Child Abuse. Pocket Atlas Series. Sexual Abuse. STM Learning, Inc. Volume Two

Transcription

1 WARNING This excerpt is intended for use by medical, legal, social service, and law enforcement professionals. It contains graphic images that some may find disturbing or offensive. Minors and/or nonprofessionals should not be allowed to access this material. Child Abuse Pocket Atlas Series Volume Two Sexual Abuse STM Learning, Inc. Leading Publisher of Scientific, Technical, and Medical Educational Resources Saint Louis i

2 Our Mission To become the world leader in publishing and information services on child abuse, maltreatment, diseases, and domestic violence. We seek to heighten awareness of these issues and provide relevant information to professionals and consumers. A portion of our profits is contributed to nonprofit organizations dedicated to the prevention of child abuse and the care of victims of abuse and other children and family charities.

3 Child Abuse Pocket Atlas Series Volume Two Sexual Abuse Randell Alexander, MD, PhD Professor of Pediatrics and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida Angelo P. Giardino, MD, PhD Vice President/Chief Medical Officer Medical Affairs Texas Children s Health Plan Clinical Professor, Pediatrics and Section Chief Academic Pediatrics Department of Pediatrics Baylor College of Medicine Houston, Texas Debra Esernio-Jenssen, MD, FAAP Professor of Pediatrics University of Florida at Gainesville Medical Director Child Protection Team Gainesville, Florida Jonathan D. Thackeray, MD, FAAP Physician The Center for Family Safety and Healing Division of Child and Family Advocacy Department of Pediatrics Nationwide Children s Hospital Columbus, Ohio Joyce A. Adams, MD Professor of Clinical Pediatrics Division of General Academic Pediatrics and Adolescent Medicine School of Medicine University of California, San Diego Specialist in Child Abuse Pediatrics Rady Children s Hospital San Diego, California Suzanne P. Starling, MD, FAAP Professor of Pediatrics Eastern Virginia Medical School Division Director, Child Abuse Pediatrics Medical Director, Child Abuse Program Children s Hospital of the The King s Daughters Norfolk, Virginia David L. Chadwick, MD Director Emeritus Chadwick Center for Children and Families Children s Hospital - San Diego Adjunct Associate Professor Graduate School of Public Health San Diego State University San Diego, California Rich Kaplan, MSW, MD, FAAP Child Abuse Pediatrician Children s Hospitals and Clinics of Minnesota Associate Professor of Pediatrics University of Minnesota Medical School Medical Director The Center for Safe and Healthy Children University of Minnesota Amplatz Children s Hospital Associate Medical Director Midwest Children s Resource Center Children s Hospitals and Clinics of Minnesota Minneapolis, Minnesota iii

4 Publishers: Glenn E. Whaley and Marianne V. Whaley Graphic Design Director: Glenn E. Whaley Managing Editor: Paul K. Goode, III Print/Production Coordinator: Jennifer M. Jones and G.W. Graphics Cover Design: Jennifer M. Jones and G.W. Graphics Color Prepress Specialist: Kevin Tucker Acquisitions Editor: Glenn E. Whaley Developmental Editor: Paul K. Goode, III Copy Editor: Paul K. Goode, III Proofreader: Paul K. Goode, III Editorial/Publishing Consultant: Kerry Blasingim Copyright 2016 STM Learning, Inc. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher. Printed in the United States of America. Publisher: STM Learning, Inc. Saint Louis, Missouri Phone: (314) Fax: (314) orders@stmlearning.com The Library of Congress has cataloged the printed edition as follows: Names: Alexander, Randell, 1950-, editor. Title: Sexual abuse / [edited by] Randell Alexander, Angelo P. Giardino, Debra Esernio-Jenssen, Jonathan D. Thackeray, Joyce A. Adams, Suzanne P. Starling, David L. Chadwick, Rich Kaplan. Other titles: Sexual abuse (Alexander) Child abuse pocket atlas series ; v. 2. Description: Florissant, MO : STM Learning, Inc., [2016] Series: Child abuse pocket atlas series ; volume 2 Includes bibliographical references and index. Identifiers: LCCN (print) LCCN (ebook) ISBN (pbk. : alk. paper) ISBN (ebook) Subjects: MESH: Child Abuse, Sexual--diagnosis Infant Child Adolescent Case Reports Atlases Handbooks Classification: LCC RC560.C46 (print) LCC RC560.C46 (ebook) NLM WS 17 DDC /836--dc23 LC record available at iv

