Posterior Fourchette Research Articles

A Review of Lesions of the Posterior Fourchette, Posterior Vestibule (Fossa Navicularis), and Hymen.

Lesions specific to the posterior fourchette, posterior vestibule (fossa navicularis), and hymen are reviewed. Knowledge of these regional lesions will be helpful if such a patient is encountered.

Evaluation of the angled Episcissors-60(®) episiotomy scissors in spontaneous vaginal deliveries.

BackgroundObstetric anal sphincter injuries (OASIs) are the leading cause of anal incontinence in women. Episiotomies with a postdelivery suture angle of less than 30° to the midline are more likely to injure the anal sphincter directly, while those with a suture angle of more than 60° are associated with increased incidence of OASIs, as they do not relieve the pressure on the perineum. A safe zone of 40°–60° has been proposed. Recently, two new types of episiotomy scissors (Episcissors-60® Straight version and angled version) were introduced to ensure a standardized cutting angle of 60° to the midline. We audited our results with the angled Episcissors-60 in spontaneous vaginal deliveries.Materials and methodsConsecutive patients delivering in two private maternity hospitals in Thane, India undergoing clinically indicated episiotomies were included. Only patients delivering spontaneously were included. The scissors were introduced vaginally at crowning, and aligned to orient the guide limb vertically from the posterior fourchette to the anus. While a single cut was preferred, a stagger cut was needed for some women. Postdelivery angles were measured by placing a protractor transparency on the perineum after delivery and marking the angle with an indelible ink pen. Per rectal examination was performed prior to suturing to detect OASIs.ResultsA total of 25 women underwent clinically indicated episiotomies. Of these, 16 women were nulliparous, eight women were para 1, and one woman was a para 2. One woman had a vaginal breech delivery (para 2), and the rest were cephalic vertex deliveries. The average age was 27 (range 20–35) years. The median birth weight was 2,800 g (standard deviation 312 g, interquartile range 2,500–3,000 g). The median postdelivery suture angle of the episiotomy was 50° (standard deviation 3.5°, interquartile range 48°–54°, range 45°–55°). No cases of OASI were detected in this series.ConclusionThe Episcissors-60 angled version demonstrated a postdelivery suture angle of 50° in a cohort of Indian women undergoing spontaneous vaginal deliveries.

Normal anatomic relationships in prepubescent female external genitalia

ObjectiveFemale congenital abnormalities and concomitant ambiguous genitalia constitute the primary reason for female genital reconstruction, however, objective data describing normal female anatomy is lacking. The aim of this study is to describe the normal anatomical relationships and size of the external genital structures in prepubescent females. Materials and methodsData were collected prospectively from consecutive Tanner stage 1 females undergoing surgery unrelated to the genitalia. Recorded measurements included: clitoris length and width, length from clitoris to anus, clitoris to urethra, clitoris to posterior labia majora, mucosa behind vagina or posterior fourchette, and radius to labia minora at vagina. Patients were stratified by age into four age groups: <2 years, 2–5 years, 5–11 years and >11 years. ResultsFifty-six patients met inclusion criteria. Clitoral width was similar in all age groups. The regression plots for the remaining measurements modeled on age all show a significant linear growth distribution. ConclusionsThe average clitoral width was 3.8 mm, which remained constant between age groups. Clitoral length, length from clitoris to anus, clitoris to posterior labia majora, clitoris to urethra and posterior fourchette length increased across age groups. This study provides insight into the dimensions of normal external genitalia in tanner stage 1 females.

The role of thumb and index finger placement in manual perineal protection.

