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WARNING — This excerpt is intended for use by medical, legal, social service, and lawenforcement professionals. It contains graphic images that some may find disturbing oroffensive. Minors and/or nonprofessionals should not be allowed to access this material.Child AbusePocket Atlas SeriesVolume TwoSexual AbuseSTM Learning, Inc.Leading Publisher of Scientific, Technical, and Medical Educational ResourcesSaint Louiswww.stmlearning.comSaint Louiswww.stmlearning.comi
Our MissionTo become the world leader in publishing andinformation services on child abuse,maltreatment, diseases, and domestic violence.We seek to heighten awareness of these issuesand provide relevant information toprofessionals and consumers.A portion of our profits is contributed to nonprofit organizations dedicated to the prevention of child abuse and the careof victims of abuse and other children and family charities.
Child AbusePocket Atlas SeriesVolume TwoSexual AbuseRandell Alexander,MD, PhDJonathan D. Thackeray,MD, FAAPAngelo P. Giardino,MD, PhDJoyce A. Adams, MDProfessor of Pediatrics and ChiefDivision of Child Protection andForensic PediatricsDepartment of PediatricsUniversity of FloridaJacksonville, FloridaVice President/Chief Medical OfficerMedical AffairsTexas Children’s Health PlanClinical Professor, Pediatrics andSection ChiefAcademic PediatricsDepartment of PediatricsBaylor College of MedicineHouston, TexasDebra Esernio-Jenssen,MD, FAAPProfessor of PediatricsUniversity of Florida at GainesvilleMedical DirectorChild Protection TeamGainesville, FloridaPhysicianThe Center for Family Safety and HealingDivision of Child and Family AdvocacyDepartment of PediatricsNationwide Children’s HospitalColumbus, OhioProfessor of Clinical PediatricsDivision of General Academic Pediatricsand Adolescent MedicineSchool of MedicineUniversity of California, San DiegoSpecialist in Child Abuse PediatricsRady Children’s HospitalSan Diego, CaliforniaSuzanne P. Starling,MD, FAAPProfessor of PediatricsEastern Virginia Medical SchoolDivision Director, Child Abuse PediatricsMedical Director, Child Abuse ProgramChildren’s Hospital of the The King’sDaughtersNorfolk, VirginiaDavid L. Chadwick, MDDirector EmeritusChadwick Center for Children andFamiliesChildren’s Hospital - San DiegoAdjunct Associate ProfessorGraduate School of Public HealthSan Diego State UniversitySan Diego, CaliforniaRich Kaplan,MSW, MD, FAAP†Child Abuse PediatricianChildren’s Hospitals and Clinics ofMinnesotaAssociate Professor of PediatricsUniversity of Minnesota MedicalSchoolMedical DirectorThe Center for Safe and HealthyChildrenUniversity of Minnesota AmplatzChildren’s HospitalAssociate Medical DirectorMidwest Children’s Resource CenterChildren’s Hospitals and Clinics ofMinnesotaMinneapolis, Minnesotaiii
Publishers: Glenn E. Whaley and Marianne V. WhaleyGraphic Design Director: Glenn E. WhaleyManaging Editor: Paul K. Goode, IIIPrint/Production Coordinator: Jennifer M. Jones and G.W. GraphicsCover Design: Jennifer M. Jones and G.W. GraphicsColor Prepress Specialist: Kevin TuckerAcquisitions Editor: Glenn E. WhaleyDevelopmental Editor: Paul K. Goode, IIICopy Editor: Paul K. Goode, IIIProofreader: Paul K. Goode, IIIEditorial/Publishing Consultant: Kerry BlasingimCopyright 2016 STM Learning, Inc.All rights reserved. No part of this publication may be reproduced, stored in a retrievalsystem, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission from the publisher.Printed in the United States of America.Publisher:STM Learning, Inc.Saint Louis, MissouriPhone: (314) 434-2424 Fax: (314) 434-2425http://www.stmlearning.com orders@stmlearning.comThe Library of Congress has cataloged the printed edition as follows:Names: Alexander, Randell, 1950- , editor.Title: Sexual abuse / [edited by] Randell Alexander, Angelo P. Giardino,Debra Esernio-Jenssen, Jonathan D. Thackeray, Joyce A. Adams, Suzanne P.Starling, David L. Chadwick, Rich Kaplan.Other titles: Sexual abuse (Alexander) Child abuse pocket atlas series ; v.2.Description: Florissant, MO : STM Learning, Inc., [2016] Series: Childabuse pocket atlas series ; volume 2 Includes bibliographical referencesand index.Identifiers: LCCN 2016006971 (print) LCCN 2016007656 (ebook) ISBN9781936590599 (pbk. : alk. paper) ISBN 9781936590643 (ebook)Subjects: MESH: Child Abuse, Sexual--diagnosis Infant Child Adolescent Case Reports Atlases HandbooksClassification: LCC RC560.C46 (print) LCC RC560.C46 (ebook) NLM WS 17 DDC 616.85/836--dc23LC record available at http://lccn.loc.gov/2016006971iv
