul odor. He was underweight and had firm, nontender sausage-shaped masses in the left iliac fossa. There were no anal tags or obvious perianal scars but the anus was patulous, and the perianal region was soiled with copious foul-smelling purulent discharge. A pale object was visible on parting the anal verge, and further digital examination revealed a firm object lying along the axis of the anal canal, which fragmented into three pieces in the attempt at manual evacuation [Figure 1]. The fragments, which had become friable, were manually evacuated and were identified to be pieces of a corncob which measured 4 cm × 4 cm after reassembling. The mucosa was inflamed but had no necrotic areas, lacerations, or fissure-in-ano. A diagnosis of CSA with complications of sepsis and anusitis was made. Abdominal ultrasound showed fecal masses in the rectum, and serological tests for sexually transmitted diseases (STDs) were negative. He was placed on parenteral antibiotics, thrice-daily sitz baths, vaccinated against hepatitis B and commenced on antiretroviral therapy (ART) for postexposure prophylaxis (PEP) following guidelines for risk assessment. His clinical condition improved remarkably even though he became withdrawn and remained bedridden despite improvement of his physical condition. He was subsequently reviewed while still on admission along with a psychologist and hospital social welfare officer on a joint comanagement approach in consideration for the emotional and posttraumatic impact. On the 5th day, he had improved remarkably and had regained full sphincteric continence, following which he was discharged home to continue on oral antibiotics, ART, and sitz baths. A visit by the social worker revealed a stable and supportive home environment, but it was reported that the child had remained withdrawn and had become apprehensive when sent on errands out of the home unaccompanied. He completed 4 weeks of PEP, and a repeat HIV serologic testing was negative 12 weeks following discharge. Although the case was reported to the law enforcement authorities, no arrests were made as the assailant was unidentified and thus remained at large. He continues to receive psychotherapy for anxiety and posttraumatic stress disorder (PTSD).
|Figure 1: (a) Anterior view of anus with corncob fragments in the anal verge. (b) Oblique view of anus with corncob fragments in the anal verge|
Click here to view
| Discussion|| |
The World Health Organization defines CSA as “the involvement of a child in sexual activity that he or she does not fully comprehend is unable to give informed consent to, or for which the child is not developmentally prepared, or else that violates the laws or social taboos of society. This may include but is not limited to an inducement or coercion of a child to engage in any unlawful sexual activity, the exploitative use of a child in prostitution or other unlawful sexual practices and the exploitative use of children in pornographic performance and materials.”
This case is in conformity with the above definition in all its features as this male child could not have given consent to these acts and was being coerced, lured with gifts, while also being threatened to dissuade him from disclosure. The prevalence of male CSA from several studies is about 7.6%–10%,, which is similar to the reported prevalence of 10% from a national survey among 13–24-year olds in 2014 by the Nigerian National Population Commission. These studies, like many others, have consistently shown higher prevalence in females compared to males. However, many agree that the low rates reported among males may be related to poor disclosure of abuse implying that the rates of male CSA may be higher than what is commonly reported in the literature.,, The case presented conforms with the observation that male CSA may go unnoticed for years. The parents of the index child victim had been apparently oblivious of the serial abuse until the occurrence of the complications of the impaction of the corncob and secondary infection that led to suspicion of sexual assault by the PMV.
The perpetrator had threatened to kill the child if he disclosed their encounters, a feature that was reported to be one of the most common reasons that preclude disclosure.,, Other reasons why a child may not disclose include; the fear of being regarded as a homosexual, shame from feeling of weakness,,,, or protection of the perpetrator when a family member or acquaintance are the culprits. The act may also be portrayed to the victim (by the perpetrator) to be a way of gender role grooming with gradual sexualization of their relationship over time. Parental characteristics of low education, poverty, and large number of dependents as seen in the family history of the index child, have been identified as risk factors by Quadara et al. and Lefebvre et al.
While the motive for insertion of foreign object in the sexual act is unclear, it is conceivable that the assailant aimed either to dilate the anus for easy penile penetration, erotically stimulate the child or just to plug off feces to prevent soiling. Other possible explanations are that the child could have inserted the cob for sexual gratification (having become used to the perceived sexual pleasure) or to relieve anal itch from recurrent anal mucosal irritation brought about by serial assaults and accidentally got the cob retained his anus. Impaction of inserted anal and rectal foreign bodies during the act of sexual abuse has been reported in the literature.,, Anorectal foreign body insertion is more common in males, especially adolescents and young adults as a form of self-exploration and autoeroticism, while in the elderly, it has been associated with mental illness or alleviation of constipation. It may also be used as torture in cases of nonsexual physical assault. Objects that have been reportedly retained following insertions in the anorectum range from pebbles, carrots, bottles, candle, wooden sticks, bulbs, and thermometers., Despite numerous publications on CSA, there is a dearth of literature on organic foreign body insertion into the anus and rectum as a form of male CSA. A search in medical literature using the same keywords in this article using EMBASE, Google Scholar, African Journals Online, and PubMed revealed only one reported case of self-insertion of a maize corncob into the anus of a German middle-aged male farmer which became impacted in the rectum. However, the motive for the corncob insertion in the farmer's case was to relieve intractable diarrhea.
