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Hymen Pictures
In prepubertal girls, a pelvic examination with a speculum is unnecessary unless there is unexplained, active vaginal bleeding. In most cases, thorough visual inspection of the external genitalia, vaginal vestibule, and hymenal structures, hymen, himen, hymin, cherry, broken hymen, pictures, photographs. The vaginal vestibule is the space below the clitoris, above the posterior commissure, and between the
The supine frog-leg position is comfortable for most girls. Separate the labia majora by applying gentle traction. Grasp the labia bilaterally between thumb and forefinger and pull gently outward and downward. Because tension of other pelvic muscles can obscure the view of vaginal vestibular structures, allow the girl time to relax while
The knee-chest position is tolerated well by most girls. Instruct her or him to lie prone on the examining table. Then assist the girl to assume a kneeling position while he or she maintains head and chest contact with the table surface and lordosis of the back. Once the child is positioned properly, lift the labia upward and apart gently. Use this examination position routinely to verify normal or abnormal findings first noted when the patient is supine. This technique allows excellent noninvasive visualization of the posterior hymen, vagina, anus, and frequently the
The redundancy of the estrogenized postpubertal hymen makes close inspection of hymenal tissues for traumatic injury difficult in adolescents. You can separate these redundant hymenal folds with
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Figure 1. Normal prepubertal genitalia visualized while patient is in the supine frog-leg position (labial traction applied). The vaginal vestibule is the space below the clitoris, above the posterior commissure, and between the labia minora. The hymenal morphology is annular, ie, circumferential. The fossa navicularis or posterior fossa is the lower part of the vaginal vestibule below the vaginal orifice, extending to the posterior commissure. In nonabused prepubertal children, the posterior hymen appears
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Figure 2 illustrates normal prepubertal vestibular structures and an annular hymen. An annular hymen extends 360 degrees circumferentially. Figure 3 demonstrates a crescentic hymen, which is the most common morphology. A crescentic hymen has attachments at approximately the 10 o'clock to 11 o'clock and 1 o'clock to 2 o'clock positions and no hymenal tissue at the 12 o'clock position (relating location in the supine position to the face of a clock). Hymenal appearance may vary over time due to the effects of pubertal or exogenous estrogen, as illustrated in
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Figure 3. A prepubertal child in the supine frog-leg position with labial traction applied reveals crescentic hymenal morphology. A crescentic hymen has attachments at approximately the 10 o'clock to 11 o'clock and 1 o'clock to 2 o'clock positions. No hymenal tissue is present at the 12 o'clock position. The crescentic hymenal morphology is the most common variant. The arch-like, symmetric bands lateral to the urethra and connected to the vestibular wall are
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Figure 4. This female, who is at sexual maturity rating 1, is in the knee-chest examination position. The hymen appears thin, almost translucent in this colposcopic photograph
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The hymenal opening size varies, depending on examination technique, degree of patient relaxation, and the patient's age. There is a wide range of normal hymenal opening sizes among prepubertal children selected for non-abuse. A significantly enlarged hymenal opening is diagnostic of penetrating sexual abuse only in the presence of posterior hymenal defects confirmed in
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Routine examination of genital-rectal structures during well child care visits offers an opportunity to learn the many normal variations. Colposcopy offers an additional learning opportunity. The widespread use of colposcopic photography in the medical evaluation of child sexual abuse has allowed extensive peer review of such photos at educational conferences and in the medical literature. Significant concurrence on "normal" versus "abnormal" findings has resulted. Excellent color atlases of colposcopic photographs are
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PHYSICAL FINDINGS FOLLOWING SEXUAL ABUSE
For many reasons, most sexual abuse leaves no visible scars. Perpetrators may avoid physical injury to the child. Vaginal vestibular tissues are elastic. Figures 6 and 7 illustrate that genital injuries often heal rapidly.
Figure 5. This female in the supine frog-leg position is at a sexual maturity rating of 5. The estrogenized hymen of this postpubertal female appears thick, redundant, and paler or more pinkish in color than perihymenal tissues. An estrogenized hymen may be seen in neonates or after use of estrogen cream or other exogenous estrogens.
Figure 6. Labial traction in the supine frog-leg position of a 9-year-old rape victim examined within 72 hours of her assault reveals mucosal lacerations of the fossa navicularis, posterior commissure, and the base of the hymen between the 6 o'clock and 8 o'clock positions.
Figure 7. Repeat examination 2 weeks later reveals total healing. Thus, normal genital-rectal examination neither confirms nor excludes sexual abuse.
Digital fondling commonly causes no tissue damage. The anus was designed to stretch. Early pubertal estrogen effects increase hymenal elasticity, hymenal redundancy, and physiologic vaginal secretions, all of which lessen the likelihood of traumatic hymenal tearing. Longitudinal studies of sexually abused prepubertal children reveal that hymenal defects become less visible following puberty. Some children who have normal genital examinations disclose penile penetration that is verified independently by confession of the perpetrator. For all these reasons, a normal physical examination neither confirms nor excludes sexual abuse. If required to testify, pediatricians should expect to explain the common absence of physical abnormalities.
DIFFERENTIATION FROM ACCIDENTAL GENITAL INJURIES
Female genital trauma from accidental straddle injuries most commonly affects the clitoris, clitoral hood, mons pubis, and labial structures. These anterior structures are injured when squeezed between the offending object and the underlying pubic bone. Usually, straddle injuries are asymmetric and do not involve the hymen. Conversely, when penetrating sexual abuse of girls results in tissue damage, the injuries involve primarily the posterior commissure, fossa navicularis, and posterior hymen. Colposcopic studies of
Figure 8. The posterior hymen of a 7-year-old sexual maturity rating 1 female 1 day after acute rape. The child is in the supine frog-leg position. A cotton-tipped applicator marks the location of the hymenal opening. The posterior hymen is lacerated acutely, and the torn hymenal tissue edges are edematous and erythematous from early changes of healing.