Comparison of the modifications of the Viennese method of manual perineal protection (VMPP) and hands-off delivery techniques by applying basic principles of mechanics with assessments of tensions within perineal structures using a novel biomechanical model of the perineum. Evaluation of the role of the precise placements of the accoucheur's posterior (dominant) thumb and index finger in perineal tissue tension when performing a modified Viennese method of MPP. We carried out an experimental study on a biomechanical model of the perineum at NTIS (New Technologies for Information Society, Pilsen, Czech Republic). Hands-off and 38 variations of VMPP were simulated during vaginal delivery with the finite element model imitating a clinical lithotomy position. The main outcome measures were quantity and extent of strain/tension throughout the perineal body during vaginal delivery. Stress distribution between modifications of VMPP showed a wide variation in peak perineal tension from 72 to 102 % compared with 100 % for the "hands-off" technique. Extent of reduction depended on the extent of finger movement across a horizontal, transverse x-axis, and on final finger position on a vertical, antero-posterior y-axis. The most effective modification of VMPP was initial position of fingers 12 cm apart (x = ±6) on the x-axis, 2 cm anteriorly from the posterior fourchette (y = +2) on the y-axis with 1cm movement of both finger and thumb toward the midline on the x-axis (Δx = 1) with no movement on the y-axis (Δy = 0). In a biomechanical assessment with simulation of vaginal delivery, exact placement of fingertips on the perineal skin, together with their co-ordinated movement, plays an important role in the extent of reduction of perineal tension.

Number of External Anogenital Warts is Associated with the Occurrence of Abnormal Cervical Cytology

Anogenital warts (AGWs) are common results of sexually transmitted infection (STI). Human papillomavirus (HPV) types 6 and 11, which are non-oncogenic types, account for 90% of the clinical manifestations. Although the quadrivalent HPV vaccine has been launched, AGW remains prevalent in some countries and shows association with abnormal cervical cytology. To study the prevalence of abnormal cervical cytology (low grade squamous intraepithelial lesions or worse; LSIL+) in immunocompetent Thai women newly presenting with external AGWs. Medical charts of all women attending Siriraj STI clinic during 2007-2011 were reviewed. Only women presenting with external AGWs who were not immunocompromised (pregnant, human immunodeficiency virus positive or being on immunosuppressant drugs) and had not been diagnosed with cervical cancer were included into the study. Multivariate analysis was used to determine the association between the characteristics of the patients and those of AGWs and LSIL+. A total of 191 women were eligible, with a mean age of 27.0±8.9 years; and a mean body mass index of 20.6±8.9 kg/m2. Half of them finished university. The most common type of AGWs was exophytic (80.1%). The posterior fourchette appeared to be the most common affected site of the warts (31.9%), followed by labia minora (26.6%) and mons pubis (19.9%). The median number of lesions was 3 (range 1-20). Around 40% of them had recurrent warts within 6 months after completing the treatment. The prevalence of LSIL+ at the first visit was 16.3% (LSIL 12.6%, ASC-H 1.1%, HSIL 2.6%). After adjusting for age, parity and miscarriage, number of warts ≥ 5 was the only factor associated with LSIL+ (aOR 2.65, 95%CI 1.11-6.29, p 0.027). LSIL+ is prevalent among immunocompetent Thai women presenting with external AGWs, especially those with multiple lesions.

Modeling manual perineal protection during vaginal delivery

We compared hands-on manual perineal protection (MPP) and hands-off delivery techniques using the basic principles of mechanics and assessed the tension of perineal structures using a novel biomechanical model of the perineum. We also measured the effect of the thumb and index finger of the accoucheur's dominant-posterior hand on perineal tissue tension when a modified Viennese method of MPP is performed. Hands-off and two variations of hands-on manual perineal protection during vaginal delivery were simulated using a biomechanical model, with the main outcome measure being strain/tension throughout the perineal body during vaginal delivery. Stress distribution with the hands-on model shows that when using MPP, the value of highest stress was decreased by 39 % (model B) and by 30 % (model C) compared with the hands-off model A. On the cross section there is a significant decrease in areas of equal tension throughout the perineal body in both hands-on models. Simulation of the modified Viennese MPP significantly reduces the maximum tension on the inner surface of the perineum measured at intervals of 2 mm from the posterior fourchette. In a biomechanical assessment with a finite element model of vaginal delivery, appropriate application of the thumb and index finger of the accoucheur's dominant-posterior hand to the surface of the perineum during the second stage of delivery significantly reduces tissue tension throughout the entire thickness of the perineum; thus, this intervention might help reduce obstetric perineal trauma.