5 Contributors Joyce A. Adams, MD Professor of Clinical Pediatrics Division of General Academic Pediatrics and Adolescent Medicine School of Medicine University of California, San Diego Specialist in Child Abuse Pediatrics Rady Children s Hospital San Diego, California Randell Alexander, MD, PhD Professor of Pediatrics and Chief Division of Child Protection and Forensic Pediatrics Department of Pediatrics University of Florida Jacksonville, Florida Debra Esernio-Jenssen, MD, FAAP Professor of Pediatrics Child Protection Team University of Florida at Gainseville Lori D. Frasier, MD Clinical Professor University of Utah School of Medicine Director of the Fellowship in Child Abuse Pediatrics University of Utah Salt Lake City, Utah Kristi A. Green, MSN, ARNP Advanced Registered Nurse Practitioner Department of Pediatrics University of Florida Jason Schulman, MD Pediatrician Miami, Florida v

6 Preface The concept of medical care for children who are possible victims of child sexual abuse is relatively new. In the recent past, we have seen the medical care for these children undergo a significant evolution, in which we now view these children as patients who require medical attention and care. The focus of this book is to address the medical care for these children from a variety of perspectives. In creating this book, our goal has been to demystify the medical care of sexually abused children. When caring for a child who is a possible survivor of child sexual abuse, the essential principles and standards of medical care apply, such as obtaining a complete and well-documented history and physical examination, performing an appropriate and scientifically driven laboratory evaluation, and forming a medical diagnosis to guide the ongoing care needs of the patient. It should be clear that the medical component is simply one part of the response to maltreatment. While legal issues certainly are important for the safety and well-being of children, the focus of this text primarily will be on the medical and therapeutic care these children need to heal and, hopefully, to have a happy and productive life. This book, the second volume of the Child Abuse Pocket Atlas Series, brings together experts and scholars with a variety of expertise related to the care of young survivors. While the focus of this book is medical care, it is our hope that other members of the multidisciplinary team will find this a useful reference. Rich Kaplan, MSW, MD, FAAP Joyce A. Adams, MD Suzanne P. Starling, MD, FAAP Angelo P. Giardino, MD, PhD vii

7 Contents in Brief Chapter 1: Basic Anogenital Anatomy 1 Chapter 2: Equipment for the Documentation of Sexual Abuse 39 Chapter 3: Interpretation of Anogenital Findings 55 Chapter 4: Sexual Abuse 107 ix

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9 Contents in Detail Chapter 1: Basic Anogenital Anatomy Embryology Normal Variations Effects of Puberty The Hymen The Vagina The Cervix The Anus Conclusion Features of Genital and Anal Anatomy References Chapter 2: Equipment for the Documentation of Sexual Abuse Photodocumentation Laboratory Specimens Forensic Evidence Collection Medication Telemedicine Sexual Abuse Documentation Equipment Photodocumentation Laboratory Specimens Forensic Evidence Collection Medication Telemedicine References Chapter 3: Interpretation of Anogenital Findings. 55 History Studies in Genital and Anal Findings in Children and Adolescents With Suspected Sexual Abuse Research Hymenal Data Sexually Transmitted Infections Mimics Anal Dilation Injuries Conclusion Normal Variations and Forensic Photography References xi

