Saturday, January 28, 2012

Genital Examination in Girls

A small child is often most easily examined on her mother's knee, particularly if only a visual
inspection is needed. The mother can hold the child's legs apart. Alternatively a similar inspection
can be done with the child lying prone over the mother's knee with the clinician examining from
With older children, the usual technique is for the child to be examined lying supine on the medical
couch with her knees flexed and hips externally rotated. Whilst in this position the labia may be
gently separated (labial separation) by the examiner's fingers or traction exerted in a forward and
downward direction with the examiner holding the labia gently between thumb and forefinger
(labial traction).
The genital area can also be examined thoroughly with the child in the kneechest position.p In this
position the important posterior edge of the hymen can often be seen more clearly than when the
child is lying supine on the couch.
Ideally the child should be examined in both positions. The child should however be given control
over the choice. Many children appear to prefer the knee chest position.
Ideally a colposcope should be used, but in the absence of this a magnifying glass or optical loups
are an alternative. The colposcope should include optical measurement and recording.
In many cases when the genitalia are examined in different positions, the edge of the hymen will
have been clearly visualised without the need for any kind of intrusive examination, but in some
cases it is helpful to use a glass probe (Glaister's globe).
Glaister's globes are glass rods with a diameter of 0.6 mm with one end of the rod being expanded
into a globe from 1-2.5 cm in diameter. They can be inserted gently behind the hymen to display its
edges over the glass. In this way apparent folds and indentations often smooth out and small nicks
and tears can be more easily identified. Glass rods used in this way, with explanation and
demonstration to the child, are much less traumatic than using a moistened cotton wool swab which
often causes pain in a delicate area.
If swabs have been taken for forensic purposes, or to carry out tests for STD, then it is helpful to
show the child an unused swab. In some cases it helps to allow the child to use the swab herself and
keep control. Again the child should be allowed to halt the proceedings if distressed.
In most cases where indecent acts are alleged it is not necessary, after the above procedures, to
insert any object into the vagina. However, where there is an allegation of full sexual intercourse or
findings such as a completely torn hymen,
p Crouched on the examination couch with the small of the back arched downwards, knees flexed under the
chest and bottom in the air.
then in some cases it is appropriate to carry out a gentle digital examination of the vagina to
establish whether:
—The hymenal ring is completely torn
—Whether the vagina can admit an object the size of an erect penis and
—Whether its walls are rugose or smooth and the canal enlarged
In older girls it may be appropriate to carry out a full gynaecological examination, including the
insertion of a speculum, to inspect the cervix. Bimanual palpation may indicate pregnancy and a
pregnancy test may be advisable.
Genital Examination in Boys
There is rarely any genital injury in boys who have been indecently assaulted. The penis and
testicles should be thoroughly inspected for signs of bruising, tears of the frenulum, or "love-bites"
and signs of sucking. The root of the penis may show bruising or other lesions. It is important to
consider that the penis may have been sucked and to swab for saliva, in the knowledge that saliva,
on the unwashed penis, may survive for up to one week.
The testicles should be examined for signs of bruising or biting.
The Anal Area
The anus should be inspected in every case. This may be done in the left lateral or knee-chest
The buttocks should be gently separated, without applying traction, and the anal orifice observed for
about 30 seconds to see if there is any dilatation. Slight twitchiness or dilatation of the external
sphincter is probably of no significance. Anal dilatation in the presence of a stool in the rectum is
regarded by most experienced examiners as being unlikely to be a sign of abuse. If observed,
however, it should be recorded.
The anal folds should be regular and symmetrical around the anal opening but there is often a
redundant fold, particularly in boys, anteriorly which can be confused with a skin tag or healed
fissure. A midline raphe extending backwards from the scrotum is normal and should not be
confused with signs of injury.
Prominent veins have sometimes been claimed to be significant pointers to abuse. However, they
often come up during the examination as the child tenses and relaxes his muscles, and no great
significance can be attached to them, though they must, of course, be noted.
If no abnormality is seen on careful inspection of the anus then it is appropriate to do no more.
However if there is an allegation of anal abuse then a finger gently can be placed against the anal
orifice to test its tone. A very good estimate
of anal tone can be obtained in this way without doing a full digital examination. In some cases a
digital examination should be done, the subject asked to squeeze the examining finger to test the
anal tone. It is important to remember, however, that this procedure relies on a subjective
assessment of the examiner based on experience and can be unreliable.


Alice McNally

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