ANOGENITALFINDINGS ONEXAMINATION Category 1 Category 1a: Normal (found in Category 1b: Normal variants Category 1c: Other conditions

newborns) Septate hymen Hemangiomas of the labia, hymen, or perihymenal area (may give the appearance of Periurethral (or vestibular) bands Failure of midline fusion (perineal bruising or sub-mucosal hemorrhage) Longitudinal intravaginal ridge or groove) Lichen sclerosus et atrophicus (may result in friability and bleeding) column Groove in the fossa in a pubertal Bechets Disease (causes genital and oral ulcers, may be mistaken for Herpes Simplex Hymenal tag female lesions) Hymenal bump or mound Diastasis ani Streptococcal cellulitis of perianal tissues (Causes red, inflamed tissues) Linea vestibularis Perianal skin tag Molluscum contagiosum (warty lesions) Hymenal cleft/notch in the Increased perianal pigmentation Verruca vulgaris (common warts) anterior (superior) half of the Venous congestion in the perianal Vaginitis caused by streptococcus or enteric organisms hymenal rim, on or above the 3 area Urethral prolapse (causes bleeding, appearance of trauma) oclock to 9 oclock line,patient Vaginal foreign bodies (may cause bleeding, discharge) supine External hymenal ridge Category 2: Nonspecific findings(findings that may be the result of sexual abuse, depending on the timing of the examination with respect to the abuse, but that may also be due to other causes) Erythema (redness) of the vestibule, penis, scrotum, or perianal tissues (may be due to irritants, infection, or trauma) Increased vascularity (dilatation of existing blood vessels) of vestibule (may be due to local irritants) Labial adhesion (may be due to irritation or rubbing) Vaginal discharge (many causes, including sexually transmitted infections) Vesicular lesions in the genital or anal area (cultures for Herpes Type 1 and 2, and testing for syphilis must be done) Wart-like lesions in the genital or anal area (may need biopsy to confirm diagnosis) Friability of the posterior fourchette or commisure (may be due to irritation, due to infection, or caused by examiners traction on the labia majora) Thickened hymen (may be due to estrogen effect, folded edge of hymen, swelling from infection, or swelling from trauma) Anal fissures (usually due to constipation or perianal irritation) Flattened anal folds (may be due to relaxation of the external anal sphincter) Anal dilatation of any size, if stool is present in the rectal vault or if it occurs after the child has been in the prone knee-chest position for 30 seconds or more (a normal reflex) Vaginal bleeding (may be from other sources, such as urethra, or may be due to vaginal infections, vaginal foreign body, or accidental trauma, and abuse) Notch or cleft in the posterior (inferior) portion of the hymen, which extends through no more than 50% of the width of the hymenal rim (found in an equal number of abused and nonabused girls ages 3 to 8 years) (Berenson et al., 2000) Category 3: Concerning for abuse or trauma (findings that have been noted in children with documented abuse and may be suspicious for abuse but for which insufficient data exist to indicate that abuse is the only cause; history is crucial in determining overall significance) Marked, immediate dilation of the anus, with no stool visible or palpable in the rectal vault, when the child is examined in the knee-chest position, provided there is no history of encopresis, chronic constipation, neurological deficits, or sedation Hymenal notch/cleft extending through more than 50% of the width of the hymenal rim, in the posterior (inferior) segment (often an artifact of examination technique, but if persistent in all examination positions, may be due to previous blunt force or penetrating trauma) Acute abrasions, lacerations, or bruising of labia, perihymenal tissues, penis, scrotum, or perineum (may be from accidental trauma or inflicted as physical punishment) Bite marks or suction marks on the genitalia or inner thighs Scar or fresh laceration of the posterior fourchette, not involving the hymen (may be caused by accidental injury) Perianal scar (rare, may be due to other medical conditions such as fissures or lesions of Crohns Disease or from previ-ous medical procedures) Category 4: Clear evidence of blunt force or penetrating trauma (findings that can have no explanation other than trauma to the hymen or perianal tissues) Laceration of the hymen, acute Ecchymosis (bruising) on the hymen Perianal lacerations extending deep to the external anal sphincter Hymenal transection (healed): An area where the hymen has been torn through, to the base, so there is no hymenal tissue remaining between the vaginal wall and the fossa or vestibular wall. This finding has also been referred to as a complete cleft in sexually active adolescent and young adult women Absence of hymenal tissue: Wide areas in the posterior (inferior) half of the hymenal rim with an absence of hymenal tissue, extending to the base of the hymen, which is confirmed in the knee-chest position OVERALLASSESSMENT OF THELIKELIHOOD OFABUSE Class 1: No indication of Class 2: Possible abuse Class 3: Probable abuse Class 4: Definite evidence of abuse or abuse Category 1 or Category 2 findings in Child has given a spontaneous, clear, sexual contact Normal exam, no history, no combination with significant behavior changes, consistent, and detailed description of Category 4 physical findings with no behavioral changes, no especially sexualized behaviors, but child being molested, with or without history of accident witnessed abuse unable to give a history of abuse abnormal or positive physical findings Finding sperm or seminal fluid in or on Nonspecific findings with Herpes Type 1 anogenital lesions, in the on examination a childs body another known or likely absence of a history of abuse and with an Positive culture (not rapid antigen Pregnancy explanation and no history otherwise normal examination test) for Chlamydia trachomatisfrom Positive, confirmed cultures for N. of abuse or behavior Condyloma accuminata, with otherwise genital area in a prepubertal child, or gonorrheafrom vaginal, urethral, anal, changes normal examination; no other STDs present, cervix in an adolescent female or pharyngeal source Child considered at risk for and child gives no history of abuse (Condyloma (assuming that perinatal transmission Evidence of syphilis acquired after sexual abuse but gives no in a child older than 3-5 years is more likely to has been ruled out) delivery (i.e., not perinatally acquired) history and has only be from sexual transmission, and a thorough Positive culture for Herpes Simplex Cases where photographs or nonspecific behavior investigation must be done) Type 2, from genital or anal lesions videotape show a child being abused changes Child has made a statement, but the Trichomonas infection, diagnosed by HIV infection, with no possibility of Physical findings of injury statement is not sufficiently detailed, given the wet mount or culture from vaginal perinatal transmission or transmission consistent with history of childs developmental level; is not consistent; swab, if perinatal transmission has via blood products or contaminated accidental injury that is or was obtained by the use of leading been ruled out needles clear and believable questions concerning physical findings with no disclosure of abuse