ContributorsJoyce A. Adams, MDProfessor of Clinical PediatricsDivision of General Academic Pediatrics andAdolescent MedicineSchool of MedicineUniversity of California, San DiegoSpecialist in Child Abuse PediatricsRady Children’s HospitalSan Diego, CaliforniaRandell Alexander, MD, PhDProfessor of Pediatrics and ChiefDivision of Child Protection and ForensicPediatricsDepartment of PediatricsUniversity of FloridaJacksonville, FloridaDebra Esernio-Jenssen, MD, FAAPProfessor of PediatricsChild Protection TeamUniversity of Florida at GainsevilleLori D. Frasier, MDClinical ProfessorUniversity of Utah School of MedicineDirector of the Fellowship in Child AbusePediatricsUniversity of UtahSalt Lake City, UtahKristi A. Green, MSN, ARNPAdvanced Registered Nurse PractitionerDepartment of PediatricsUniversity of FloridaJason Schulman, MDPediatricianMiami, Floridav
PrefaceThe concept of medical care for children who are possible victims ofchild sexual abuse is relatively new. In the recent past, we have seenthe medical care for these children undergo a significant evolution,in which we now view these children as patients who require medicalattention and care. The focus of this book is to address the medicalcare for these children from a variety of perspectives.In creating this book, our goal has been to demystify the medical careof sexually abused children. When caring for a child who is a possiblesurvivor of child sexual abuse, the essential principles and standards ofmedical care apply, such as obtaining a complete and well-documentedhistory and physical examination, performing an appropriate andscientifically driven laboratory evaluation, and forming a medicaldiagnosis to guide the ongoing care needs of the patient. It should beclear that the medical component is simply one part of the responseto maltreatment. While legal issues certainly are important for thesafety and well-being of children, the focus of this text primarily willbe on the medical and therapeutic care these children need to healand, hopefully, to have a happy and productive life.This book, the second volume of the Child Abuse Pocket Atlas Series,brings together experts and scholars with a variety of expertise relatedto the care of young survivors. While the focus of this book is medicalcare, it is our hope that other members of the multidisciplinary teamwill find this a useful reference.Rich Kaplan, MSW, MD, FAAP†Joyce A. Adams, MDSuzanne P. Starling, MD, FAAPAngelo P. Giardino, MD, PhDvii
Contents in BriefChapter 1: Basic Anogenital Anatomy . . . . . . . . . . . . . 1Chapter 2: Equipment for the Documentation ofSexual Abuse . . . . . . . . . . . . . . . . . . . 39Chapter 3: Interpretation of Anogenital Findings . . . . . 55Chapter 4: Sexual Abuse . . . . . . . . . . . . . . . . . . . 107ix
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Contents in DetailChapter 1: Basic Anogenital Anatomy . . . . . . . . . . .1Embryology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .4Normal Variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5Effects of Puberty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8The Hymen . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8The Vagina . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9The Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9The Anus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11Features of Genital and Anal Anatomy . . . . . . . . . . . . . . . . . . 12References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37Chapter 2: Equipment for the Documentation ofSexual Abuse . . . . . . . . . . . . . . . . . . . . 