Abnormal Genito-Anal Findings Flashcards
What are the possible scenarios regarding genital injuries in cases of rape?
Genital injuries may or may not be present. Some scenarios include: (4)
- Genital injuries present
- No genital injuries observed
- Rape did not result in visible injuries
- Delayed reporting of the assault
Why might there be an absence of vaginal contact in cases of rape?
Absence of vaginal contact could be due to anal penetration instead of vaginal, or there might have been no penetration at all.
What are some challenges healthcare providers may face in diagnosing genital injuries in cases of rape?
Challenges may include inadequate equipment, such as insufficient lighting, and lack of provided training, leading to difficulty in thoroughly examining patients.
What are some indicators of non-aggressive perpetration and non-resistant survivors?
Non-aggressive perpetration may result in a lack of visible bruises, while non-resistant survivors may show signs of submission against their will, such as being held at gunpoint or being drugged.
Why is it important to pay attention to the perineum and surrounding areas during a genital examination in cases of rape?
Injuries may also occur in the perineum and surrounding areas, as they are often injured during sexual assault.
What are some signs of forceful actions that may result in injuries to the perineum and surrounding areas?
Signs may include bruising, scratches, and fingerprint bruises on the thighs, especially on the inner aspects of the knees, as well as bruises and grazes on the buttocks or shoulder blades.
How might bite marks be indicative of sexual assault?
Bite marks may indicate forceful actions or struggle during the assault, providing evidence of non-consensual activity and the use of force.
What do bruises on the inner thigh indicate in cases of sexual assault?
Bruises on the inner thigh can indicate forcing the legs open during the assault.
What type of bruising may be observed on the inner thighs in cases of sexual assault?
Ecchymosis, which is bruising, may be observed on the inner thigh on both sides. Additionally, small round bruises may be present, which could be finger marks or fingerprints.
Why are bruises on the inner thigh particularly alarming in children?
Children typically do not get bruises on their inner thighs from common falls or accidents, so bruises in this area may raise concerns about potential sexual assault.
Finger Grab Marks:
What is the importance of using correct terminology when describing findings in a sexual assault examination?
Using correct terminology ensures clarity and accuracy in documenting injuries and evidence.
How should the location of injuries be described during a sexual assault examination?
The location of injuries should be described by orienting to anatomy and using clock-face notation, with 12 o’clock being anterior (towards the urethra) and 6 o’clock being towards the anus.
Why is it important to record injuries on the J88 form during a sexual assault examination?
Recording injuries on the J88 form ensures proper documentation and preservation of evidence for legal proceedings.
What types of evidence should be documented and collected during a sexual assault examination?
Evidence such as trace evidence (debris), fluids on the body (semen, saliva, blood), and any foreign-looking fluid on the legs or other areas should be documented and swabbed for analysis.
What is the role of a forensic odontologist in a sexual assault examination?
A forensic odontologist may be called upon to examine bite marks and check for matches to teeth impressions.
How can the timing of injuries be indicated during a sexual assault examination?
Timing can be indicated by describing injuries as fresh, healing, or healed, although it may be difficult to determine the exact timing.
Straddle injury
Areas most likely to be damaged:
Stories that hear that girl fell on her buttocks ect, The injuries are bad, labia purple, don’t usually get in rape cases are more on the outside.
What is the legal definition of penetration?
Legally, penetration refers to penetration beyond the labia majora.
What is the medical definition of penetration?
Medically, penetration refers to penetration beyond the hymen or introitus, indicating deeper penetration.
What are the features of acute genital trauma?
The features of acute genital trauma can be remembered using the acronym “TEARS”: (5)
What are the potential sequelae or long-term effects of penetration?
Long-term effects may include sexually transmitted infections (STIs), pregnancy resulting from intercourse, and the need for post-contraception to prevent pregnancy.
Describe the following image: (2)
- Abrasion on labia minora
- Red graze mark, not torn, only in one area and redness, not all over but found in one place
Describe the following image:
- A swollen, red labia, haematoma, not the same swelling on both sides
Describe the following image: (2)
- Abrasion on the inner side of labia
- A white exudate which could be a STI or part of the healing process of past trauma (the white colour is not normal)
Circle shows the vaginal opening and the surrounding part is the hymen
- Left:
- Right:
Left: Hymen on the outside
Right: Hymen moved to the side - see the laceration on the right side where it is red and there is a tear in a small specific area
Fossa Navicularis:
- Top circle - _____ _______
- Groove at the bottom of the hymen, at 6 o’clock where the ____ _____ fuse (posterior facet, forms a canal)
- Bottom circle - skin part is part of the perineum and the ____ ____ is on the perineum
vaginal opening
labia minora
red abrasion
Posterior Fourchette:
- First picture =
Laceration (may also occur when you are examining a patient and open their legs)
Posterior Fourchette:
- The second picture =
- A tear which can happen on first intercourse and the tear heals within 2 weeks as it is a very vascularized area
- May even tear in a young girl when doing an exam – be gentle
Hymen:
- First picture =
Fimbriated hymen - has rough bumpy edges, at the top can see a lump with ecchymosis and bruising and change in colour, this is seen more in adults
Hymen:
- Second picture =
Same as first, but healing of ecchymosis
- If the bruise is a yellow, green, brown colour then it is not a fresh bruise and is a few days old
Hymen:
- Third picture =
Acute hemorrhage on the hymen - it is red, swollen, blood due to tears on the hymen
Hymen:
- Fourth picture = (2)
- The same as the third picture, but in the healing stage - a resolved hemorrhage and can see the V or U shape on the posterior cleft at the bottom 6 clock on the hymen
- Defect in the hymen edge that has healed from acute injury – evidence of previous trauma
See if the V cleft goes all the way down to the vaginal wall
What are the types of hymenal injuries that can occur due to penetration beyond the hymen?