Novel presentation of labial synechiae: two urinary streams.

Labial synechiae, also referred to as labial adhesion or labial agglutination, is a disorder of the female genitalia characterized by thin, membranous adherence of the labia minora. Typically, the fusion originates from the posterior fourchette and advances toward the clitoris. Complete labial fusion may conceal the vaginal introitus completely. Partial labial fusion is also possible and may occur near the posterior fourchette.

Sexual violence and HIV transmission: summary proceedings of a scientific research planning meeting.

This summarizes proceedings of a Scientific Research Planning Meeting on Sexual Violence and HIV transmission, convened by the Social Science Research Council on 19–20 March 2012 at the Greentree Foundation in New York. The Meeting brought together an interdisciplinary group of basic, clinical, epidemiological and social science researchers and policy makers with the aim of: (1) examining what is known about the physiology of sexual violence and its role in HIV transmission, acquisition and pathogenesis; (2) specifying factors that distinguish risks throughout the maturation of the female genital tract, the reproductive cycle and among post-menopausal women; and (3) developing a research agenda to explore unanswered questions. The Meeting resulted in a consensus Research Agenda and White Paper that identify priorities for HIV research, policy and practice as it pertains to the role of sexual violence and genital injury in HIV transmission, acquisition and pathogenesis, particularly among women and girls.

Different episiotomy techniques, postpartum perineal pain, and blood loss: an observational study

The lateral episiotomy technique has been postulated to cause more postpartum perineal pain and blood loss compared to the midline and mediolateral episiotomy technique. The aim of the study was to explore the association with postpartum perineal pain and blood loss between different episiotomy techniques. Clinical evaluation of episiotomy was performed 0-3 days after delivery on 300 participating women. Episiotomy technique was classified by millimeter distance from the incision point to the posterior fourchette and by angle from the sagittal plane in degrees. Postpartum perineal pain was scored on a visual analogue scale (VAS) the first day after delivery. Blood loss data were collected from medical charts. Different episiotomy techniques and different episiotomy incision point groups were compared in relation to perineal pain perception and blood loss. We found no difference between midline, mediolateral, and lateral episiotomy techniques in perineal pain perception the first postpartum day (p = 0.74) or in estimated blood loss (p = 0.38). No differences were found in perineal pain or blood loss between midline and lateral incision points. Mediolateral angles were significantly narrower than lateral angles (p < 0.005). Physicians performed longer episiotomies than midwives (p < 0.005), but episiotomy angle did not vary between professions (p = 0.075). No differences in perineal pain perception the first postpartum day and no differences in estimated blood loss were found when comparing different episiotomy techniques or when comparing midline and lateral incision points.

Anal transposition (trans-sphincteric ano-rectoplasty) for recto-vestibular fistula

Background: Imperforate anus with recto-vestibular fistula is the most common form of imperforate anus in females and is an intermediate type of this disease, which is treated surgically. The current study aimed to compare three techniques used for the treatment of imperforate anus with recto-vestibular fistula. Materials and Methods: Fifty-four cases of imperforate anus with recto-vestibular fistula were managed using three main approaches: posterior sagittal ano-rectoplasty, anterior sagittal ano-rectoplasty, and the anal transposition or trans-sphincteric ano-rectoplasty (TSARP). The functional results and cosmetic appearance for each case after treatment were evaluated in patients above 3 years of age (43 cases). Results: The functional outcomes were good in all treatment groups; however, the better cosmetic results were evident in the group treated using TSARP, a technique, which preserves the skin bridge between the new anus and the posterior fourchette, does not disturb the perineal body, and avoids division of the levator muscles. In this group, a continence rate of 100% but a higher constipation rate (41%) than in the other groups was recorded. Conclusion: TSARP is recommended for imperforate anus with recto-vestibular fistula.