39Photodocumentation . . . . . . . . . . . . . . . . . . . . . . . . . . 40Laboratory Specimens . . . . . . . . . . . . . . . . . . . . . . . . . . 41Forensic Evidence Collection . . . . . . . . . . . . . . . . . . . . . . 42Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43Sexual Abuse Documentation Equipment . . . . . . . . . . . . . . . . 45Photodocumentation . . . . . . . . . . . . . . . . . . . . . . . . 45Laboratory Specimens . . . . . . . . . . . . . . . . . . . . . . . 46Forensic Evidence Collection . . . . . . . . . . . . . . . . . . . . 49Medication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52Telemedicine . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53Chapter 3: Interpretation of Anogenital Findings .55History . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55Studies in Genital and Anal Findings in Children andAdolescents With Suspected Sexual Abuse . . . . . . . 56Research . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56Hymenal Data . . . . . . . . . . . . . . . . . . . . . . . . . . . 57Sexually Transmitted Infections . . . . . . . . . . . . . . . . . . . 59Mimics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59Anal Dilation . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 60Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61Normal Variations and Forensic Photography . . . . . . . . . . . . . . 62References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104xi
Chapter 4: Sexual Abuse . . . . . . . . . . . . . . . . . . . 107Techniques and Basic Skills . . . . . . . . . . . . . . . . . . . . . . . 108Hymenal Configurations . . . . . . . . . . . . . . . . . . . . . . . . 115Findings Confused With Abuse . . . . . . . . . . . . . . . . . . . . . 120Imperforate Hymen . . . . . . . . . . . . . . . . . . . . . . . . 120Prolapsed Uterus . . . . . . . . . . . . . . . . . . . . . . . . . 120Lichen Sclerosis . . . . . . . . . . . . . . . . . . . . . . . . . . 121Urethral Prolapse . . . . . . . . . . . . . . . . . . . . . . . . . 122Failure of Midline Fusion . . . . . . . . . . . . . . . . . . . . . 123Labial Fusion . . . . . . . . . . . . . . . . . . . . . . . . . . . 123Straddle Injury . . . . . . . . . . . . . . . . . . . . . . . . . . 123Vaginal Duplication . . . . . . . . . . . . . . . . . . . . . . . . 124Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124Foreign Body . . . . . . . . . . . . . . . . . . . . . . . . . . . 125Toxic Shock . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126Hymenal Projection . . . . . . . . . . . . . . . . . . . . . . . . 128External Hymenal Midline . . . . . . . . . . . . . . . . . . . . 128Extensive Labial Fusion . . . . . . . . . . . . . . . . . . . . . . 129Failed Midline Fusion . . . . . . . . . . . . . . . . . . . . . . . 129Possible Foreign Body . . . . . . . . . . . . . . . . . . . . . . . 130Lichen Sclerosis Causing Bleeding . . . . . . . . . . . . . . . . . 132Labial Bruising . . . . . . . . . . . . . . . . . . . . . . . . . . 133Duplication of Reproductive Structures . . . . . . . . . . . . . . 133Pinworm . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 134Hemangioma . . . . . . . . . . . . . . . . . . . . . . . . . . . 134Perianal Vitiligo . . . . . . . . . . . . . . . . . . . . . . . . . . 134Vaginal Discharge . . . . . . . . . . . . . . . . . . . . . . . . . 135Normal Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137Crescentic Hymen . . . . . . . . . . . . . . . . . . . . . . . . . 137Annular Hymen . . . . . . . . . . . . . . . . . . . . . . . . . . 137Large Urethral Opening Above Normal Hymen . . . . . . . . . . 137Normal Intact Hymen . . . . . . . . . . . . . . . . . . . . . . 138Anal Tag . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138Normal Intact Annular Hymen . . . . . . . . . . . . . . . . . . 139Intravaginal Ridge . . . . . . . . . . . . . . . . . . . . . . . . . 139Normal Examination . . . . . . . . . . . . . . . . . . . . . . . 140Normal Anal Findings . . . . . . . . . . . . . . . . . . . . . . . 141Thickened Crescentic Hymen . . . . . . . . . . . . . . . . . . . 141Circumferential or Annular Hymen . . . . . . . . . . . . . . . . 142Anterior Anal Venous Pooling . . . . . . . . . . . . . . . . . . . 142Extensive Anal Pooling . . . . . . . . . . . . . . . . . . . . . . 142Midline White Line . . . . . . . . . . . . . . . . . . . . . . . . 143Normal Examination After Sexual Assault . . . . . . . . . . . . . 143Smooth Avascular Posterior Area . . . . . . . . . . . . . . . . . 144Hymenal Projection . . . . . . . . . . . . . . . . . . . . . . . . 144xii
