A Normal Ano-genital Exam: Sexual Abuse or Not?

Gail Hornor, RNC, MS, CPNP

Disclosures

J Pediatr Health Care. 2010;24(3):145-151. 

In This Article

Normal Genital Anatomy

There can be significant variation in hymenal configuration, making the hymen more difficult to recognize. The three most common hymenal configurations are: annular (hymenal tissue present from 12 to 12 o'clock) (Figure 2); crescentic (hymenal tissue absent from 11 to 1 o'clock) (Figure 3); or redundant (hymenal tissue that folds onto self; opening may be difficult to visualize) (Figure 4) (Berenson et al., 1992, Heger et al., 2002). Another normal variant for hymenal configuration is the septate hymen where bands of tissue bisect the orifice, creating two or more openings (Figure 5).

Figure 2.

Annular hymen. This figure is available in color online at www.jpedhc.org.

Figure 3.

Crescentic hymen. This figure is available in color online at www.jpedhc.org

Figure 4.

Redundant hymen floated with normal saline solution. This figure is available in color online at www.jpedhc.org

Figure 5.

Septate hymen. This figure is available in color online at www.jpedhc.org

The prepubertal hymenal edge may be smooth and delicate or have shallow notches (Figure 6) or bumps (Figure 7), which are variants of normal (Myhre, Berntzen, & Bratlid, 2003). Partial/shallow notches occur in 360 degrees of the hymenal rim (Heger, Ticson, Guerra, et al., 2002). Complete (extending entirely through the hymen) and deep (extending deep into the hymen but not entirely through the hymen) clefts or notches normally are found in the anterior rim, but complete/deep clefts normally do not occur in the posterior rim. To assist in defining the anterior versus posterior rim of the hymen, consider the patient lying in a supine position and think of the hymen as the face of a clock. The anterior rim is from 9 o'clock to 12 o'clock to 3 o'clock and the posterior rim is from 3 o'clock to 6 o'clock to 9 o'clock. A deep cleft or notch in the posterior hymenal rim is an indeterminate finding of sexual abuse (Adams et al., 2007). A deep notch or cleft in the posterior hymenal rim may support a child's history of sexual abuse but, without a history of sexual abuse, the finding should be interpreted with caution. The PNP noting a deep notch/cleft in the posterior hymenal rim should strongly consider obtaining a second opinion examination by a skilled child sexual abuse examiner and consider reporting to Child Protective Services. A complete notch/cleft in the posterior hymenal rim is more accurately referred to as a transaction and is highly suspicious of sexual abuse and must be reported to Child Protective Services (Figure 8).

Figure 6.

Prepubescent hymen with shallow notch at 7 to 8 o'clock. This figure is available in color online at www.jpedhc.org

Figure 7.

Prepubescent hymen with bump at 6 o'clock. This figure is available in color online at www.jpedhc.org

Figure 8.

Prepubescent hymen with complete cleft at 6 o'clock; 6-year-old gave no history of sexual abuse; vaginal culture positive for gonorrhea. This figure is available in color online at www.jpedhc.org

A complete notch/cleft in the posterior hymenal rim is more accurately referred to as a transaction and is highly suspicious of sexual abuse and must be reported to Child Protective Services.

Historically it was thought that the size of the hymenal orifice (vaginal opening) could be used as an indicator of sexual abuse; however, neither horizontal nor vertical hymenal orifice measurements have any relationship to sexual abuse (Berenson et al., 2002, Ingram et al., 2001). Narrowing of the posterior hymenal rim less than 1 mm also was thought to be suspicious for sexual abuse (Adams, Harper, Knudson, & Revilla, 1994). However, subsequent studies (Berenson et al., 2001, Heger et al., 2002) have found narrowing of the hymenal rim posteriorly to be difficult to measure accurately, and this narrowing can be found in more than 20% of girls who have not been sexually abused as well as those who have been sexually abused. (Figure 9).

Figure 9.

Narrow hymen on prepubescent examination. This figure is available in color online at www.jpedhc.org

Take a moment to study the photo (Figure 1) and anatomic parts with the understanding that the prepubescent hymen is very sensitive to touch, and when touched even gently with a tiny applicator during examination the child will indicate discomfort. Consider a prepubescent girl who is giving a history of penile or digital penetration of the vagina. Note that the hymen is recessed and protected by the labia majora and minora. The labia must be penetrated in order to touch the hymen. Labial penetration does not cause discomfort to the child. It is possible for labial penetration to occur without full or even partial penetration of the hymen. If the child is not disclosing pain or discomfort with the sexual abuse, it is possible that labial penetration occurred without touching the hymen. If the child is disclosing pain/discomfort with the penetration yet denying any bleeding, a likely explanation is labial penetration with touching the hymen yet not penetrating the hymen. Note that the hymen is elastic and will stretch to allow penetration, or at least partial penetration, without evidence of trauma. It is impossible to determine whether the penetration was only through the labia or partially into the vagina without a videotaped event or a third-party witness (Adams et al., 1994).

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