Évaluation d’une crème œstrogénique vaginale dans le traitement de la vestibulodynie provoquée : essai randomisé à double insu

ObjectiveOur objective was to assess the short-term effect of an estrogen cream on symptoms associated with provoked vestibulodynia. MethodsWe undertook a double-blind randomized trial in women who had experienced dyspareunia satisfying the Friedrich criteria for at least three months. We compared the daily application of 3 g of vaginal cream containing 1.875 g of conjugated estrogens for six weeks (estrogen group) with the application of a comparable cream without estrogens (placebo group). The main outcome was modification of dyspareunia, determined by a visual analogue scale of pain from the pretreatment period to the post-treatment period. Secondary outcomes were colposcopic evaluation of the vulva and pain reported during the swab test. ResultsOf 69 women randomized, 61 participated for the full duration of the trial. Dyspareunia was significantly lessened in both groups (estrogen group: 7.4±1. 9 pre-treatment vs. 4.8±3.0 post-treatment, P<0.01; placebo group: 7.1±1. 9 vs. 4.9±2.7, P<0.01), but the difference observed in terms of decrease between the two groups was not found to be significant (P=0.5). Alternatively, the group treated with estrogen cream showed (1) a more substantial decrease of the pain reported at the orifices of the Bartholin’s glands when palpated with a swab (P<0.01), and (2) a decrease of the inflammation observed at the orifices of the Bartholin’s glands orifices and the posterior fourchette (P<0.01). ConclusionApplying a vaginal cream, whether it contains estrogens or not, for six weeks lessens dyspareunia. Adding estrogens to such a cream could facilitate a decrease of the inflammation observed at the orifices of the Bartholin’s glands and the vestibule.

A case control study of anovaginal distance and bacterial vaginosis

We aimed to test the hypothesis that a short anovaginal distance may increase the risk of bacterial vaginosis (BV) due to faecal contamination and disruption of the vaginal microbiota. Women attending two sexually transmitted infection (STI) clinics in Baltimore, Maryland, USA, who complained of a vaginal discharge were asked to participate in a study to measure mucosal immune responses. In this pilot study of all enrolled women, a small plastic ruler was used to measure the anatomic distance from the posterior fourchette to the anus with the participant in the lithotomy position. Cases of BV, defined by Amsel's clinical criteria (n = 62), were compared with controls (n = 31) without BV. We used linear and logistic regression models to adjust for potential confounders. A total of 93 women were recruited (median age 28.6 years, 93% black, 4.4% gonorrhoea infection, 7.4% chlamydia infection, 8.6% trichomonas infection, 67% BV diagnosed). Mean anovaginal distance was 3.22 cm (SD: 0.74, range 1.8-5.2) for controls and 3.37 cm (SD: 0.76, range: 1.8-5.7) for cases (P = 0.38). There was no difference between cases and controls when comparing median values, quartiles and after adjusting for potential confounders. Among high-risk women with multiple co-infections, there was no association between anovaginal distance and clinical diagnosis of BV.

Sexual Violence toward Children and Youth in War-Torn Eastern Democratic Republic of Congo