Integrity of Hymen . . . . . . . . . . . . . . . . . . . . . . . . 145Hymenal Mound . . . . . . . . . . . . . . . . . . . . . . . . . 145Anterior Intravaginal Ridge . . . . . . . . . . . . . . . . . . . . 145Knee-Chest Position . . . . . . . . . . . . . . . . . . . . . . . . 146Intact Posterior Rim . . . . . . . . . . . . . . . . . . . . . . . . 146Prominent Urethral Support Structures . . . . . . . . . . . . . . 146Hymenal Tag . . . . . . . . . . . . . . . . . . . . . . . . . . . 147Normal Posterior Hymenal Rim . . . . . . . . . . . . . . . . . 147Hymenal Projection . . . . . . . . . . . . . . . . . . . . . . . . 147Intravaginal Rugae and Normal Hymen . . . . . . . . . . . . . . 148Estrogenized Hymen in Abused Girl . . . . . . . . . . . . . . . 148Normal Hymenal Mound . . . . . . . . . . . . . . . . . . . . 148Posterior Mound With Cleft . . . . . . . . . . . . . . . . . . . 149Possible Precocious Puberty . . . . . . . . . . . . . . . . . . . . 149Cribriform Hymen . . . . . . . . . . . . . . . . . . . . . . . . 150Estrogenized and Intravaginal Rugae . . . . . . . . . . . . . . . 150Vascularization . . . . . . . . . . . . . . . . . . . . . . . . . . 151Examination With and Without Traction . . . . . . . . . . . . 151Hymenal Pit . . . . . . . . . . . . . . . . . . . . . . . . . . . . 152Normal Cribriform Hymen in Alleged Abuse . . . . . . . . . . . 152Penetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 153Acute Findings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 154Hematoma and Hymenal Tear . . . . . . . . . . . . . . . . . . 154Partial Healing After Transection of the Hymen . . . . . . . . . 154Anal Tears . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 155Lacerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156Unexplained Genital Bleeding . . . . . . . . . . . . . . . . . . . 158Acute Penetration . . . . . . . . . . . . . . . . . . . . . . . . . 160Traumatic Superficial Hymenal Laceration . . . . . . . . . . . . 160Anal Laceration . . . . . . . . . . . . . . . . . . . . . . . . . . 161Laceration With Bruising . . . . . . . . . . . . . . . . . . . . . 162Perianal Laceration . . . . . . . . . . . . . . . . . . . . . . . . 163Acute Laceration After Penile Penetration . . . . . . . . . . . . . 163Vaginal Bleeding After Penile Penetration . . . . . . . . . . . . . 164Vaginal Bleeding . . . . . . . . . . . . . . . . . . . . . . . . . 164Anal Tear . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 168Linear Abrasions . . . . . . . . . . . . . . . . . . . . . . . . . 168Hymenal Transections . . . . . . . . . . . . . . . . . . . . . . . 170Hymenal Septum . . . . . . . . . . . . . . . . . . . . . . . . . 171Hymenal Transection . . . . . . . . . . . . . . . . . . . . . . . 172Vaginal Discharge . . . . . . . . . . . . . . . . . . . . . . . . . 173Digital Penetration . . . . . . . . . . . . . . . . . . . . . . . . 174Penetration . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175Anal Abuse . . . . . . . . . . . . . . . . . . . . . . . . . . . . 176Complete Disruptions . . . . . . . . . . . . . . . . . . . . . . . 178xiii
