Anatomy, Physiology, and Patient Assessment (Adult and Adolescent)
External and internal anatomy you must be able to name
External female structures: mons pubis, labia majora and minora, clitoris and prepuce, vestibule, urethral meatus, Skene glands, Bartholin glands, hymen and hymenal ring, fossa navicularis, posterior fourchette, perineal body. Internal: vagina, cervix, uterus, adnexa. Anal region: anal verge, dentate line, sphincter tone, hemorrhoids, skin tags. Male: glans, coronal sulcus, frenulum, penile shaft, scrotum, perineum.
Hymenal shapes (crescentic, annular, septate, cribriform, imperforate) and estrogen status are high-yield. Estrogenized tissue is thick, rugated, and pink; hypoestrogenized tissue is thin, pale, and more friable. Estrogen status changes what is normal and how injuries appear.
Assessment sequence
Stabilize first: airway, breathing, circulation, vital signs, level of consciousness, and screen for head injury, strangulation, heavy bleeding, and pregnancy complications before any genital examination. Then history - mechanism, weapon, strangulation, loss of consciousness, substances, last consensual intercourse, contraception, menses, baseline health, medications, allergies - followed by a head-to-toe examination with attention to concealed areas (scalp, mouth, ears, neck, breasts, axillae, thighs, buttocks, soles).
A speculum examination is not mandatory in every case; it may be deferred when not clinically indicated, when the patient declines, or when the patient is prepubertal. Document the patient's choice.
Traps
- Treating hymenal appearance as proof of virginity or of penetration.
- Expecting to find injury: in most examinations, including after assault, no genital injury is identified.
- Forgetting that the posterior fourchette is the most common site of acute genital injury.
Rule of thumb: Normal and absent findings are findings - describe what you see anatomically, not what you assume it means.