BackgroundThe epidemic of gender-based violence in the Democratic Republic of the Congo (DRC) has garnered popular media attention, but is incompletely described in the medical literature to date. In particular, the relative importance of militarized compared to civilian rape and the impact on vulnerable populations merits further study. We describe a retrospective case series of sexual abuse among children and youth in eastern DRC.MethodsMedical records of patients treated for sexual assault at HEAL Africa Hospital, Goma, DRC between 2006 and 2008 were reviewed. Information extracted from the chart record was summarized using descriptive statistics, with comparative statistics to examine differences between pediatric (≤18 yrs) and adult patients.Findings440 pediatric and 54 adult sexual abuse cases were identified. Children and youth were more often assaulted by someone known to the family (74% vs 30%, OR 6.7 [95%CI 3.6–12], p<0.001), and less frequently by military personnel (13% vs 48%, OR 0.14 [95%CI 0.075–0.26], p<0.001). Delayed presentation for medical care (>72 hours after the assault) was more common in pediatric patients (53% vs 33%, OR 2.2 [95%CI 1.2–4.0], p = 0.007). Physical signs of sexual abuse, including lesions of the posterior fourchette, hymeneal tears, and anal lesions, were more commonly observed in children and youth (84% vs 69%, OR 2.3 [95%CI 1.3–4.4], p = 0.006). Nine (2.9%) pediatrics patients were HIV-positive at presentation, compared to 5.3% of adults (p = 0.34).InterpretationWorld media attention has focused on violent rape as a weapon of war in the DRC. Our data highlight some neglected but important and distinct aspects of the ongoing epidemic of sexual violence: sexual abuse of children and youth.

Patterns of accidental genital trauma in young girls and indications for operative management

Background/purpose The aim of this study was to define the injury patterns of accidental genital trauma (AGT) in female patients and examine the indications and outcomes of operative intervention. Methods Review of patients younger than 16 years with AGT from 1980 to 2007 excluding sexual- and obstetric-related injuries. Results One hundred sixty-seven patients met the criteria. Mean (±SEM) age was 6.9 (0.2) years. There were 70.5% straddle injuries, followed by nonstraddle blunt injuries (23.5%) and penetrating injuries (6.0%). Injuries to the labia were most frequent (64.0%). Injuries to the posterior fourchette (7.8%) and hymenal disruption (8.4%) were less frequent. There was 87.9% of AGT that was managed expectantly without further sequelae. Twenty patients (12.1%) were managed operatively. Penetrating injuries were more likely to require operative management ( P ≤ .03). The operative group was also more likely to have multiple genital injuries (60% versus 25%, P < .01). Proctoscopy, vaginoscopy, and/or cystoscopy were performed in 55% of patients in the operative group. Conclusions Accidental genital trauma is most commonly caused by straddle-type injuries and is usually amenable to nonoperative management. Hymenal disruption and injuries to the posterior fourchette are uncommon with these types of injuries.

Defektdeckung an der Vulva mit plastisch-rekonstruktiven Verfahren – Indikationen, Techniken und Ergebnisse

Fragestellung: Die zunehmende Inzidenz an Vulvakarzinomen in den letzten Jahren lässt die Anzahl an Patientinnen, die mit plastisch-rekonstruktiven Verfahren an der Vulva versorgt werden müssen, ansteigen. Material und Methodik: Zwischen 2004 und 2009 wurden 20 Frauen mit primären bzw. rezidivierten Vulva-/Vaginalkarzinomen, ausgedehnter VIN/AIN, großen Defekten nach Wundheilungsstörungen oder Scheidenstenose mit 24 Lappenplastiken operiert. Dazu wurden 9 distante (6 VRAM, 2 M. gracilis und ein M. tensor fasciae latae) und 15 regionäre Lappen eingesetzt (8 Gluteal Fold, 4 Transpositionslappen, 3 Singapore-Flaps). Bei den distanten Lappen war die Indikation in der Regel ein großer Defekt nach Rezidiventfernung, bei den lokoregionären Lappen kleinere Defekte und Erhalt der Vita sexualis bei jungen Patientinnen mit Vulvakarzinom der hinteren Kommissur. Ergebnisse: Der VRAM-Lappen erwies sich als sehr verlässlicher Lappen zur Defektdeckung im Mons-pubis-Bereich und bei großen Defekten im gesamten Vulvabereich, der Gluteal-Fold-Flap wurde zur Rekonstruktion größerer Defekte lateral und dorsal verwendet, der Singapore-Flap zur Rekonstruktion der Vagina und bei periurethralen Defekten. Transpositionslappen helfen, Introitusverengungen bei Läsionen an der hinteren Kommissur zu verhindern. Ein individualisiertes Vorgehen nach Einzelbefund ist ausschlaggebend für den Erfolg. Die Rate schwerer Komplikationen in unserer Serie war sehr gering. Schlussfolgerung: Wir schlussfolgern, dass die individualisierte Lappendeckung an der Vulva in der Hand von plastisch-rekonstruktiv erfahrenen operativ tätigen Gynäkologen ein sicherer Eingriff zum Erhalt der Sexualfunktion und Deckung von großen Defekten nach Rezidiventfernung von Malignomen darstellt.