Contents in DetailDiscontinuity of Hymen . . . . . . . . . . . . . . . . . . . . . 179Labial Intercourse . . . . . . . . . . . . . . . . . . . . . . . . . 179Straddle Injury-Related Bruising . . . . . . . . . . . . . . . . . 180Alleged Rape . . . . . . . . . . . . . . . . . . . . . . . . . . . 180Perianal Bruising . . . . . . . . . . . . . . . . . . . . . . . . . 181Bruising of Penis . . . . . . . . . . . . . . . . . . . . . . . . . 181Burned Penis . . . . . . . . . . . . . . . . . . . . . . . . . . . 181Perianal Laceration Caused by Penetration . . . . . . . . . . . . 182Accidental Anal Hematoma . . . . . . . . . . . . . . . . . . . . 182Sexually Transmitted Diseases . . . . . . . . . . . . . . . . . . . . . . 183Herpes Simplex Virus Type 1 . . . . . . . . . . . . . . . . . . . 183Syphilitic Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . 183Genital Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . 184Perianal Herpes . . . . . . . . . . . . . . . . . . . . . . . . . . 185Condyloma Acuminata . . . . . . . . . . . . . . . . . . . . . . 185Hemorrhagic Herpes . . . . . . . . . . . . . . . . . . . . . . . 185Scrotal Condyloma Acuminata . . . . . . . . . . . . . . . . . . 186Cylindrical Perianal Condylomata . . . . . . . . . . . . . . . . . 186Perianal Streptococcal Infection . . . . . . . . . . . . . . . . . . 187Penile Lichen Planus . . . . . . . . . . . . . . . . . . . . . . . 187Flatwarts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 187Molluscum contagiosum . . . . . . . . . . . . . . . . . . . . . . 188Genital Warts . . . . . . . . . . . . . . . . . . . . . . . . . . . 188Old Injuries . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189History of Penile Penetration . . . . . . . . . . . . . . . . . . . 189Previous Vaginal Penetration . . . . . . . . . . . . . . . . . . . 189Digital Penetration . . . . . . . . . . . . . . . . . . . . . . . . 190Healed Transection . . . . . . . . . . . . . . . . . . . . . . . . 190References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 190xiv
Child AbusePocket Atlas SeriesVolume TwoSexual AbuseSTM Learning, Inc.Leading Publisher of Scientific, Technical, and Medical Educational ResourcesSaint Louiswww.stmlearning.comSaint Louiswww.stmlearning.comxv
Chapter 1Basic AnogenitalAnatomyJoyce A. Adams, MDIn order to recognize signs of child sexual abuse, it is necessary to firstbe familiar with normal genital anatomy, its variations, and its development. While this may seem obvious, the lack of understandingof the many variations in normal appearance of the genital and analtissues in children has led to misunderstandings among medical andnonmedical professionals alike. Even after the publication of the firstdetailed descriptions of anal and genital anatomy in nonabused prepubertal children,1-3 some physicians and nurses who perform childsexual abuse medical evaluations are not familiar with the findingsfrom those and subsequent studies.4-9When a child’s examination is thought to show signs of injury orabuse but actually represents normal findings or evidence of anothermedical condition, the medical provider may contact child protectionand/or law enforcement officials to report the suspicions. The childand family would then be unnecessarily traumatized by a referral andinvestigation of those suspicions.It is also important for medical and nursing professionals, as well asnonmedical professionals, to be able to speak the same language whendescribing features of genital and anal anatomy in children and adolescents. Anatomy courses in medical and nursing school rarely providethe necessary detail about the features of genital anatomy in children,usually focusing on adults and on pathology common to adult patients.In the early 1990s, a group of physicians met at conferences to agreeon proper terminology for describing features of genital and analanatomy, and the results of a 4-year consensus development processwas published by the American Professional Society on the Abuse ofChildren in 1995. Some of the definitions were taken from standardmedical dictionaries and anatomy textbooks, but out of necessity,other definitions were created by specialists working in the field ofsexual abuse medical evaluation.Table 1-1 is a list of terms and definitions from that publication.101