10 xii Chapter 4: Sexual Abuse Techniques and Basic Skills Hymenal Configurations Findings Confused With Abuse Imperforate Hymen Prolapsed Uterus Lichen Sclerosis Urethral Prolapse Failure of Midline Fusion Labial Fusion Straddle Injury Vaginal Duplication Vitiligo Foreign Body Toxic Shock Hymenal Projection External Hymenal Midline Extensive Labial Fusion Failed Midline Fusion Possible Foreign Body Lichen Sclerosis Causing Bleeding Labial Bruising Duplication of Reproductive Structures Pinworm Hemangioma Perianal Vitiligo Vaginal Discharge Normal Findings Crescentic Hymen Annular Hymen Large Urethral Opening Above Normal Hymen Normal Intact Hymen Anal Tag Normal Intact Annular Hymen Intravaginal Ridge Normal Examination Normal Anal Findings Thickened Crescentic Hymen Circumferential or Annular Hymen Anterior Anal Venous Pooling Extensive Anal Pooling Midline White Line Normal Examination After Sexual Assault Smooth Avascular Posterior Area Hymenal Projection

11 Integrity of Hymen Hymenal Mound Anterior Intravaginal Ridge Knee-Chest Position Intact Posterior Rim Prominent Urethral Support Structures Hymenal Tag Normal Posterior Hymenal Rim Hymenal Projection Intravaginal Rugae and Normal Hymen Estrogenized Hymen in Abused Girl Normal Hymenal Mound Posterior Mound With Cleft Possible Precocious Puberty Cribriform Hymen Estrogenized and Intravaginal Rugae Vascularization Examination With and Without Traction Hymenal Pit Normal Cribriform Hymen in Alleged Abuse Penetration Acute Findings Hematoma and Hymenal Tear Partial Healing After Transection of the Hymen Anal Tears Lacerations Unexplained Genital Bleeding Acute Penetration Traumatic Superficial Hymenal Laceration Anal Laceration Laceration With Bruising Perianal Laceration Acute Laceration After Penile Penetration Vaginal Bleeding After Penile Penetration Vaginal Bleeding Anal Tear Linear Abrasions Hymenal Transections Hymenal Septum Hymenal Transection Vaginal Discharge Digital Penetration Penetration Anal Abuse Complete Disruptions xiii

12 Contents in Detail Discontinuity of Hymen Labial Intercourse Straddle Injury-Related Bruising Alleged Rape Perianal Bruising Bruising of Penis Burned Penis Perianal Laceration Caused by Penetration Accidental Anal Hematoma Sexually Transmitted Diseases Herpes Simplex Virus Type Syphilitic Lesion Genital Warts Perianal Herpes Condyloma Acuminata Hemorrhagic Herpes Scrotal Condyloma Acuminata Cylindrical Perianal Condylomata Perianal Streptococcal Infection Penile Lichen Planus Flatwarts Molluscum contagiosum Genital Warts Old Injuries History of Penile Penetration Previous Vaginal Penetration Digital Penetration Healed Transection References xiv

13 Child Abuse Pocket Atlas Series Volume Two Sexual Abuse STM Learning, Inc. Leading Publisher of Scientific, Technical, and Medical Educational Resources Saint Louis xv