Perineal length: norms in gravid women in the first stage of labour

The purpose of this study was to generate normative data for perineal length for Caucasian and Asian women in labour. The distance from the posterior fourchette to the centre of the anal orifice was measured in 1,000 women in the first stage of labour. Data on ethnicity, body mass index, delivery mode and perineal trauma were collected prospectively. The mean perineal length in Caucasian women was 3.7 +/- 0.9 cm and in Asian women, 3.6 +/- 0.9 cm. Primigravid women with short perineum were more likely to have a third-degree perineal tear in labour (p = 0.03). This is the first paper to report normative data for perineal length in Caucasian and Asian women in labour. We found a negative correlation between perineal length and third-degree tear in primigravid women. These data may be useful in clinical practice to determine the risk of significant perineal tears in labour.

Anogenital distance from birth to 2 years: a population study.

BackgroundAnogenital distance (AGD) is sexually dimorphic in rodents and humans, being 2- to 2.5-fold greater in males. It is a reliable marker of androgen and antiandrogen effects in rodent reproductive toxicologic studies. Data on AGD in humans are sparse, with no longitudinal data collected during infancy.ObjectiveThis study was designed to determine AGD from birth to 2 years in males and females and relate this to other anthropometric measures.Materials and MethodsInfants were recruited from the Cambridge Baby Growth Study. AGD was measured from the center of the anus to the base of the scrotum in males and to the posterior fourchette in females. Measurements were performed at birth and at 3, 12, 18, and 24 months of age.ResultsData included 2,168 longitudinal AGD measurements from 463 male and 426 female full-term infants (median = 2 measurements per infant). Mean AGD (± SD) at birth was 19.8 ± 6.1 mm in males and 9.1 ± 2.8 mm in females (p < 0.0001). AGD increased up to 12 months in both sexes and in a sex-dimorphic pattern. AGD was positively correlated with penile length at birth (r = 0.18, p = 0.003) and the increase in AGD from birth to 3 months was correlated with penile growth (r= 0.20, p = 0.001).ConclusionWe report novel, longitudinal data for AGD during infancy in a large U.K. birth cohort. AGD was sex dimorphic at all ages studied. The availability of normative data provides a means of utilizing this biological marker of androgen action in population studies of the effects of environmental chemicals on genital development.

Abdominoanterior sagittal approach for sphincter-saving low anterior resection for carcinoma of the rectum in females: a modified anatomical approach

Safe access to the lower rectum is of the utmost importance when performing sphincter-saving resection for rectal cancer. We describe an abdominoanterior sagittal approach for low anterior resection in females. The abdominal part of the procedure is similar to conventional low anterior resection. The perineal part includes making an anterior sagittal incision from the posterior fourchette to the anterior edge of the anus. The use of a muscle stimulator allows identification of the external sphincters. The rectum and both puborectal slings are identified. Lower margin division and completion of total mesorectal excision is done from below, under vision. The specimen is delivered and mobilized colon is brought down, a hand-sewn end-to-end colorectal anastomosis is formed, and a diverting colostomy is fashioned. Seven patients underwent low anterior resection via the abdominoanterior sagittal approach. Two patients (29%) developed anastomotic stricture, one in association with a rectovaginal fistula and still had a defunctioning stoma, while the other responded to dilatation. The six patients who underwent stoma closure achieved continence to solid stools with a mean Kelly score of 5. The abdominoanterior sagittal approach for low anterior resection is an alternative option for sphincter-saving resection in female patients as it defines the sphincteric anatomy, and minimizes the risk of sphincter injury.

