a. Purpose. Most important purpose of exam is to reassure child that he or she is or will be physically all right. Other purposes are to document physical or forensic findings produced by sexual contact, screen for sexually transmitted infections, and look for physical findings indicative of other medical conditions. Most physical exams of sexually abused children will not yield any specific physical findings for sexual contact.
b. Preparation. Exam should not require physical force. It is essential to describe steps of exam in advance and reassure child that it will not be painful. A general physical exam should be conducted before the anogenital exam.
c. Documentation. Photograph significant or suspicious findings (or draw a detailed diagram if camera is unavailable).
2. Behavior. Document child's behavior and demeanor during exam, although no specific behavior proves abuse did or did not occur.
3. Skin. Skin findings (eg, bruising, abrasions, or ligature marks) are occasionally seen in support of history of use of physical force. Findings are typically absent in younger children because use of physical force is uncommon.
4. HEENT. Palatal bruising and lip injury are occasionally seen in forced oral penetration.
5. Genital exam. Anogenital exam should be done with child in multiple positions, including supine frog-leg, supine knee-chest, and prone knee-chest positions. Specific genital findings are uncommon. Erythema is a common nonspecific finding, often associated with hygiene problems. Warts, vesicular or ulcerative rashes, or purulent discharges raise concerns about STDs. Genital bruises, abrasions, and lacerations can be seen in sexual abuse or accidental injury. Hymenal lacerations or scars, or missing portions of the posterior hymeneal margin, are specific for penetrating trauma.
6. Anal exam. Specific anal findings are rare. Erythema is a common nonspecific finding, often associated with hygiene problems. Anal fissures, perianal abrasions, midline anal tags, and anal dilation are common nonspecific findings. Anal tears or scars that extend through the anal sphincter are diagnostic for anal penetration.
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