14 Chapter 1 Basic Anogenital Anatomy Joyce A. Adams, MD In order to recognize signs of child sexual abuse, it is necessary to first be familiar with normal genital anatomy, its variations, and its development. While this may seem obvious, the lack of understanding of the many variations in normal appearance of the genital and anal tissues in children has led to misunderstandings among medical and nonmedical professionals alike. Even after the publication of the first detailed descriptions of anal and genital anatomy in nonabused prepubertal children, 1-3 some physicians and nurses who perform child sexual abuse medical evaluations are not familiar with the findings from those and subsequent studies. 4-9 When a child s examination is thought to show signs of injury or abuse but actually represents normal findings or evidence of another medical condition, the medical provider may contact child protection and/or law enforcement officials to report the suspicions. The child and family would then be unnecessarily traumatized by a referral and investigation of those suspicions. It is also important for medical and nursing professionals, as well as nonmedical professionals, to be able to speak the same language when describing features of genital and anal anatomy in children and adolescents. Anatomy courses in medical and nursing school rarely provide the necessary detail about the features of genital anatomy in children, usually focusing on adults and on pathology common to adult patients. In the early 1990s, a group of physicians met at conferences to agree on proper terminology for describing features of genital and anal anatomy, and the results of a 4-year consensus development process was published by the American Professional Society on the Abuse of Children in Some of the definitions were taken from standard medical dictionaries and anatomy textbooks, but out of necessity, other definitions were created by specialists working in the field of sexual abuse medical evaluation. Table 1-1 is a list of terms and definitions from that publication. 10 1

15 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse Table 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms. 10 Anatomical Structures in the Female Mons pubis: The rounded, fleshy prominence, created by the underlying fat pad that lies over the symphysis pubis (pubic bone). Vulva: The external genitalia or pudendum of the female. Includes the anterior commisure, clitoris, labia majora, labia minora, vaginal vestibule, urethral orifice, vaginal orifice, hymen, and posterior commisure. Anterior commisure: The union of the 2 labia minora anteriorly/superiorly. Clitoris: A small, cylindrical, erectile body, situated at the anterior (superior) portion of the vulva, covered by a sheath of skin called the clitoral hood; homologous with the penis in the male. Labia majora (singular: labium majus): Rounded folds of skin forming the lateral boundaries of the vulva. Labia minora (singular: labium minus): Longitudinal thin folds of tissue enclosed within the labia majora. In the prepubertal child, these folds extend from the clitoral hood to approximately the midpoint on the lateral walls of the vestibule. In the adult, they enclose the structures of the vestibule. Vaginal vestibule: An anatomic cavity containing the opening of the vagina, the urethra, and the ducts of Bartholin s glands. Bordered by the clitoris superiorly, the labia minora laterally, and the posterior commisure inferiorly. Urethral orifice: External opening of the canal (urethra) from the bladder. Vestibular bands: Small bands of tissue lateral to the urethral orifice that connect the periurethral tissues to the anterior lateral walls of the vestibule (urethral support ligaments), or bands of tissue lateral to the hymen connecting to the vestibular wall. Vaginal orifice: The opening to the uterovaginal canal. Vagina: The internal structure extending from the uterine cervix to the inner edge of the hymen. Hymen: A membrane that partially, or rarely completely, covers the vaginal orifice. Fossa navicularis/posterior fossa: Concavity on the lower part of the vestibule situated inferiorly to the vaginal orifice and extending to the posterior commisure or posterior fourchette. Posterior commisure: The union of the 2 labia majora inferiorly (toward the anus). (continued) 2

16 Chapter 1: Basic Anogenital Anatomy Table 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms. 10 (continued) Anatomical Structures in the Male Penis: Male sex organ composed of erectile tissue through which the urethra passes; homologous with the clitoris in the female. Glans penis/balanus: The cap-shape expansion of the corpus spongiosum at the end of the penis. It is covered by mucous membrane and sheathed by the prepuce (foreskin) in uncircumcised males. Scrotum: The pouch that contains the testicles and their accessory organs. Median raphe: A ridge or furrow that marks the line of union of the 2 halves of the perineum. Descriptive Terms Related to the Perineum and Anus Perineum: The external surface or base of the perineal body, lying between the vulva and the anus in the female and the scrotum and the anus in the male. Underlying the external surface of the perineum is the pelvic floor and its associated structures occupying the pelvic outlet, which is bounded anteriorly by the pubic symphysis (pubic bone), laterally by the ischial tuberosity (pelvic bone), and posteriorly by the coccyx (tail bone). Perineal body: The central tendon of the perineum located between the vulva and the anus in the female and between the scrotum and anus in the male. Anus: The anal orifice, which is the lower opening of the digestive tract, lying in the fold between the buttocks through which feces is extruded. Anal skin tag: A protrusion of anal verge tissue that interrupts the symmetry of the perianal skin folds. Anal verge: The tissue overlying the subcutaneous division of the external anal sphincter at the most distal portion of the anal canal (anoderm) and extending exteriorly to the margin of the anal skin. Pectinate/dentate line: The sawtoothed line of demarcation between the distal (lower) portion of the anal valves and the pectin, ie, the smooth zone of stratified epithelium that extends to the anal verge. This line may be apparent when the external and internal anal sphincters relax and the anus dilates. Definitions taken from Practice Guidelines: Descriptive Terminology in Child Sexual Abuse Medical Evaluations published by the American Professional Society on the Abuse of Children, Adapted and reprinted with permission from the American Professional Society on the Abuse of Children. 3

