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Greg Dayman - Yarrow Place Rape and Sexual Assault Centre, Adelaide - Anal Anatomy, Examination, Injuries, Forensic Testing and Interpretation for Adult Sexual Assault Victims

Greg Dayman - Yarrow Place Rape and Sexual Assault Centre, Adelaide - Anal Anatomy, Examination, Injuries, Forensic Testing and Interpretation for Adult Sexual Assault Victims



Dr Gregory Dayman, Medical Coordinator, Yarrow Place Rape and Sexual Assault Centre, Adelaide presented this at the 2nd Annual Forensic Nursing Conference. ...

Dr Gregory Dayman, Medical Coordinator, Yarrow Place Rape and Sexual Assault Centre, Adelaide presented this at the 2nd Annual Forensic Nursing Conference.

This is the only national even of its kind promoting research and leadership for Australia's Forensic Nursing Community. The program addresses future training of forensic nursing examiners, forensic mental health consmers, homicide and its aftermath, ethical dilemmas in clinical forensic medicine, child sexual abuse, providing health care to indigenous patients in the forensic arena and more.

To find out more about this conference, please visit http://www.healthcareconferences.com.au/forensicnursing



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    Greg Dayman - Yarrow Place Rape and Sexual Assault Centre, Adelaide - Anal Anatomy, Examination, Injuries, Forensic Testing and Interpretation for Adult Sexual Assault Victims Greg Dayman - Yarrow Place Rape and Sexual Assault Centre, Adelaide - Anal Anatomy, Examination, Injuries, Forensic Testing and Interpretation for Adult Sexual Assault Victims Presentation Transcript

    • External Anatomy •OHT# 1
    • External Anatomy • Buttocks • Perineum- area between post fourchette or base of penis and anus. • Perianal Skin- tissues immediately surrounding the anus. • Anal Verge- tissue overlying the ext anal sphincter at the distal anal canal (anoderm) and extending to perianal skin. Not fixed (RCP UK 2008). OHT# 2
    • Anatomy OHT# 3
    • Internal Anatomy • Anal Canal- terminal part of large intestine from rectum to anal orifice.(RCP UK 2008). • Skin – keratinised squamous, squamous, transitional, columnar. • Dentate Line / Anal Crypts OHT# 4
    • Anatomy OHT# 5
    • Anatomy OHT# 6
    • Musculature • External Sphincter – deep, superficial, subcutaneous. Circumferential, striated, voluntary. • Internal Sphincter- longitudinal, smooth, involuntary. • Supporting Musculature OHT# 7
    • Anatomy OHT# 8
    • Anatomy OHT# 9
    • Anatomy OHT# 10
    • Anatomy OHT# 11
    • Internal Vessel Anatomy • External Haemorrhoidal Plexus • Internal Haemorrhoidal Plexus OHT# 12
    • Anatomy OHT# 13
    • Anatomy OHT# 14
    • Anal Skin Fold • Folding or puckering of the perianal skin radiating from the anal verge (RCP UK 2008). OHT# 15
    • Anal Skin Tag • A protrusion of anal verge tissue, which interrupts the symmetry of the perianal skin folds. • A projection of tissue of the perianal skin • (RCP UK 2008). OHT# 16
    • Perineal Raphe • Ridge or furrow that marks the line of union of the two halves of the perineum. OHT# 17
    • Scar • Fibrous tissue that replaces normal tissue after the healing of a wound. (RCP UK 2008). OHT# 18
    • Failure of Midline Fusion • A midline congenital defect in the skin • Bounded by dermal ridges that are elevated and reddened • Situated on the perineum usually between genitalia and anus. • Static (RCP 2008). OHT# 19
    • Anal Gaping • An anus that is open on separation of the buttocks such that a view into the anal canal or rectum is possible. • More than anal laxity ( decreased muscle tone of anal sphincters resulting in anal dilatation) • Both are static. (RCP UK 2008). OHT# 20
    • Examination • Examine the buttocks, perianal skin, and anal folds for injury, foreign materials, and other findings. If rectal penetration is reported or suspected, an anoscope can be used as a tool to identify and evaluate trauma (it may also be used to help obtain anal swabs and trace evidence). • (A p r i l 2 0 1 3 A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents Second Edition USA) OHT# 21
    • Internal Anal Examination • If needed, an anoscope can be used to identify anal injuries and obtain anal swabs after perianal cleansing. These swabs should be obtained by direct visualization from the rectal mucosa visible above the tip of the anoscope. OHT# 22