The validity and reliability of the StationMaster: A device to improve the accuracy of station assessment in labour

Objective To compare the accuracy of digital assessment and the StationMaster (SM) in the assessment of fetal head station. The SM is a simple modification of the amniotomy hook which works by relocating the point of reference for station assessment from the ischial spines to the posterior fourchette. It is first adjusted to the woman's pelvic size, and then inserted into the vagina until it touches the fetal head. The station is then read off at the posterior fourchette in cm. Study design An in vitro study of test validity and reliability was conducted at Liverpool Women's Hospital, Liverpool, UK. An apparatus was constructed in which a model fetal head could be accurately positioned within a mannequin's pelvis. Twenty midwives and 20 doctors (in current labour ward practice) gave their consent to take part. First, the head was placed in 5 random stations (−2 to +7 cm) and the participant asked to record their digital assessment for each. The participant was then taught to use the SM and the experiment repeated with 5 new stations. The complete experiment was repeated at least 2 weeks later using the same stations but in reverse order. The true values were compared with both the digital and SM assessments using mean differences with 95% limits of agreement. The repeatability of the two methods was assessed in the same way. Results Overall, the SM was more accurate than digital examination. The mean error (S.D.) ranged from 0.1 (1.2) to 2.6 (1.6) for the StationMaster and 0.3 (1.3) to 4.3 (1.1) for digital examination. Inaccuracies increased as the head descended through the pelvis. When assessed digitally, the true value fell outside one standard deviation for stations of more than +1 cm. In contrast, with the SM the true value remained inside one standard deviation for all stations up to +5. Conclusions In vitro the SM improves the accuracy of intrapartum station assessment.

Genital and Anal Injuries Requiring Surgical Repair in Females Less Than 21 Years of Age

Study Objective The injuries of sexually abused and assaulted girls seldom require surgical repair, and genital and anal injuries due to other causes appear to require repair uncommonly. We sought to determine the causes of genital and anorectal injuries requiring surgical repair in relation to such variables as injury sites and severity. Design Retrospective study Setting A large tertiary care children's hospital Participants Forty-four girls less than 21 years of age who required surgical repair of genital injuries between June 1986 and April 2007 were identified. Main Outcome Measures Information collected included the victims' ages, trauma mechanisms, and sites and severity of injuries. Results Injuries requiring repair of the genital and anal areas were uncommon in the 20 year period of this study. Although most injuries were due to straddle and impalement mechanisms, sexual abuse or assault was identified in 25% of the girls. The remaining 11% were victims of motor vehicle accidents. Straddle/impalement injuries involved only the external genitalia, vestibule, perineum, or posterior fourchette of 21 of the 28 girls (76%) with those injuries. The injuries of 9 of the 11 sexually abused/assaulted girls (82%) also involved the hymen, vagina, anus, or rectum. Injuries due to sexual abuse/assault and motor vehicle accidents (MVA) had average severity scores of 2.1 and 2.2, respectively, while straddle injuries had an average severity score of 1.4. (Exact Pearson chi-square P < 0.003.) The ages of the girls were unrelated to the severity of their injuries. Conclusions Although straddle/impalement was the most commonly found mechanism of genital and anorectal injury requiring surgical repair, sexual abuse or assault was identified in 25% of the girls. Sexual abuse and assault should always be considered and assessed appropriately when such injuries are found. Consultation of a social worker or child abuse specialist may be appropriate, especially when injuries clearly not due to an MVA involve the vagina or anorectum. A suspicion of sexual abuse or assault should be reported to the legally mandated state agency in accordance with the laws of state.