17 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse 4 Embryology An appreciation of the wide variation in the appearance of the genital and anal tissues in children requires an understanding of embryology and how the external genital tissues develop. For the first 6 weeks of development, the genital structures of the human embryo are in an undifferentiated state. In males, a transcription factor encoded on the sex-determining region of the Y chromosome (SRY) is produced during the seventh week, which triggers male development. In the absence of a Y chromosome and SRY production, female development progresses. From the indifferent stage (4 to 7 weeks) through the 12th week, the genital tubercle differentiates into the glans and shaft of the penis in the male and into the glans and shaft of the clitoris in the female. The definitive urogenital sinus develops into the penile urethra in the male and the vestibule of the vagina in the female. The urethral fold becomes the penis surrounding the penile urethra in the male or the labia minora in the female. The labioscrotal fold develops into either the scrotum in the male or the labia majora in the female. 11 A detailed study of the development of the perineum was published in 2005, which provided a new understanding of the formation of the vagina and hymen. 12 In the undifferentiated state, the distal ends of the fused paramesonephric ducts are separated from the urogenital sinus by the dense stroma of the Mullerian tubercle. In females, the mesonephric ducts regress and the fused paramesonephric ducts form the uterus and vagina. The mesonephric orifices are incorporated into the orifice of the developing vagina, and the epithelium is replaced by the epithelium from the Mullerian tubercle. The vagina expands and extends downward to bulge into the vestibulum, and the paramesonephric epithelium is transformed into vaginal epithelium. The glycogen-filled cells begin to disintegrate, which forms the lumen of the vagina. The data from the study by van der Putte provide support for the theory that the vagina is formed mainly from paramesonephric epithelium, not from the urogenital sinus. 12 Alternate theories postulated prior to this study held that the inferior portion of the vagina was formed from a portion of the urogenital sinus called the sinuvaginal bulb. 11 The lengthening of the vagina into the vestibulum, where it meets the dense stromal tissue of the Mullerian tubercle, forms the hymen. 12 Folds in the urogenital sinus contribute to the lateral folds of the hymen. The deepening of the dorsal vestibular groove accentuates the dorsal segment of the hymen, which in clinical terms is referred to as the posterior or inferior rim. Both the inner side and the outer side of the hymen are