    • Internal Anal Examination • If patients are unable to tolerate a water-moistened anoscope or anal speculum, lightly coat the instrument with lidocaine jelly or use manual traction and obtain samples from the anal canal. If a lubricant (other than water or saline) or lidocaine jelly is used, document its use and the reason for it. OHT# 23
    • Internal Anal Examination • The examiner should use discretion in determining whether a case warrants the use of the anoscope for medical and/or forensic purposes, as well as obtain patients’ informed consent for anoscopy. Particularly if a patient has been anorectally penetrated, that patient may be uncomfortable with the use of the anoscope and could possibly even feel revictimized by it. The discomfort this procedure may cause the patient should be weighed against its potential medical or forensic uses. or forensic uses Victims, 2001, p. 48.) • OHT# 24 . (The California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse
    • Internal Anal Examination • Technique • Rationale – pain, bleeding, suspected perforation, hx of haemorrhoids, evaluate extent of injury, rectal DNA sampling, more complete examination OHT# 25
    • Digital Rectal Examination • The anus can easily accommodate a gentle examining finger even in the newborn. (Paul DM, 1977). • Technique • Rationale- tone, mass, blood, tenderness, faeces, prostate OHT# 26
    • Ano-Rectal Samples • • Collect swabs from the anal cavity. Avoid contact with external skin surfaces. • • Optional—smear swabs on microscopic slides, according to jurisdictional policy. • • Air-dry swabs and slides. • • Package swabs and slides, place in envelope, label, seal, and initial the seal. • At this time, any additional examinations or tests involving the anus should be conducted. • ( U.S. Department of Justice Office on Violence Against Women ). OHT# 27
    • Conditions OHT# 28
    • Anal Fissure  An anal fissure which is a tear in the anoderm, starts within the anal canal. This may help to differentiate the anal fissure from an anal laceration caused by trauma where the injury is likely to be within the perianal skin.  Acute fissures are very painful and it is unlikely that insertion of a proctoscope will be possible if there is an acute anal fissure present.  Anal fissures are characteristically found at the 6 o’clock and 12 o’clock positions, with the vast majority in the 6 o’clock position. They are more likely to be anterior in a female, and post-childbirth fissures are often anterior. An exception would be fissures that occur with Crohn’s Disease. OHT# 29
    • Anal Fissure  Primary anal fissures only occur below the dentate line and extension above this may be caused by trauma, malignancy, Crohn’s Disease or previous surgery.  A chronic anal fissure may have raised edges, the transverse fibres of the internal sphincter may be visible in the base, hypertrophied anal papilla may be seen at the proximal edge and a sentinel pile at the distal edge. • Fissures occur at any age but predominantly in the third and fourth decades. The aetiology is unknown, but several factors are implicated such as previous surgery, change in bowel habit or recent pregnancy or delivery. It is likely that internal anal sphincter hypertonia with consequent anoderm hypoperfusion hypoxia and poor healing allows the fissure to develop. OHT# 30
    • Anal Fissure OHT# 31
    • Anal Fissure OHT# 32
    • Anal Fissure OHT# 33
    • Haemorrhoids OHT# 34
    • Haemorrhoids OHT# 35
    • External Thrombosed Haemorrhoid / Perianal Haematoma • Peri-anal haematomas may come up acutely following anal penetration, may arise with no obvious cause or be caused by an increase in intra-abdominal pressure. Such causes of an increase in pressure include straining with constipation, heavy lifting, coughing sneezing and diarrhoea. (Neiger, 1990) OHT# 36
    • Perianal Haematoma OHT# 37
    • Internal Haemorrhoids OHT# 38
    • Fistulae OHT# 39
    • Fistulae OHT# 40
    • Frequency of Anal Injuries • Studies related specifically to injuries from anal penetration are limited: • 131 males reporting non consensual anal penetration 26% (34) had at least on anal injury (McLean 2004) OHT# 41
    • ANO-RECTAL INJURIES Incidence of ano-rectal injuries following reports of anal sexual assault: •56% (31/55) using colposcopy (Slaughter) Most common anal injuries noted: •Laceration •Abrasions •Bruising •Swelling Most common rectal injuries: •Laceration •Abrasions •Bruising OHT# 42