Hymenal injuries can include transection (tear/laceration through entire width) or partial tear/laceration (does not extend to the vaginal wall), which may heal to form notches or clefts.
How can healed hymenal injuries be identified?
Notches or clefts are U- or V-shaped indentations that indicate healing. Changing the patient’s position during examination can help determine the depth and persistence of these indentations.
What indicates trauma in hymenal injuries?
Trauma may be indicated if the injury extends to more than 50% of hymenal tissue, is located in the posterior half of the vagina (between 3 o’clock and 9 o’clock), or extends to the vaginal wall.
What is caruncula myrtiformes, and how does it relate to hymenal changes?
Caruncula myrtiformes are remnants of the hymen that remain after frequent penetration. As the hymen stretches and thins with penetration, it may leave behind these remnants.
What are some descriptions of hymenal changes that may indicate trauma or injury?
“Attenuated hymen” refers to narrowing of the hymen, while “angularity hymen” describes sharp angles in the contour of the hymen’s inner edge. These changes may indicate hymenal trauma if located on the posterior rim and persist during multiple examination techniques.
Penetration beyond the hymen
- First picture = (2)
- Variant lump or cleft on the side but it is in the upper half of the hymen close to 12 o’clock and
- The hymen is not irregular and round and so this shows a regularly variant in the hymen
Penetration beyond the hymen
- Second picture =
- Hymen has notches or clefts at 6 o’clock which is a deep V shaped cleft and shows a healed laceration
- The rest of the hymen is attenuated on the sides and is irregular and so have been penetrated and is abnormal
Posterior rim:
- The pictures shows penetration as there is a large vagina opening with the _____ tearing at 6 o’clock into the posterior rim
- Opening _____ than should be for age - measure
hymen
wider
Other causes of injuries not all being due to rape: (4)
- Straddle injury
- Tampon insertion – diameter is 15mm or 1.5 cm, can cause laceration or notches of hymen
- Masturbation
- Consensual intercourse – over the age of 16 years
Anal Changes:
Acute trauma -
- Use the acronym TEARS to look for abnormalities and painful areas (tenderness/ tears, ecchymoses, abrasions, redness, swelling, scars)
Anal Changes:
Chronic changes = (4)
- Have muco-cutaneous changes where you lose the puckering of the skin and the skin becomes smooth - called funneling
- Venous engorgement where the blood vessels dilate as they spread open the bum cheeks
- Dilation of the sphincter can be internal, external or both
- Can also diagnose STIs taken from the anal swabs
Structural changes
* Muco-cutaneous: (2)
o Thickening
o Distortion
Structural changes
* Venous engorgement: (2)
o Localized or diffuse
o Within 30 seconds of holding the butt cheeks apart and the veins start to fill
Structural changes
* Dilatation: (3)
o All three muscle groups ie all three sphincters, within 30 seconds
o No visible stool then can say that it is from chronic trauma
o However if there is stool the body’s natural response is to dilate the two sphincters and so must check if there is stool and then know if the dilation is because the person is constipated or needs to poo or if it is due to chronic abuse
Perianal Lacerations:
* First picture =
o Perianal laceration
o Perianal laceration
* Second picture = (2)
o Anal laceration is healing and leaves
scarring behind
o Takes a few weeks to heal as there is good blood supply in the area after abuse
Venous engorgement:
* Anal area touched –
30-60 seconds later
you start to see the veins dilating and
becoming engorged - due to abuse
Partial Dilation:
* First picture =
o Cupping sign - external sphincter is dilated but the internal sphincter is still tight – can’t see in
Partial Dilation:
* Second picture =
o Tire sign - internal sphincter dilates and the external sphincter constricts
Complete dilation
* First picture = (2)
o There has been abuse and can be chronic abuse
o This causes the sphincter to dilate on palpation
Complete dilation
* Second picture = (2)
o Stool in the rectum and so the anal canal may be dilated due to a natural response to poo
o Maybe not due to only chronic abuse
Can the presence or absence of injuries determine whether consent was given?
No, the presence or absence of injuries does not answer the question of consent.
Is traumatic penetration synonymous with non-consensual penetration?
No, traumatic penetration is not synonymous with non-consensual penetration.
Are rape and consent medical diagnoses?
No, rape and consent are legal principles, not medical diagnoses. The examiner can verify findings, but the court will determine the credibility of the history.
Can rape or consent be diagnosed from a medical examination?
No, neither rape nor consent can be diagnosed from a medical examination.
What should the examiner form an opinion on during the examination?
The examiner should form an opinion on whether the injuries correlate with the history provided.
Does the absence of non-genital injury exclude violent rape?
No, the absence of non-genital injury does not exclude violent rape.
Does the absence of genital injury exclude rape?
No, the absence of genital injury does not exclude rape.
