TEARS Classification and Anogenital Injury Patterns

TEARS provides a five-category framework for recording any anogenital physical finding. Each category is applied to each anatomical structure examined (labia majora, labia minora, posterior fourchette, fossa navicularis, hymen, vaginal walls, cervix, perineum, perianal region) and any finding is documented by category, exact location, size, and characteristics.

Multiple prospective studies, including those by Slaughter et al. (1997), Marchetti et al. (2011), and Campbell et al., have examined injury rates in patients presenting after sexual assault. Across studies, a substantial minority -- sometimes the majority -- of patients with consistent assault histories have no detectable anogenital injury.

• Penetrative vaginal assault: injury rates in studies range from approximately 20% to 50%, depending on population, time to examination, and colposcopy use.
• Anal assault: injury rates are similarly variable; absence of anal injury is common even after documented anal penetration.
• Factors increasing injury rate: assaults by strangers, physical force used, younger patients, shorter time from assault to examination.
• Colposcopy improves detection: magnification reveals injuries invisible to the naked eye, and studies using colposcopy consistently find higher injury rates than non-colposcopy examinations.

Research also shows that consensual sexual activity produces anogenital injuries. Sommers et al. (2003) documented abrasions and lacerations in women following consensual intercourse. This dual finding -- assault without injury, and injury with consent -- means that the presence or absence of anogenital findings cannot, by itself, determine whether assault occurred. The examination finding is one piece of evidence in a larger picture.

Several normal anatomical structures in the anogenital region are regularly misidentified as injury or prior trauma. Recognition of these variants is a core competency in forensic nursing training.

• Vestibular papillomatosis: symmetrical, soft, micropapillary projections in rows on the inner labia and vestibule. Distinguished from HPV warts by symmetry, regular size, and lack of epithelial disruption. Very common.
• Hymenal notches: V-shaped interruptions in the hymenal rim. Normal variants are typically found anteriorly and laterally; posterior (6 o'clock) notches are clinically significant and require careful documentation.
• Median raphe: a midline seam running from perineum to anus, representing the fusion line of embryological structures. Normal. Can be mistaken for a healed laceration.
• Fordyce spots: sebaceous glands visible as small pale or yellowish papules on the labia majora or penile shaft. Normal. Occasionally misidentified as signs of infection or injury.
• Hymenal remnants (carunculae myrtiformes): tissue tags at the hymenal ring in adults. Normal post-pubertal finding. Their configuration does not reliably encode sexual history.

When anogenital injuries occur after sexual assault, they are not randomly distributed. Studies using colposcopy consistently identify the posterior fourchette as the most frequent single injury site, because it is the first structure stretched during penetration, has relatively thin mucosa, and receives maximum tension from downward force.

• Posterior fourchette: most common injury site. Typically presents as a transverse or V-shaped laceration at the posterior midline. Document depth, length, whether margins are fresh or healing.
• Fossa navicularis: second most commonly documented site. Abrasions and lacerations in this shallow fossa are frequently seen with posterior fourchette tears.
• Lateral vaginal walls: lacerations in the lateral fornices are associated with high-energy penetration or positional factors; they are seen in a minority but are significant when present.
• Perianal region: anal fissures, lacerations at 6 or 12 o'clock, and perianal ecchymosis are documented findings after anal assault. Note: anterior anal fissures in children can also result from constipation.

Male sexual assault is underreported, and training programmes have historically focused on female anatomy. Forensic nursing competency includes male anogenital examination; the TEARS framework is the same, applied to different anatomy.

• Penile examination: inspect the glans, coronal sulcus, foreskin (retracted where present), and penile shaft. Document abrasions, contusions, and lacerations by location using clock-face notation relative to the glans.
• Scrotal examination: contusions and lacerations; note that scrotal skin has high laxity and bruising may spread significantly.
• Anal and perianal examination: identical to female examination; same TEARS categories apply; normal variants (e.g., skin tags, haemorrhoids) must be distinguished from traumatic findings.
• Absence of injury: injury-free assault applies equally to male patients. A negative examination does not negate a history of assault.