Child Abuse Pocket Atlas Series, Volume 2: Sexual AbuseTable 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms.10Anatomical Structures in the Female— Mons pubis: The rounded, fleshy prominence, created by the underlying fatpad that lies over the symphysis pubis (pubic bone).— Vulva: The external genitalia or pudendum of the female. Includes theanterior commisure, clitoris, labia majora, labia minora, vaginal vestibule,urethral orifice, vaginal orifice, hymen, and posterior commisure.— Anterior commisure: The union of the 2 labia minora anteriorly/superiorly.— Clitoris: A small, cylindrical, erectile body, situated at the anterior (superior)portion of the vulva, covered by a sheath of skin called the clitoral hood;homologous with the penis in the male.— Labia majora (singular: labium majus): Rounded folds of skin formingthe lateral boundaries of the vulva.— Labia minora (singular: labium minus): Longitudinal thin folds of tissueenclosed within the labia majora. In the prepubertal child, these folds extendfrom the clitoral hood to approximately the midpoint on the lateral walls ofthe vestibule. In the adult, they enclose the structures of the vestibule.— Vaginal vestibule: An anatomic cavity containing the opening of the vagina,the urethra, and the ducts of Bartholin’s glands. Bordered by the clitorissuperiorly, the labia minora laterally, and the posterior commisure inferiorly.— Urethral orifice: External opening of the canal (urethra) from the bladder.— Vestibular bands: Small bands of tissue lateral to the urethral orifice thatconnect the periurethral tissues to the anterior lateral walls of the vestibule(urethral support ligaments), or bands of tissue lateral to the hymen connecting to the vestibular wall.— Vaginal orifice: The opening to the uterovaginal canal.— Vagina: The internal structure extending from the uterine cervix to the inneredge of the hymen.— Hymen: A membrane that partially, or rarely completely, covers the vaginalorifice.— Fossa navicularis/posterior fossa: Concavity on the lower part of thevestibule situated inferiorly to the vaginal orifice and extending to theposterior commisure or posterior fourchette.— Posterior commisure: The union of the 2 labia majora inferiorly(toward the anus).2(continued)
Chapter 1: Basic Anogenital AnatomyTable 1-1. Basic Genital Anatomy, Related Terminology, and Definition of Terms.10(continued)Anatomical Structures in the Male— Penis: Male sex organ composed of erectile tissue through which the urethrapasses; homologous with the clitoris in the female.— Glans penis/balanus: The cap-shape expansion of the corpus spongiosumat the end of the penis. It is covered by mucous membrane and sheathed bythe prepuce (foreskin) in uncircumcised males.— Scrotum: The pouch that contains the testicles and their accessory organs.— Median raphe: A ridge or furrow that marks the line of union of the2 halves of the perineum.Descriptive Terms Related to the Perineum and Anus— Perineum: The external surface or base of the perineal body, lying betweenthe vulva and the anus in the female and the scrotum and the anus in themale. Underlying the external surface of the perineum is the pelvic floor andits associated structures occupying the pelvic outlet, which is bounded anteriorly by the pubic symphysis (pubic bone), laterally by the ischial tuberosity(pelvic bone), and posteriorly by the coccyx (tail bone).— Perineal body: The central tendon of the perineum located between thevulva and the anus in the female and between the scrotum and anus in themale.— Anus: The anal orifice, which is the lower opening of the digestive tract,lying in the fold between the buttocks through which feces is extruded.— Anal skin tag: A protrusion of anal verge tissue that interrupts the symmetryof the perianal skin folds.— Anal verge: The tissue overlying the subcu
Norfolk, Virginia Child Abuse Pocket Atlas Series Sexual Abuse Volume Two David L. Chadwick, MD Director Emeritus Chadwick Center for Children and Families Children's Hospital - San Diego Adjunct Associate Professor Graduate School of Public Health San Diego State University San Diego, California Rich Kaplan, MSW, MD, FAAP† Child Abuse .
