Female genital injury—which findings have to be considered physiological using colposcopy with and without toluidine blue dye?

All data was stored in a Microsoft Excel sheet. After a thorough check for false data entry, the data was imported into SAS® (release 9.4, SAS Institute Inc., Cary, NC, USA). For normally distributed quantitative variables mean and standard deviation were calculated. For ordinally scaled data and quantitative discrete data, median values together with minimum and maximum are given. For qualitative data, absolute and relative frequencies are presented.

A total of 200 participants were recruited; three questionnaires were returned incomplete and photo documentation of 6 women was rated as qualitatively insufficient. Hence, 191 observations were statistically assessed.

The mean age of the study population was 41 (standard deviation ± 13) years. Table 1 summarizes demographic data and gynecologic history; characteristics of sexual history are depicted in Table 2. A total of n = 10 (5%) women did not have sexual intercourse before being examined, n = 108 (57%) did have consensual sex more than 7 days before examination. The remaining 38% reported to have had sex within the last week.

Macroscopically a total of 9 women (5%) were found to have at least one genital lesion, two (1%) had more than one injury. A total of 11 lesions (n = 10 lacerations, n = 1 abrasion) were identified.

Using colposcopic examination only, 17 women (9%) were found to have at least one genital lesion. Seven (4%) of these had more than one lesion and a total of 25 lesions (laceration, abrasion, bruise) were categorized. After toluidine blue dye, 55 women (28%) had at least one lesion, of these 14 (7%) had more than one and a total of 73 lesions were recorded respectively. Considering postmenopausal women only, the injury prevalence was found to be substantially higher (42%, 16/38) compared to premenopausal individuals (24%, 36/151).

Using solely colposcopic magnification, of the 17 women with a lesion, 12 (71%) had at least one lesion affecting the posterior fourchette, 6 (35%) with lesions affecting the perineum or the labia minora. No further site was found to be injured.

Subdividing the vaginal introitus into quadrants (see Fig. 1), the most common injury localization was the before mentioned “6 o’ clock position” (56%, 14/25), followed by the lower right quadrant (24%, 6/25) and the lower left quadrant (20%, 5/25). No lesions were found in the upper quadrants.

After toluidine blue dye 63% of genital trauma was found at the “6 o’clock position” (n = 46/73), 16% in the lower right (n = 12/73) and 15% in the lower left quadrant (n = 11/73) respectively. Additionally, one lesion was found in the upper right (1%; n = 1/73) and three (4%; n = 3/73) in the upper left quadrant. Table 3 summarizes injury characteristics. In our collective, regardless of the application of toluidine blue dye, a vertically aligned laceration was the most frequent type of injury observed.

We identified several factors correlating with the prevalence of genital injuries. As expected, the menopausal status appeared to have a significant impact (p = 0.0165), as well as vaginal dryness (p = 0.0228), usage of topical vaginal medication (p = 0.0369) and dyspareunia (p = 0.0234). Furthermore, genital injury was also found to inversely correlate with the frequency of intercourse (p = 0.0022). Hence, lower genital injury rates were found in women with a higher intercourse frequency. Sub-classifying the entire collective into pre- and postmenopausal women we found this observation persistent for the premenopausal group only (p = 0.0052). As explained below, it has to be stressed that the majority of women (57%) in our collective did not have intercourse within seven days before examination. The remaining factors assessed, which were shown to have no influence on injury prevalence, are summarized in Table 4.

Performing the toluidine blue dye, we observed a “U”-shaped (see Fig. 2) staining in some women: this staining is strictly delimited and superficial, reaching from the posterior fourchette to the posterior half of the hymen as well as to the inner area of the labia minora. The anterior part of the vaginal introitus remains free of coloration. Analyzing data, we found this staining to correlate significantly with history of sexual intercourse (p = 0.0001). This staining was not detected in any participants without a history of vaginal intercourse. Of all women who reported to have had consenting intercourse, this staining was observed in 29% if intercourse took place within the past 2 days, and in 51% if intercourse took place within the last 3 to 7 days.

The first publications on genital trauma after consensual sexual intercourse were published by Laumer and McCauley et al. in the 1980s [8, 9]. Both investigations were prospective, recruiting women presenting with gynecological symptoms after consenting sexual intercourse, which has to be considered as a potential bias. While the number of patients include n the studies (22 and 48 patients with an injury prevalence of 5 and 10% respectively) were rather small, the authors assessed genital trauma using toluidine blue dye, focusing on lacerations only.