18 Index A abrasions, linear, abused girl, estrogenized hymen in, 148 accidental anal hematoma, 182 acute laceration, 163 acute penetration, 160 alleged abuse, cribriform hymen in, 152 alleged rape, 180 anal abuse, anal anatomy, features of, 1, anal dilation, 60 anal erythema lacerations, 77 anal findings in children, 56 anal folds, venous pooling and flattening of, 36 anal hematoma, accidental, 182 anal laceration, 87, 161 anal polyp, 95 anal tag, 10, 138 anal tear, 155, 168 anatomy anogenital, 1 3 courses, 1 genital and anal, structures in female, 2 structures in male, 3 annular hymen, 13, 15 anogenital anatomy, 1 3 effects of puberty, 8 11 embryology, 4 5 genital and, normal variations, 5 8 anterior anal venous pooling, 142 anterior commisure, 2 anterior intravaginal ridge, 145 anus, 3, skin tag, 3 verge, 3 B bleeding, 55, , 132 genital, lichen sclerosis causing, 132 vaginal, 74, Bowenoid papulosis, 186 bruising of penis, 181 burned penis, 181 buttocks lesion, 183 C Candida albicans, 61, 78 cervical ectropion, 33 cervix, 9, 33 child sexual abuse, 5 signs of, 1 societal awareness of, 5 children cross-sectional studies of, 8 genital and anal findings in, 56 genital and anal tissues in, 4 injuries, medical examination of, 107 sexual abuse. See sexual abuse Chlamydia, 167 circumferential/annular hymen, 142 cleft, posterior mound with, 149 clitoris, 2 condyloma acuminata, 185, 187 crescentic hymen, 7, 14, 28, 137 defined, 7 cribriform hymen, 150 in alleged abuse, 152 cylindrical perianal condylomata,

19 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse D diastasis ani, 9, 34 digital penetration, 162, 174, 190 discontinuity of hymen, 179 disruptions of posterior hymen, 178 documentation of sexual abuse, forensic evidence collection, 42, laboratory specimens, 41 42, medication, 43, 52 photodocumentation, 40 41, 45 telemedicine, 43 44, 52 E embryology, 4 5 erythema, 101 estrogenization, , 149, 150 estrogenized hymen, 92 in abused girl, 148 extensive anal pooling, 142 extensive labial fusion, 129 external hymenal midline, 128 external hymenal ridge, 6 F failed midline fusion, 129 fimbriated hymen, 6 flatwarts, 187 focal erythema of hymen, 83 foreign body, 125, forensic evidence collection, 42, forensic photography, normal variations and, fossa navicularis/posterior fossa, 2, 91 G Gardnerella vaginalis, 78, 90 genital anatomy, features of, 1, genital bleeding, genital findings in children, 56 genital herpes, 185 genital warts, 184, 188 glans penis/balanus, 3 H healed transection, 190 healing after transection of hymen, 154 hemangioma, 134 hematoma, 154 hemorrhagic herpes, 185 herpes simplex virus (HSV-1), 185 type 1, 183 HPV. See human papillomavirus (HPV) HSV-1. See herpes simplex virus (HSV-1) human embryo, 4 human papillomavirus (HPV), 187 infections, 184 hymen, 2, 5, anatomical structures in female, 6 anatomical variations of, 6 circumferential/annular, 142 crescentic, 7, 137 cribriform, 150, 152 discontinuity of, 179 disruptions of, 178 dorsal segment of, 4 estrogenized, 30, 92 features by age, 7 focal erythema of, 83 hematoma and tearing of, 154 imperforate, 120 in adolescents, 31 in neonates, 5 integrity of, 145 irregular, 89 laceration of, 165 microperforate, 25 morphology of, 5 normal, 137, 148 partial notch in, 86 petechial hemorrhages on, 166 posterior rim of, 8 septate, 22 thickened crescentic, 141 transection of, 154 tulip-shaped, 9 192