    • Yarrow Place Audit Anal Injuries July 2001-June 2008 Audit of 1319 women, 75 men 13% (170) women anally assaulted 53% (40) men anally assaulted External anal injury 52/162 (32.9%) women 10/38 (26%) men Most common injuries Abrasions and lacerations OHT# 43
    • Documenting genito-anal injuries Use clock-face Injury location Injury type: difficulties with laceration vs abrasion Anal injuries: note if injury within perianal skin OHT# 44
    • Healing of genital injuries McCann et al, 2007 126 pubertal adolescents Non-hymenal injuries Petechiae: not seen after 24 hours Bruising: 2 to 18 days Laceration: time of healing dependent on depth, 2 to 20 days Abrasions: not seen after 3 days OHT# 45
    • Persistence of sperm Oral swabs: 12-24 hours Vaginal swabs: 5 days Cervix: 7 days Anal swab: 46 hours Rectal swab: 65 hours (Willott and Allard, 1982) OHT# 46
    • Erythema • Redness of the skin or mucous membranes caused by dilatation of the underlying capillaries. (RCP 2008 UK). OHT# 47
    • ABRASIONS Superficial injury to the skin • • © Yarrow Place May have features that can assist in identifying the causative implement • OHT# 48 Identifies contact between the skin and the injurious force May define the direction of the injurious force
    • CLASSIFICATION OF ABRASIONS Linear Abrasions (Scratches) Produced by a sharp or irregularly surfaced object lifting the superficial layers of skin eg finger nails, prickles, pin Imprint abrasions Produced by a force at or close to the skin resulting in an imprint or pattern of the object Friction abrasions Produced by tangential contact between the skin and abrasive surface resulting in shearing of layers of skin eg grazes, carpet burns OHT# 49 © Yarrow Place
    • AGE OF ABRASION Ageing of injuries dependent on direct observation of healing process Wound showing no signs of healing and containing serous fluid, fresh or dry blood is very likely to have been caused recently Scab formation for small injury may start around 24 hours Epithelial regrowth may be seen at 72 hours Granulation tissue easily seen around 5 to 7 days Wound contraction may begin from second week of injury OHT# 50
    • LACERATIONS Ragged or irregular tears or splits in the skin, subcutaneous tissues or organs caused by blunt trauma. Caused by: •Compression of the skin between 2 hard objects •Shearing or tearing of tissues •Penetration of tissues by a relatively blunt object eg compound fracture OHT# 51 © Yarrow Place
    • CHARACTERISTICS OF A LACERATION • • Margins may be inverted • Nerves and tendons intact or crushed in the wound • Tissue bridges • Foreign material or hairs in the wound • OHT# 52 Margins ragged, irregular, abraded, crushed or bruised Shape of laceration may reflect the shape of the causative implement © Yarrow Place
    • BRUISES An area of haemorrhage beneath or within the skin Determination of the colour of the bruise may be effected by a number of factors The site of the bruising is not necessarily the site of the trauma The shape of the bruise does not necessarily reflect the shape of the causative implement The size of the bruise is not necessarily a reflection of the amount of force received Extent of bruising may be effected by: diseases, drugs, site of trauma, condition of the tissues, treatment, time © Yarrow Place OHT# 53
    • CLASSIFICATION OF BRUISES Tramline bruises Parallel or linear bruises separated by a central area of pallor. Caused by forceful contact with linear objects eg rod Bite marks Oval or circular bruise with central area of pallor, with or without abrasion Imprint bruises Produced by force to the surface of the skin resulting in an imprint or pattern of the object Fingertip bruising Petechial bruises Probable cause is acute rise in venous pressure with distension and rupture of venules eg strangulation, suction marks OHT# 54 © Yarrow Place
    • AGE OF BRUISESof determining the No precise method age of a bruise on clinical assessment. Langlois and Gresham, 1991 A bruise with a yellow colour is very likely to be more than 18 hours old Red, blue and purple black within a bruise can occur at any time after causation to resolution No significant change in red colouration with time Bruises of identical age and aetiology may not show same colour change Langlois Review 2007: OHT# 55 A bruise with a yellow colour is not of recent causation.
