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Ciara Earley VFPMS VFPMS Seminar Monday June 2 nd 2014.

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Presentation on theme: "Ciara Earley VFPMS VFPMS Seminar Monday June 2 nd 2014."— Presentation transcript:

1 Ciara Earley VFPMS VFPMS Seminar Monday June 2 nd 2014

2  Timing of the examination,< 72 hours in acute cases  Location  The purpose of the examination  The genital examination as a part of a complete medical examination  Not just “hymenologists!”  Consent NB (Gillick competent, court order, parental)

3  Equipment: Adequate light and privacy  Colposcopy recommended if available  Magnification and illumination, enables Peer Review  Can be awkward and technically difficult in younger children  Who else needs to be present ?


5  Comfortable position and clothing  The hymen as a clock face  Position of patient  Supine frog leg  Prone knee-chest  Left lateral  Supine knee chest

6 Labial traction technique


8  Don’t forget that the prepubertal hymen is sensitive  Relaxation enables a better view of the hymen  Elevation of the pelvis may help visualisation  Reposition  Extra pair of hands!  Moistened swab in adolescents  May need a repeat examination in certain cases

9  Several changes from neonatal period to adolescence  Oestrogen effects may remain for the first year or two  Pre-pubertal: Less oestrogen effect, thin atrophic tissues,  Labia majora flat appearance, labia minora thin,

10  Influence of Oestrogen returns  Thickened hymenal tissue with more elastic and fibre content  Fimbriated appearance  Thicker tissues less vulnerable to damage and infection

11  “The most insignificant anatomical structure of the female without an analog in the male has assumed a social importance at variance with its almost neutral physiologic value or its potential influence upon health” Wile Is The Psychology of the hymen. J Nerv Ment Dis.1937 (Feb):143-156

12  Vary with age  Newborn hymens annular or fimbriated  Hymenal configuration changed in 65%  68% of hymenal tags present at birth disappeared, 9 tags formed Berenson, A, A longitudinal study of hymenal morphology in the first 3 years of life, Pediatrics 1995; 95: 490-496

13  Cresenteric configuration more common as children aged  The number of mounds and intravaginal ridges increased as the children aged  No deep notches or transections observed in those who did not have a history of sexual abuse  A decrease in the amount of tissue in the posterior hymen was noted but some tissue always present Berenson, AB, Grady, JJ, A longitudinal study of hymenal development from 3 to 9 years of age, Journal of Pediatrics, 2002; 140: 600-607

14  Notches/cleft: an angular V shaped indentation on the edge of the hymenal membrane which does not extend right through to the vaginal wall. Common at 3 and 9 o clock positions.  Bumps : Localised rounded areas of tissue can be seen anywhere on the hymen Berenson A.B. Normal anogenital anatomy. Child Abuse and Neglect 1998;22(6) 589-96

15  Tags : Flaps or appendages extending more than 1mm from the rim. Common in the newborn  Hymenal Ridges : External ridges may be seen at 12 and 6 oclock. Most easily observed at birth. 86% of newborns in one study. Usually tend to resolve Berenson et al Appearance of the hymen in newborns Pediatrics,87,458-465

16  Linea vestibularis : Pale midline avascular streaks of the posterior vestibule  Median Raphe: More obvious in males also present in females  Failure of midline fusion: The defect can extend from the fossa navicularis to the anus. The tissue at the base of the defect is pale and avascular with smooth borders.  Periurethral bands

17  Normal  Non specific: Erythema  Concerning findings include:  Bruising or abrasions of the genitalia  Decreased amount or absent tissue in the posterior aspect  Injury or scarring of the posterior fourchette/fossa navicularis or hymen  Complete transection of the hymen  Deep hymenal cleft 3-9 oclock

18  Case control study “Most hymenal measurements lack sensitivity or specificity to be used to confirm previous penetration”  Berenson A.B. et al Use of hymenal measurements in the diagnosis of previous penetration Pediatrics2002;109(2) p 228- 235  Berenson et al A case control study of anatomic changes resulting from sexual abuseAmJ Obstet Gynecol2000;182:820- 34  Vaginal discharge more common in abused children  A hymenal transection,perforation, or deep notch was observed in 4 children all of whom were abused  Kellog N et al Genital Anatomy in Pregnant Adolescents: “Normal” doesn’t mean “Nothing Happened”Pediatrics 2004;113e67-e69  Only 2/36 had definitive findings of penetration

19  Inspection of urethral meatus, foreskin and penis  Scrotum and testes

20  Left lateral or supine knee chest  Lateral buttock separation technique not recommended (post Cleveland inquiry

21  Several Non specific findings  McCann et al 318 children selected for non abuse  Erythema 41%  Increased pigmentation 30%  Venous engorgement 52% (after 2 minutes knee chest position)  “Smooth areas” 26% (always on midline)  Anal tags 11%  McCann et al Perianal findings in prepubertal children selected for non abuse :a descriptive study.Child Abuse and Neglect1989;13(2)179-93

22  McCann study 49% of children ( AP diameter <0.1cm-2.5cm, mean 1.0cm)  Small % (1.2%) > 20mm without the presence of stool  Hobbs and Wynne “ Dilatation over 0.5cm does not in our experience occur in normal children” McCann et al Perianal findings in prepubertal chilren selected for non abuse :a descriptive study.Child Abuse and Neglect1989;13(2)179-93 Hobbs C.J. & Wynne J.M. Sexual abuse of boys and girls: The importance of anal examination.Child abuse and Neglect 13 (2) : 195-210 1989

23  Cleveland inquiry : 125 children diagnosed as sexually abused over a 5 month period.  Several other causes of anal dilatation  Chronic constipation  Crohn’s disease  Neurological disorders  During anaesthesia Summary of the Cleveland Inquiry BMJ ;297: July 1988 : p190-191

24  Anal lacerations (may need further surgical intervention/ EUA)  Anal tags outside the midline (not noted in McCann’s study)  Important to correlate clinical findings and relevant history and medical history

25  Berenson and McCann studies  Gall J et al Current Practice in Forensic Medicine” chapter on “The paediatric hymen”  Child Abuse and Neglect, diagnosis, treatment and evidence Carole Jenny. Chapter 10 &11  Child Abuse, Medical Diagnosis and management 3 rd edition Reece & Christian

26  The genital examination is only a part of the overall evaluation of sexual abuse in children  Preparation is important  A detailed knowledge of normal anatomy and variants is required  Most examinations are normal

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