20 Index hymenal cleft, 6 hymenal configurations, hymenal cyst, 6 hymenal data, hymenal laceration, traumatic superficial, 160 hymenal morphology, 7 features of, 7 hymenal mound/bump, 6, 145, 148 hymenal orifice, hymenal pit, 152 hymenal projection, 128, 144, 147 hymenal septum, 171 hymenal tag, 6, 147 hymenal tear, 154 hymenal transection, 170, 172 hymeneal notch, 84 hypertrophic papillary lesions, 183 I imperforate hymen, 6, 120 injuries, 60 61, 130, straddle, 123 intact hymen, 138 intact posterior rim, 146 intercourse, labial, 179 intravaginal ridge, 139 intravaginal rugae, 148, 150 irregular hymen, 89 K knee-chest position, 146 L labia majora, 2 labia minora, 2, asymmetric development of, 32 thickness and pigmentation of, 24 labia, external surface of, 9 labial bruising, 133 labial fusion, 123 labial intercourse, 179 labial separation, 12 labial traction, 12, 17, 26, 27, 64 examination using, 16, labium minus, 29 laboratory specimens, 41 42, laceration, with bruising, 162 lichen planus, 187 lichen sclerosis, 100, 121, 132 linear abrasions, M median raphe, 3 medication, 43, 52 microperforate hymen, 25 midline fusion, failure of, 123 midline white line, 143 Molluscum contagiosum, 188 mons pubis, 2 Mullerian tubercle, 4 Myhre study, 10 N NAATs. See nucleic acid amplification tests (NAATs) neonates, hymen in, 5 normal cribriform hymen, in alleged abuse, 152 normal hymen, 148 normal variations, and forensic photography, nucleic acid amplification tests (NAATs), 167 P pectinate/dentate line, 3 penetration, 153, 175 digital, 174, 190 penile, 189 perianal laceration caused by, 182 vaginal, 189 penile lichen planus, 187 penile penetration, , 189 penis, 3 bruising of, 181 burned, 181 perianal bruising, 176, 181 perianal herpes, 185 perianal laceration, 163 caused by penetration, 182 perianal streptococcal infection,

21 Child Abuse Pocket Atlas Series, Volume 2: Sexual Abuse perianal vitiligo, 134 perineal body, 3 perineal groove, 11 perineal lacerations, 85 perineum, 3, 4 photodocumentation, 40 41, 45 pinworm, 134 possible precocious puberty, 149 posterior commisure, 2, 6 posterior hymenal rim, 147 posterior mound with cleft, 149 primordial urethral glands, 5 prolapsed uterus, 120 prominent urethral support structures, 146 puberty, effects of anus, 9 11 cervix, 9 hymen, 8 9 vagina, 9 R rape, alleged, 180 redundant hymen, 6 reproductive structures, duplication of, 133 research design, gold standard for, Rett s syndrome, 176 S scrotal condyloma acuminata, 186 scrotum, 3 septate hymen, 6, 22 sexual abuse, 14, acute findings, documentation of. See documentation of sexual abuse examination positions, findings confused with, hymenal configurations, injuries, normal findings, sexually transmitted diseases, suspicion of, 9 techniques and basic skills, sexual assault, 55 normal examination after, 143 sexually transmitted diseases condyloma acuminata, 185 cylindrical perianal condylomata, 186 flatwarts, 187 genital warts, 184, 188 hemorrhagic herpes, 185 herpes simplex virus type 1, 183 Molluscum contagiosum, 188 penile lichen planus, 187 perianal herpes, 185 perianal streptococcal infection, 187 scrotal condyloma acuminata, 186 syphilitic lesion, 183 sexually transmitted infections, 59 smooth avascular posterior area, 144 straddle injury, 123 related bruising, 180 syphilitic lesion, 183 T Tanner Stage 2 development, 8 telemedicine, 43 44, 52 thickened crescentic hymen, 141 toluidine blue dye uptake, 61, 75, 77, toxic shock, traction, examination with and without, 151 transection, healed, 190 traumatic superficial hymenal laceration, 160 tulip-shaped hymen, 9 U urethral orifice, 2 urethral prolapse,

22 Index V vagina, 2, vaginal bleeding, after penile penetration, 164 vaginal discharge, , 173 in children, 115 vaginal duplication, 124 vaginal orifice, 2 vaginal penetration, 189 vaginal vestibule, 2 vascularization, 151 vestibular bands, 2 vitiligo, 124 vulva, 2, 31, 34,