Pysical Exam
Genital exam occurs only within context of a complete physical exam
General Physical Exam (Chapter 5, pg. 35-36)
An immediate assessment of the child's status must be made to determine the presence of bleeding from any vagi-
nal, rectal, penile or other trauma sites. Once the child is stable, perform a complete physical exam.
General appearance — Document the child's general appearance and emotional state. Note the Tanner stage of
breast development in the female patient.
Skin Examination — Include a Woods lamp examination of the entire body to look for semen if the abuse is thought to have occurred within the previous 72 hours. Record the presence of any bruises, bite marks, abrasions, lacerations, burns, fractures, grab marks, suction, gag or tether marks, injection sites or other dermatologic conditions. Estimate the age of the injury. Note the color of a bruise or hematoma and degree of healing of an abrasion.
Oral Examination — Inspect the oral cavity to document the presence of injury or STD lesions. Note bruising or petechiae of lips, buccal mucosa, gums, palate; mucosal tears especially of the frenula; or dental trauma.
Genital Examination — This exam should only occur with- in the context of a complete physical exam as part of the natural progression of the head-to-toe exam. Document findings of the anal/genital region on the body diagram forms noting location and etiology offered for any lesions found. Document the exam position when locating the lesions on the anatomical diagram.
Inspection/Palpation of Female and Male Genitalia (Chapter 5, pg. 37)
pubic hair development — estimate the Tanner stage;
inguinal adenopathy — estimate diameter of nodes if enlarged;
medial aspects of thigh — examine for dried or moist secretions, ecchymotic "grab marks," bite marks or evidence of other injuries. Note any healed scars or other abnormal findings such as STD lesions.
perineum — record the presence of any fresh or healed injuries, rashes or other unusual findings such as STD lesions;
vaginal or urethral discharge — note the presence of discharge in terms of amount, color and odor and identify its source;
STDs — note presence of condyloma acuminata, condyloma lata, herpes primary syphilis lesions or herpes.
Female Genital Examination (Chapter 5, pg. 37-39)
The genital examination of the prepubertal child is principally by external visualization. Instrumentation is rarely necessary. The examination of the pubertal child may require the use of a vaginal speculum if history suggests penetration. All visualization should be done before attempting any touching or specimen collection. Gently retract the labia majora to observe the genital structures. If the child is relaxed, the vagina and introitus will gradually open to reveal its maximum size. Do not insert fingers to determine size of hymenal opening or its patency The size of vaginal opening varies with the age of the child, the exam position and the degree of sedation or cooperation of the child.
labia majora and minora — note any skin lesions, unusual pigmentation or other skin changes;
clitoris — note unusual size or changes of the clitoris or hood;
urethral meatus — note any signs of inflammation, edema or other lesions of the periurethral tissue;
perihymenal tissue (vestibule) — note any increases in vascularity, abrasions, lacerations, scarring or STD lesions;
hymen — note the shape (anatomy) of the hymen on the genitalia diagram:
Record the diameter of the tranverse vaginal opening.
Document the exam position and degree of relaxation.
Note any signs of trauma or STD lesions to the hymen.
The terms "intact, broken, virginal or marital" are not sufficient to describe hymenal findings:
posterior fourchette and fossa navicularis — note lacerations or scars, bruises, healing abraded areas, STD lesions or neovascularization;
vagina — note any bleeding, discharge, STD lesions, foreign bodies on the walls of the vagina;
cervix - note any bleeding, discharge, STD lesions, cervicitis, tears or other signs of trauma.
Male Genital Examination (Chapter 5, pg. 39)
penis — note whether patient is circumcised.
Note any STD lesions, bite marks, edema, hematomas, lacerations, abrasions or dried secretions;
urethral meatus — note any scars or STD lesions, discharge, bleeding;
testes — note the presence of descended testes and any signs of atrophy or differential firmness in the tissue.
Anal/Rectal Examination (Chapter 5, pg. 39-40)
Note the exam position on the medical record. Lateral decubitus is often best.
buttocks — note fresh or healed lesions, dried secretions, ecchymoses, rashes, STD lesions, hand or fingerprints;
perianal skin — examine for presence of inflammation. Record findings of dried secretions, bruising, tears, lacerations, fissures, abraded areas, scars and skin tags. Note whether fissures, tears or lacerations are located on the external mucosal surface, internal to the sphincter or extend across the pectinate line.
anal verge /folds/ rugae — note whether the verge or anal sphincter skin folds appear to be prominent, normal or flattened (funnelled) when the child is in a relaxed state;
one — note whether anal tone is within normal limits;
anal laxity — estimate or measure the diameter of any anal dilatation; Record the presence or absence of stool in the rectal ampulla.
rectal examination — is rarely necessary in the evaluation of sexual abuse.
