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Hymen Tearing

When we are looking at child abuse, most of the injuries occur below the 3-9 o’clock line for sexual assault. So when we see from 3,4,5,6,7,8,9 o’clock, when we see hymenal lacerations, tears and injuries, that is very specific for trauma, for sexual assault. 

The area from 9 o’clock to 3 o’clock is less specific but there still can be injuries there from sexual assault, but that area is less specific. And I’ll tell you why. Because what they’ve done is researched and they’ve looked at little girl’s hymens and little girls usually have concentric hymens or circular hymens. And what happens is, they’ve looked at girls at puberty time and they’ve looked at it and in the newborn period little girls usually have concentric hymens but when they look at the percentage of the older girls, they are more crescentic. And what the feeling is, between that time period, that between 9 o’clock and 3 o’clock there is some normal disappearance of the hymenal tissue between times and that’s why that area is less specific. And between the 3 o’clock, 6 o’clock, 9 o’clock, that hymenal area does not undergo changes and that’s more of the area that you can imagine the force or impact of trauma occurring. So that’s the area you want to look. In the knee-chest position you really can see that posterior hymen sometimes drop down.

When we look at anatomy - just want to run over it quickly once or twice - the clitoral hood, over here on the little girl, covering the clitoris. The fingers are holding out the labia majora, then you have the labia minora. You can see that hymenal opening and inside there is a ridge, a vaginal ridge. But you see this hymenal opening, it’s very smooth, it’s a crescentic hymen. Now a couple of terms I think people get confused are fossa navicularis and posterior fourchette. The posterior fourchette is this tissue right here, the fossa navicularis is this cavity inside. So in this slide you have the clitoral hood, the labia majora, the labia minora here, you have the vaginal opening right here and down here the anal opening, you have the posterior fourchette area. So when you look at the forms you have to fill out - and they label those - that way you’ll know which one is which for the injury. Here again, the newborn little girls have hymens that are circular and later on they get more cresentic hymens.

Normal anatomy is very important. This is a little girl with labial adhesions. Twenty-five percent of little girls have labial adhesions and we don't tear them apart any longer. It causes a significant amount of pain. The only time you would want to use Premarin cream is if they have urinary difficulties or urinary tract infections. A lot of times what happens, at puberty with all the hormones inside this opens up spontaneously so there is nothing to do. So normal anatomy is very important. Accidental injuries are important to realize. What is not sexual abuse. This is a child, a little girl, who had an accidental straddle injury. Again, this is in the upper portion. It’s not concerning. So this is a straddle injury. This is an impaling injury. This little girl impaled on an object. You can’t get this kind of trauma with penile injury.

Other things that can mimic child abuse; things such as the differential diagnosis of anal-genital bruising. This is a child who has perianal strep. So this is a strep infection. It may look like some type of injury but it is important to culture. Little girls will get it in the vaginal as well as anal area, little boys can get it in the anal area. This one, lichen sclerosis can really mimic child abuse. The tissue is very thin, very fragile, very red and it can bleed and hemorrhage.

This just talks about other things in your differential diagnosis, of redness, of itching, as well as vaginal discharges. The one important thing you have to realize is that kids with vaginal discharge, the number one cause is this. Your foreign body and it’s usually retained toilet paper for little girls. Retained toilet paper is the number one cause of clear discharge. So that’s actually a question they might ask you in your differential diagnosis.

I just want to tell you about some other things they may ask you about, and that’s sexually transmitted diseases. Sexually transmitted diseases; what they are going to ask you is, "Which diseases are highly specific, which are less specific?" When it comes to sexually transmitted diseases, gonorrhea and syphilis. The important thing is, if not perinatally acquired. Up to around 18-months-of-age there is that gray area because this may be a child that has congenital syphilis that was missed, or had GC that was picked up from the mother that got missed. So during those first 18 months it’s difficult. If you get a six-year-old, on their exam, six-year-old, Gonorrhea and syphilis, they should have presented long ago if it was congenital. A six-year-old with gonorrhea and syphilis, it’s child abuse until proven otherwise. So that is very specific. Less specific is your Trichomonas, your Herpes simplex II, Chlamydia.