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Evaluation and Management of the
Sexually Assaulted or Sexually Abused Patient
Behavioral Indications of Child Sexual Abuse
Chapter 13
Clinical Presentation
Special Examination Tools
and Techniques
The patient may present with a behavioral complaint or a physical complaint. Signs and symptoms of sexual abuse
can range from subtle (nightmares) to obvious (vaginal discharge). A partial list of signs and symptoms of sexual
abuse is outlined in the following table:
Indications of Child Sexual Abuse
Aggressive behavior
Clinging behavior
Excessive Masturbation*
Sudden change in behavior
Phobias; fears
Sexualization of play*
Attempted suicide
Regression of toileting skills
Abdominal pain
Painful defecation
Rectal bleeding
Sexually transmitted infection
Vaginal itching, discharge, or bleeding
Urethral discharge or bleeding
*Possibly indicative of sexual abuse
Reece RM (ed). Child Abuse: Medical Diagnosis and Treatment. Lea & Febiger, Malvern, PA, 1994.
Pillai, M. Genital Findings in Prepubertal Girls: What Can Be Concluded from an Examination?, J Pediatr Adolesc Gynecol. 2008 Aug ;21 (4):177–
3. Berenson AB: A longitudinal study of hymenal morphology in the first 3 years of life. Pediatrics 1995; 95:490
4. Berenson AB, Grady JJ: A longitudinal study of hymenal development from 3 to 9 years of age. J Pediatr 2002; 140: 600
5. The Evaluation of Sexual Abuse in Children, Pediatrics, 2005; 116(2): 506–512
6. Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, & Botash AS, et al. Guidelines for medical care of children who may have been sexually
abused. Journal of Pediatric and Adolescent Gynecology, 2007; 20, 163–172.
7. McCann J, Voris J, Simon M. Genital injuries resulting from sexual abuse: A longitudinal study. Pediatrics 1992; 89(2): 307–317.
8. Muram D. Anal and perianal abnormalities in prepubertal victims of sexual abuse. Am J Obstet Gynecol 1989; 161(2): 278–281.
9. McCann J, Voris J, Simon M, et al. Perianal findings in prepubertal children selected for nonabuse: A descriptive study. Child Abuse Negl 1989; 13:
10. Lamb, ME, Orbach, Y, Hershkowitz, I; Structured forensic interview protocols improve the quality and informativeness of investigative interviews
with children: A review of research using the NICHD Investigative Interview Protocol; Child Abuse Negl. 2007; 31(11-12): 1201–1231
Chamé Blackburn, MD and Lindsay Stokes, MD
Several tools and techniques can aid in the identification of injuries and evidence in sexual assault patients. This
chapter will cover the use of special procedures including colposcopy, anoscopy, toluidine staining, alternative light
source use, and the foley catheter technique as adjuncts to the physical exam.
The colposcope (from the Greek kolpos “womb, vagina” + skopos “to look at”) provides the examiner a magnified view
of the external anogenital tissues, vagina and cervix to greatly enhance the detection of injuries that might be missed
with the unaided eye. While significantly improving detection of genital microtrauma, the interpretation of these
injuries may be controversial as consensual intercourse can also cause microinjuries. Colposcope magnification varies
between devices, ranging between 4x and 30x. Most colposcopes have photographic or video recording capabilities
that can further enhance documentation. Use of photographic or video equipment in the examination reduces the
likelihood of the patient having to submit to a reexamination and improves overall documentation and quality review.
To begin the colposcopic exam, the adult patient should remain in the lithotomy position, and the child patient
should be placed in either a frog-legged or knee-to-chest position. Inspection of the labia and external genitalia
should be performed first at a low magnification (usually 5x) and increased to obtain a more detailed view of areas
of interest. Application of warm water to adherent mucosal surfaces with a moistened fingertip or cotton swab can
aid in separation and examination of the entire hymen. Examining in several positions (especially in children) can
increase the chance of not only finding true injury but reduce the chance of erroneously identifying variations in
anatomy as injury.
After evaluation of the exterior anatomy, insertion of a speculum is necessary for colposcopic examination of the
interior vaginal walls and cervix of adults and adolescents. Again, the colposcope should be returned to the lowest
magnification, and increased to fully inspect the cervix and interior vaginal walls.
An anoscope can be used not only to check for internal anal injury but also for evidence collection. If the patient
reports bleeding or rectal pain, the anoscope may be used to medically evaluate the patient for injuries. In addition,
positive evidence swabs taken from the anal mucosa above the tip of the anoscope clearly indicate that the swabs were
not contaminated with vaginal evidence that has “pooled” in the perianal area. Unfortunately, anoscopy after assault
can also be painful and poorly tolerated by the patient.
To perform anoscopy, place the patient in a comfortable position such as on their side. Knee-chest and lithotomy
positions may also be used. Gently insert a lubricated, lighted, anoscope into the anal canal having the patient breathe
slowly and concentrate on relaxing the anal sphincter. Remove the obturator and immediately inspect the anal canal
for injury before swabs are inserted. Anorectal evidence is most likely to be found within 24 hours of the assault and
semen tends to collect at the anal mucocutaneous junction. Swabs should be moistened lightly with water prior to
insertion for the patient’s comfort.
Evaluation and Management of the Sexually Assaulted or Sexually Abused Patient | ACEP
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