    • Perianal Venous Congestion • The collection of venous blood in the (external haemorrhoidal) venous plexus creating a flat or swollen purple discolouration which may be localised or diffuse. • Distinct from bruising • Dynamic • (RCP 2008 UK). OHT# 56
    • Injury Interpretation • Anal erythema • “Anal erythema (redness) is a non-specific sign that indicates inflammation. Inflammation may be caused by trauma as in penetration of the anus with an object such as a penis. Other possible causes include an infection or skin condition.” • OHT# 57
    • Interpretation • Anal swelling or bleeding • “Swelling at the anus is a non-specific finding, but it may be caused by caused by blunt force trauma, such as in penetration of the anus. Other possible causes include haemorrhoids and skin conditions.” • • “Bleeding from the anus can be caused by lacerations, fissures, haemorrhoids, dermatitis, ulcerative colitis and tumours.” OHT# 58
    • Interpretation • Anal abrasions • Abrasions are the result of simultaneous application of pressure and movement causing disruption to the superficial layers of the skin. Broadly anal abrasions can be classified as: • Linear abrasion caused by a sharp or irregularly surfaced object such as a fingernail lifting the superficial layers of skin. • Split type abrasion caused by stretching and splitting of the perianal skin. These abrasions are typically seen within the perianal skin folds. • Friction abrasion caused by an object such as a penis, finger or other object rubbing over and disrupting the superficial layers of the skin. • OHT# 59
    • Interpretation • Practically, it may be difficult to differentiate between a split type abrasion and a linear abrasion. However, a linear abrasion that does not fall within the perianal folds is likely to have been caused by an object lifting the layers of skin. • “The linear abrasion was noted next to the anus and lay with a vertical orientation extending from the 10 o’clock to the 8 o’clock position. The likely causation is a sharp or irregularly surfaced object such as a fingernail lifting the superficial layers of skin.” • OHT# 60
    • Interpretation • Anal lacerations • An anal laceration is a full thickness injury to the anal tissues. It is caused by blunt force trauma which can be either direct trauma as in an object hitting the anal tissues causing them to split, or stretching the anus beyond its elastic potential thus causing the skin to split. The causation in the second situation is similar to the causation of a split type abrasion. The difference is that a laceration is a full thickness injury. • • “The numerous lacerations of the anus, especially at multiple positions, plus the swollen bruised peri-anal skin are likely to be the result of blunt force applied to the anus as could occur with anal penetration.” OHT# 61
    • Interpretation • Anal bruising • It can be hard to identify bruising around the anus. The external haemorrhoidal plexus lies under the distal anoderm. This may be seen with separation of the buttocks or when the patient is straining. These vessels may appear distended and give a dusky appearance to the overlying skin, so care should be taken to differentiate this from bruising. • • “The bruising and laceration at the anus were caused by penetration or attempted penetration of the anus by a blunt object such as a penis, finger(s) or other object.” OHT# 62
    • Interpretation • Anal tone • There may be opinions required about anal tone especially when the victim has been subjected to repeated acts of receptive anal intercourse over several months or years. • A study has been conducted on the effect of anoreceptive intercourse on anorectal function. 40 men who experienced ongoing anoreceptive penetration and 18 control males were assessed with questionnaire and testing. They found that over a third of anoreceptive men reported some degree of anal incontinence and urgency of defaecation. There was a significant reduction in maximum resting anal pressure (a measure of the integrity of the internal anal sphincter) between anoreceptive men and the controls. Maximum resting pressure was significantly lower in anoreceptive men with anal incontinence. Men who practiced brachioproctic intercourse (fisting) had significantly lower maximum resting pressure. • (Miles, Allen-Mersch, Wastell, 1993). • OHT# 63
    • Interpretation • Anoreceptive men with incontinence had significantly lower maximum voluntary squeeze pressure (a measure of the integrity of the external anal sphincter) than anoreceptive men with no complaints of incontinence. (Miles, AllenMersch and Wastell 1993) • “Repeated anal penetration by a penis or other object may affect the integrity and function of the internal and external anal sphincters. This is likely to be most noticeable with practices such as brachioproctic intercourse (fisting). One study of 40 anoreceptive men found that a third experienced some form of minor anal incontinence or urgency of defaecation . OHT# 64
