Algorithm: Initial management of straddle injury in girls

* The clinician should have suspicion for sexual abuse when penetrating injuries have the following characteristics:

1. Extensive or severe trauma
2. Penetrating injury to the hymen, vagina, or rectum without explanation
3. Injury to the posterior fourchette
4. Presence of suspicious traumatic findings in addition to genital injury
5. Infants younger than nine months of age
6. Genital lesions or secretions suggesting a sexually transmitted infection

Patients with these characteristics warrant evaluation for sexual abuse and reporting of possible child abuse to proper authorities. Refer to UpToDate topics on physical and sexual abuse in children and adolescents.
¶ Provide sedation and/or analgesia prior to examination as needed.
Δ Patients with superficial lacerations of the mons, clitoris, or labia may have pooling of blood in the vagina. Gentle irrigation with normal saline can be helpful to determine whether bleeding is coming from the vagina or elsewhere.
◊ Girls who are initially reluctant to void and who do not have an overdistended bladder can receive local measures (eg, application of a cold pack) or, in the absence of serious injury, oral analgesia (eg, acetaminophen or ibuprofen) to encourage urination.
§ Large lacerations, particularly those that may involve the urethra or extend near the rectum warrant consultation with a surgeon with pediatric gynecologic expertise for repair.