Genital bruising may occur following sexual assault or after accidental or self-inflicted trauma. Hematomas occur easily on the vulva and the scrotum due to the loose connective tissue and dependent location and proximity to the underlying pubic bones. The findings on examination vary with the different mechanisms of injury. Injury to the genital area in children always gives cause for concern. Parents are often worried about permanent damage and may be concerned about sexual abuse.

Accidental injuries to the genitalia usually have a clear history, with findings on examination consistent with that history, although sometimes verbal children will be afraid to initially disclose out of fear of getting in trouble for something they were doing when injured. Straddle injuries are a type of accidental trauma that lead to compression of the soft tissues of the vulva, scrotum, or penis between the object and the pubic ramus, causing bruising, abrasions, and/or lacerations. If associated lacerations exist, they are most often superficial. Bruising of the soft tissues may be severe, but the hymen is not damaged unless the injury is impaling due to its internal position.

Severe self-inflicted injury is unlikely because of the pain caused by the trauma. Bruising is unusual with self-inflicted injury.

For girls, extensive bruising of the labia, perihymenal tissues, or perineum without any clear history is considered to have moderate specificity for abuse. Hymenal ecchymosis should not result from accidental trauma and is highly specific for sexual abuse, with the exception of an impaling injury, which can cause hymenal injury.

For boys, extensive bruising of the penis, scrotum, perineum, or perianal area without any clear history is considered to have moderate specificity of abuse, though it is not possible to say medically whether it is due to physical or sexual abuse.

Because positive physical findings of sexual abuse occur infrequently, one cannot overemphasize that the history from the child still remains the single most important diagnostic feature in assessing whether a child has been sexually abused.

Related topics: child sexual abuse, hymen trauma, impaling injury, straddle injury