Table 2

Anogenital signs in suspected sexual abuse

ClassificationPhysical signs
From The Royal College of Physicians of London. Physical signs of sexual abuse in children. 2nd ed. London: RCP, 1997.
Normal, vulvovaginalPeriurethral bands or ligaments
Longitudinal intravaginal ridges
Hymenal tags (in the newborn)
Smooth, non scarred hymenal bumps
Smooth clefts in the anterior hymenal rim (3–9 o’clock)
Septate hymen
Fourchette, midline avascular area
Non-specific, vulvovaginalErythema, vascular congestion
Friability of perineal skin
Vaginal discharge unless caused by STI
Fusion of the labia
Supportive
    VulvovaginalAcute injury—eg, localised erythema, oedema, abrasions, bruising
Notch in the posterior hymen (below 3–9 o’clock)
Scar in posterior fourchette
Labial fusion following vulval coitus
Transverse hymenal diameter, 1.5 cm
    AnalAnal laxity without other explanation
Reflex anal dilatation greater than 1.5 cm and reproducible
Acute changes—eg, erythema, swelling, fissures, bruising
Venous congestion
Chronic changes
    thickening of the anal verge skin
    increased elasticity and reduction  in the power of the anal sphincter.
Diagnostic
    VulvovaginalFresh laceration of the hymen
Old tear of hymen with scarring or interruption of the hymenal margin
Attenuation of the hymen with resultant enlargement of the hymenal orifice
Pregnancy in a child under 16 years
Positive forensic evidence
    AnalFresh laceration or scar of the anal mucosa extending beyond the anal verge and onto the perianal skin