    • Red Flags • (Engel 1994) 7 patients. (2/5) Unwanted penile / object anal penetration with incontinence. • Passive faecal incontinence. Reduced anal resting tone. Disrupted internal sphincter. • Urge incontinence. Reduced max squeeze pressure. Disrupted Ext anal sphincter. OHT# 65
    • Red Flags • Trans-rectal penetrating injuries (UAE 2008) – 12 patients 1993-2006 (2 sexual assault). Anterior, Rectosigmoid junction, Ano-rectal. Peritonitis, shock, PR bleeding, weak sphincter. Dx delayed late presentation. High Index Suspicion. OHT# 66
    • Red Flags • 4 cases of homicidal colorectal trauma. ( Kovelman, 2010). Vascular Disruption and Exsanguination most common, Peritonitis and Septic Shock. 45 yo woman, apartment blood soaked, ED T 31 degrees other obs ok, disoriented. OHT# 67
    • Kovelman 2010 contd. • Rapidly unresponsive, FNE perianal laceration 7 o’clock, absent sphincter tone, anal gaping, faeces and blood draining freely. • CT free intra-peritoneal air. • O.T. 12 cm anterior transrectal laceration. • Multi-organ failure, death < 18 hours. • Post-mortem – oval abrasion anal orifice, multiple contused perianal lacerations extending into anal canal OHT# 68
    • Red Flag • (Delacroix, 2011) 16 yo, parents ED bleeding, incontinence, shivering. • Hx- 7 cups liquor, vaginal and anal penetration with penis. • Hypotherm, Hypoten, PR135, RR24, epigastric tenderness, confused, disoriented. IVT. Hb, WCC normal. OHT# 69
    • Delacroix contd. • OG- BS present, soft abdo, sup ant perianal laceration, normal anal tone, no bleeding. PV normal. • FNE- bleeding PR, PV. Post fourchette 1cm lac. Review 2/52. • 12 hours-deteriorate, abdo tender, 2x2mm post fourchette tears, anal tears 1,3, 10, 11 o’clock OHT# 70
    • Delacroix contd. • PR bleeding, stool incontinence ? Transrectal injury • CT – free air / fluid • OT – post anal lac. Extending 6cm internally, faeces abdomen, rectal tear. • Police – fisting • Suspect organ perforation – PR, PV bleeding, abdo pain, external injuries. • Imaging + surgical R/V. OHT# 71
    • References • Royal College of Paediatrics and Child Health. The Physical Signs of Child Sexual Abuse. March 2008. • A National Protocol for Sexual Assault Medical Forensic Examinations Adults/Adolescents Second Edition, April 2013, USA. • The California Medical Protocol for Examination of Sexual Assault and Child Sexual Abuse Victims, 2001, p. 48 • Paul DM. The medical examination of in sexual offences against children. Med Sci Law 1997; 17(4):251-258. • U.S. Department of Justice Office on Violence Against Women OHT# 72 .
    • References • Neiger, 1990 Atlas of Anal Proctology, second edition, Hogrefe & Huber • McLean IA, Balding V, White C, 2004, Forensic medical aspects of male on male rape in the Greater Manchester area. Medicine, Science and Law vol. 44, no.2: pp 165-9 • Drocton P, Sachs C et al, 2008 Validation set Correlates of Ano-Genital Injury after Sexual Assault Academic Emergency Medicine March 2008 vol. 15, No. 3 pp231-238 • McCann J, Miyamoto S, Boyle C, Rogers K , 2007 Healing of nonhymenal genital injuries in prepubertal and adolescent girls : a descriptive study Pediatrics 120(5):1000-11, 2007 November. OHT# 73
    • References • Willott GM & Allard JE, 1982 “Spermatozoa-Their persistence after sexual intercourse”. Forensic Science International 1982 vol. 19, no.2 pp135-54 • Engel A et al. Unwanted anal penetration as a physical cause of faecal incontinence. Eur J of Gastr & Hepatol. 1995, Vol 7, No 1. • Myre AK et al. Perianal anatomy in nonabused preschool children. Acta Paediatr 2001; 90(11):1321-1328. • Allen-Mersch TG, Wastell C, 1993, Effect of anoreceptive intercourse on anorectal function. Journal of the Royal Society of Medicine vol 86 March 1993, pp 144-147 • Giardino A, Datner E, Asher J. Sexual Assault – Victimisation Across the Lifespan – A Clinical Guide. GW Publishing 2003. Missouri USA. OHT# 74
    • References • Astrup, B et al. Nature, frequency and duration of genital lesions after consensual sexual intercourse—Implications for legal proceedings. Forensic Science International (Online) 219.1 (2012): 50-56. • Lincoln C et al. Macroscopically detected female genital injury after consensual and non-consensual vaginal penetration: A prospective comparison study. Journal of Forensic and Legal Medicine 20 (2013) 884-901. • El-Ashaal et al. Trans-anal rectal injuries. Singapore Med J 2008; 49(1):54. • Kovelman, I et al. Fatal Anorectal Trauma in the Setting of Sexual Assault. Am J Forensic Pathol. Vol 31, No. 3, Sept. 2010) • Delacroix J et al. Rectal Perforation Secondary to Rape and Fisting in a Female Adolescent. Pediatric Emergency Care. Vol 27, No 2, Feb 2011. OHT# 75