Slaughter et al. were the first to use a colposcope and toluidine dye enhancement to analyze genital trauma in rape victims using the TEARS classification as stated above [3]. Findings were compared with a consensual sex population consisting of 75 women (two minors) with a majority of women (n = 48) who were at first evaluated as rape victims but who later admitted having had consensual intercourse. While results due to the latter aspect have to be interpreted with caution, authors found an injury prevalence of 11%.

McLean et al. assessed 68 women presenting for a routine cervical PAP-smear after consenting intercourse macroscopically, without using either a colposcope or dye. Injuries, categorized as bruise, abrasion and/or laceration, were observed in 5.9% [6].

Similarly, Lincoln et al. examined a total of 81 women presenting for routine cervical screening or with sexual health concerns after consensual sex macroscopically [4]. Injuries, also defined as bruise, abrasion and/or laceration, were found in 9.9%.

The above stated investigations were comparative investigations that recruited women after consensual and non-consensual penetrative intercourse had occurred [3, 4, 6, 8, 9]. Other authors chose to recruit women prospectively, hence before scheduled consensual intercourse [7, 10‐12]. In a comparative study Anderson examined, using a colposcope and toluidine dye, 46 women within 24 h after consensual intercourse differentiating trauma according to a modified TEARS classification (excluding swelling and redness) [10]. Authors found a genital injury prevalence of 30%. Analogously, Zink et al. examined 120 female volunteers detecting genital injuries in 55% [11].

Fraser et al. assessed 107 sexually active women two or three times over a 4- 6 month period using a consistent technique with colposcopic magnification and acetic acid [12]. Authors looked for changes in the vaginal and cervical appearance (TEARS with additional categories microtrauma and mucosal changes), which might be related to sexual intercourse or other environmental factors and found genital injuries in 25.2% within 24 h after sexual intercourse.

Finally, Astrup et al. examined a total of 98 women within 48 h after consensual intercourse and found genital injuries (bruise, abrasion, laceration) in 52% using colposcopy and toluidine dye [8].

In the above stated review of the literature it is worth noting that if examination takes places after intercourse, prevalence ranges from 4 to 11%, while prevalence is much higher (25 to 55%) if clinical assessment is accomplished before scheduled intercourse [5]. Prevalence of genital injury in our collective was 28% (including postmenopausal women; 24% for premenopausal women only). Reviewing the literature, it becomes obvious that the diagnostic methods used, definitions of injury, and the time of recruitment have an impact on injury prevalence. Of the cited investigations, the study designs (prospective design, usage of a colposcope with toluidine dye, classification of injury) by Astrup and Anderson et al. are best comparable to our data [7, 10]. However, it is important to consider in this context that 5% of women in our collective did not have intercourse at all before being examined while 57% of participants did not have consensual sex within the past 7 days before examination. Taking into account that the examined genital areas also differ slightly, as well as the above explained restrictions (especially the time of recruitment and the size of our study collective), a prevalence of approximately 25 to 30% seems to be realistic.

In the existing literature potential risk factors for genital trauma after consenting intercourse, analogously to injury prevalence, have to be considered with caution. However, reviewing the existing literature some findings of the above stated investigations are congruent. While existing data concerning skin color, penetrative use of finger(s) during intercourse and gynecological disease as potential influencing factors are controversial, findings are consistent concerning age, parity, use of lubricants and of tampons as well as contraceptives as the prevalence of injuries did not correlate with these factors [5]. Furthermore, besides timing of clinical examination as explained above (before versus after intercourse), Fraser et al. identified smoking status to correlate with injury prevalence: if women smoked prevalence was higher [12].

Our investigation additionally assessed postmenopausal women in this context and as expected menopause status had a significant impact on injury prevalence (p = 0.0165): at least one injury was observed in 42.1% of postmenopausal versus 23.8% of premenopausal women. There exists some information about genital trauma after non-consensual intercourse [3, 13‐18]. Although most authors defined menopause status depending on age and not on menstruation, which has to be considered critically, there is high consistency that a postmenopause status influences genital trauma significantly. It has to be stressed that numeric age in our collective was not identified as a risk factor, which is consistent with the findings of other authors [4, 6, 7, 19]. Regardless of menopause status, vaginal dryness, dyspareunia and lower frequency of vaginal intercourse could be identified as further influencing factors in our study population. These factors are plausible, but have not been reported before. This circumstance is surprising, as vaginal dryness, which is known to correlate with dyspareunia, is a frequent symptom reported by approximately 15% of premenopausal and 57% of postmenopausal women [20‐22]. Furthermore, vaginal dryness is arguably one of the major reasons for the increased prevalence of genital trauma in rape victims.