The case presented could, therefore, be the first report of impacted maize corncob in the anus presenting as a form of male CSA. It is unique with regard to the organic nature of the retained foreign body and the duration of retention. It is plausible that the corncob may have initially been retained in the rectum, albeit at an angle not encouraging easy evacuation but allowing the passage of liquid stools around it. However, as the cob absorbed more intestinal fluids, the size became an impediment to its expulsion and subsequently resulted in impaction in the anal canal.
The victim in this case presented with anusitis and sepsis. Other reported complications of anal sexual assault include fissure-in-ano, rectal perforation, anorectal fistula, perforations, bleeding, and STDs. In addition to the child's deteriorating school performance which was noticed earlier, he developed features of PTSD which is a common finding among victims. Cognitive behavioral therapy as a form of psychotherapy for both parents and victims has been lauded to alleviate parental distress, promote the child's retention of taught body safety skills, and improve victims' self-esteem and overall functioning. Male CSA victims also are more likely to become perpetrators of sexual abuse in adult years, thus perpetuating the cycle of abuse and violence.,,, Other long-term consequences of CSA may include sexual development problems, trust issues, shattered relationships, identity problems, personality paralysis, and self-destructive behavior.
The management of anorectal foreign object impaction is determined by the position of the object. Coskun et al. recommended that while high-lying objects may require anesthesia to allow adequate sphincteric dilatation before extraction, low-lying objects could often be removed manually as was done in the case presented.
While anorectal insertion of foreign objects into the anus is not common as a form of CSA in our environment, we have reported here the first case of corncob being the object of insertion. Childcare providers should have a high index of suspicion and thoroughly evaluate children for foreign object impaction in body orifices as a form of sexual abuse. Child caregivers/parents should be educated to recognize subtle developmental changes in children which may serve as a pointer to CSA. The protection of children is the responsibility of everyone. Thus, appropriate agencies should create awareness and educate the public on causes, consequences, and prevention as well as provide appropriate portals for reporting of CSA. Legislative reviews for more stringent punitive measures to serve as deterrent for all forms of child abuse are required.
| Conclusion|| |
This report highlights the bizarre presentations of sexual assault in children. Childcare practitioners should be wary of the possibility of foreign bodies insertion in victims, which may lead to severe complications.
Ethical approval and declaration of patient consent
Human research and ethical committee of the Ahmadu Bello University Teaching Hospital, Shika, Zaria on 15th November, 2016. The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/ her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Barth J, Bermetz L, Heim E, Trelle S, Tonia T. The current prevalence of child sexual abuse worldwide: A systematic review and meta-analysis. Int J Public Health 2013;58:469-83.
Stemple L, Meyer IH. The sexual victimization of men in America: New data challenge old assumptions. Am J Public Health 2014;104:e19-26.
Bejide F. Male child victim of sexual abuse in Nigeria. Front Leg Res 2014;2:83-99.
Koornstra JJ, Weersma RK. Management of rectal foreign bodies: Description of a new technique and clinical practice guidelines. World J Gastroenterol 2008;14:4403-6.
Coskun A, Erkan N, Yakan S, Yıldirim M, Cengiz F. Management of rectal foreign bodies. World J Emerg Surg 2013;8:11.
World Health Organisation. Responding to Children and Adolescents who have been Sexually Abused: WHO Clinical Guidelines. Geneva: World Health Organization; 2017.
Stoltenborgh M, van Ijzendoorn MH, Euser EM, Bakermans-Kranenburg MJ. A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreat 2011;16:79-101.
Sumner SA, Mercy JA, Buluma R, Mwangi MW, Marcelin LH, Kheam T, et al.
Childhood sexual violence against boys: A study in 3 countries. Pediatrics 2016;137. pii: e20153386.
Quadara K, Nagy V, Higgins D, Seigel N. Conceptualizing the Prevention of Child Sexual Abuse: Final Report (Research Report No. 33). Melbourne: Australian Institute of Family Studies,2015.
Lefebvre R, Fallon B, Van Wert M, Filippelli J. Examining the relationship between economic hardship and child maltreatment using data from the Ontario incidence study of reported child abuse and neglect-2013 (OIS-2013). Behav Sci (Basel) 2017;7. pii: E6.
Martin EK, Silverstone PH. How much child sexual abuse is “Below the surface,” and can we help adults identify it early? Front Psychiatry 2013;4:58.
Hamid R, Bhat NA, Wani SA, Baba A. Unusual rectal foreign body in a child. Pediatr Surg Case Rep 2014;2:391-3.
Stenz V, Thurnheer R, Widmer F, Krause M. Fremdkörpergeschichten [Foreign body stories]. Ther Umsch 2008;65:699-702.(Article in German). Available from: https://doi.org/10.1024/0040-5922.214.171.124
. [Last accessed on 2018 May 02].
Ameh EA. Anal injury and fissure-in-ano from sexual abuse in children. Ann Trop Paediatr 2001;21:273-5.
Deblinger E, Stauffer LB, Steer RA. Comparative efficacies of supportive and cognitive behavioural group therapies for young children who have been sexually abused and their non-offending mothers. Child Maltreat 2001;6:332-43.