Table 1 Summarizes some anatomical changes and signs and their potential etiologies and association with sexual activity

Lacerations

A laceration is defined as an acute tear through the full thickness of the skin or other tissues. When acute, a laceration may be associated with bleeding and /or bruising of the edges of the wound. A laceration to the hymen may involve the tearing of the full width of the hymen or only the partial width.

Though laceration of the hymen may indicate vaginal penetration, in one study of 205 prepubertal girls with confirmed history of vaginal penetration, only 33% had reported hymenal lacerations. [42, 48] Even though it is not common, a laceration of the hymen of any depth is highly suggestive of child sexual abuse. (68)

Lacerations of the hymen have also been described, though rarely, following accidents. These injuries can mimic those seen in child sexual abuse. [47]

In pubertal girls, evidence from five studies show that hymenal lacerations are seen in 3% to 19% of those who allege sexual abuse including penile penetration. [47]

Hymenal Transections

A transection is a defect in the posterior hymen rim that extends to or through the base of the hymen. A transection is not an acute injury, but it can be considered a sign of a healed injury.

Hymenal transections are very rarely seen in prepubertal girls who have not been sexually abused. However, a demonstrated transection, based on multiple studies, is commonly viewed as “a clear but uncommon indicator of past trauma” [42].

A transection below the 3 to 9 o’clock location is the only non-acute hymen finding that is considered clear evidence of past injury (68). When hymenal transection are found, previous or past penetrative injury should be strongly suspected. (21, 68)

Bumps and Munds

A bump or a mund is a solid, localized, rounded, thickened area of tissue on the edge of the hymen.

Bumps and mounds are considered a normal variant. They have been frequently observed in both abused and non-abused prepubertal girls. Several investigators found bumps in the anterior half of the hymen and in the posterior half of the hymen with similar frequency in abused and non-abused prepubertal girls. [42].

Clefts and Notches

Cleft and notches are indentations in the hymenal membrane.

Clefts and notches in the anterior hymen have been described in newborn and in prepubertal sexually abused and non-abused girls.

Clefts and notches can be part of the normal hymenal morphology in a fimbriated hymen. Superficial notches are defined as a notch inferior to 50% of the width of the hymenal membrane.

Superficial notches (inferior to 50%) have been reported in both prepubertal girls with a history of vaginal penetration and prepubertal girls selected for non-abuse.

Deep clefts or notches in the posterior half of a non-fimbriated hymen have only been reported in prepubertal girls with a history of vaginal penetration.

In pubertal girls, posterior deep notches or complete clefts (transections) have been reported more often in girls with a history of forced (nonconsensual) vaginal penetration or consensual sexual intercourse than in girls denying sexual intercourse (33% vs 7%) [49]

The finding of hymenal clefts increased with age. [48]

Scars

Hymenal lacerations can heal completely without scarring. They may also heal to leave a notch or a full transection. [47]