Interestingly, an increasing frequency of vaginal intercourse correlated inversely with genital injury. To what extent this finding is affected by an increased libido with corresponding lubrication is debatable. Furthermore, the majority of women (57%) in our collective did not have intercourse within seven days before examination. Fourteen percent stated they had had sex within 2 days and 24% within the last 3 to 7 days before being examined. In contrast to the findings of previous investigations, the prevalence of injury did not correlate with time passed since last intercourse: Anderson et al. found a significant reduction of injury size within 72 h after consensual intercourse. Astrup et al. found a “median survival time” of genital lesions after consenting sex of 24 h using the naked eye, 40 h using solely the colposcope, and 80 h using colposcope magnification and toluidine dye. What has to be considered in this context is the fact that in both investigations recruitment took place before examination and authors examined women only up to 3 (Anderson et al.) or 7 (Astrup et al.) days respectively [7, 23]. Our data, based on a distinct study design, should be considered as “real world data” concerning genital injury, including postmenopausal women with a demonstrably higher prevalence of genital lesions. Interestingly, of (57%) women who reported to not have had sexual intercourse within the past 7 days, 6 (6%) had evidence of genital injury macroscopically, 9 (8%) using colposcopic magnification and 38 (35%) using colposcopy with toluidine blue dye. Furthermore, we could observe a “U”-shaped coloration via toluidine dye of the introitus if women did have penetrative sex before examination (p = 0.0001). To the best of our knowledge this finding has not been described before and might be the result of blue coloration due to superficial epithelium desquamation. Future investigations assessing genital injury should focus on this observation.

In accordance with previous investigations potential influencing factors (see Table 4) such as age, parity, use of lubricants, vibrators and of tampons as well as contraceptives had no impact. Also, intimate care, method of pubic hear removal, masturbation, genital piercing and sports such as horseback riding and cycling, which to the best of our knowledge have not been investigated before, had no impact on injury prevalence either.

In total, we detected 25 lesions (n = 17 women: 20 lacerations, 5 abrasions) colposcopically and 73 (n = 55 women: 45 lacerations, 28 abrasions) using colposcope and toluidine dye. Bruises were not found. These findings are in accordance with previous investigations, as lacerations were found to be the most common genital injury after consensual intercourse [4, 7‐11, 19, 24]. Also concerning abrasions as second most frequent genital injury our results are consistent with existing publications [10, 11, 24].

In previous investigations all types of injury were observed, but despite methodical differences findings are highly consistent as most authors identified one single vertically aligned laceration affecting the posterior fourchette as the most frequent major type of injury [5]. Our results are consistent with these findings as 17 (9%) of women had injuries detected colposcopically and 55 (28%) using toluidine dye additionally. Of these 17 women, 12 (71%) had at least one lesion affecting the posterior fourchette, 6 (35%) involving the perineum or the labia minora respectively. No further locations were observed. In 59% (n = 10) of women with genital trauma using colposcope magnification and in 58% (n = 32) using additional toluidine dye the above stated vertically aligned laceration was found. These findings align with the results by Astrup et al., as the authors found the vertical laceration at the “6 o’clock position” in 75% of women with genital injuries colposcopically and in 81% with additional toluidine dye [24]. Concerning further genital injuries published data are inconsistent. Astrup et al. found the labia minora as the second most frequent localization (23/31% of women with genital injuries using colposcope/ additional toluidine dye) [24]. While in our collective labial damage was only observed in one woman, other investigations found no labial trauma at all [3, 4, 23]. On the other hand, Slaughter et al. state injuries of the hymen as the second most frequent (n = 3/ 8) [3]. As in both of these investigations the above stated bias have to be kept in mind, injuries of the labia minora as well as the hymen seem to be rather uncommon. In our collective the second most frequent were further lesions of the introitus: using colposcopy only 4 of 17 women (24%), with additional toluidine dye 11 of 55 (20%) respectively, had an injury affecting the lower right quadrant.

Few investigations focused on vaginal and cervical trauma, observing no [3, 4, 24] or occasional lesions [6, 11] of these structures after consensual intercourse.

Subdividing the topography of the external genital into quadrants we found 94% of lesions located in the lower quadrants. Hence, this region should be of special focus with respect to future scientific and forensic investigations.

Referring to the objective of this investigation, the findings of which have to be considered physiological, one can summarize that lacerations and/or abrasions of the lower quadrants (primarily a vertical laceration at the “6 o’clock position”), especially in postmenopausal women CAN be physiological.