Anal fissures and anal scars in anal abuse--are they significant?

The notes of 214 children who, over a period of 7 years, had been referred after an allegation or a suspicion of any form of child abuse, were examined retrospectively to establish the pattern of injury found, especially with regard to anal fissures or scars. These were all children who had had their genitalia examined at the time of their referral. In 81 children (Group A) who had no history or evidence of sexual abuse, two fissures were found, both with medical explanations for their presence. In 83 (Group B) who alleged sexual abuse but denied anal abuse, nine (11%) had fissures or scars, and in four of the nine there was a history of significant constipation at some time. In 50 children (Group C) who had a strong history of anal abuse, 41 (84%) had fissures or scars. The diagnosis in 13 of these cases was considered definite because there was a confession or guilty plea from the abuser; in the remainder, the diagnosis was "not proven" despite a strong history or gross anal signs and regardless of the verdict in court proceedings. The significance of the findings was discussed with a view to clarifying the relative importance of anal fissures in children with a strong history of anal abuse.