TEARS Classification and Anogenital Injury Patterns

The TEARS mnemonic for anogenital findings, normal variants versus injury, the frequency of injury-free sexual assault, and documentation standards for anogenital examination.

Last updated: 10 Jun 2026

Two facts sit in tension at the centre of anogenital forensic examination. First, physical injury after sexual assault is less common than many people expect: multiple prospective studies report that 30-70% of patients who describe penetrative assault have no detectable anogenital injury at examination. Second, the injuries that do occur follow recognisable anatomical patterns, and documenting them correctly requires both a classification system and fluency with normal anatomy.

The TEARS mnemonic organises anogenital findings into five observable categories -- Tears, Ecchymosis, Abrasions, Redness, Swelling -- providing a shared vocabulary that improves inter-examiner consistency and clarity in medical records. But TEARS is only as useful as the examiner's ability to distinguish genuine injury from normal variants, artefacts of position, and the expected effects of consensual sexual activity.

This topic builds both skills: applying the TEARS framework systematically, and understanding what the science says about injury frequency, normal variants, and the forensic significance of a negative examination. It also covers the often-neglected area of male anogenital injury, which receives less attention in training but is equally important for completeness.

Key terms

TEARS: The systematic mnemonic for anogenital findings: Tears (lacerations or fissures), Ecchymosis (bruising), Abrasions (superficial skin loss), Redness (erythema, which may be non-specific), Swelling (oedema). Each category is documented by location, size, and characteristics.
Posterior fourchette: The posterior midline junction where the labia minora meet, at the inferior border of the vaginal introitus. The most frequently reported site of anogenital injury after penetrative vaginal assault in research literature.
Fossa navicularis: The shallow fossa between the posterior fourchette and the hymenal ring, anterior to the fourchette. An anatomically vulnerable zone often involved in penetrative trauma.
Hymenal remnants: Tissue tags remaining from the hymenal membrane. In adults, remnants are normal findings and should not be described as evidence of prior injury. Their appearance does not reliably reflect sexual history.
Vestibular papillomatosis: A normal variant consisting of symmetrical micropapillary projections on the inner labia minora and vestibule. Often mistaken for condylomata acuminata (genital warts) or injury by less experienced examiners.
Injury-free assault: The documented phenomenon whereby penetrative sexual assault produces no detectable anogenital injury in a significant proportion of cases. Supported by multiple prospective studies; the examiner must not treat absence of injury as evidence of absence of assault.

The TEARS mnemonic: systematic categorisation

A shared vocabulary reduces error more reliably than individual description styles.

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.

Category	Description	Most common sites in assault	Diagnostic caution
Tears (T)	Full-thickness or partial lacerations, fissures, or clefts in mucosal or skin tissue	Posterior fourchette, fossa navicularis, hymen, perianal	Distinguish from normal hymenal notches and anal fissures from constipation
Ecchymosis (E)	Bruising in mucosal or skin tissue; may be more visible on mucosa than skin	Labia minora, posterior fourchette, perianal	Ecchymosis on mucosa resolves faster than on skin; timing limitations apply (see bruise ageing topic)
Abrasions (A)	Superficial skin or mucosal loss from friction or shear	Labia majora, perineum, perianal skin	Distinguish from dermatitis, excoriation from itching, and skin conditions
Redness (R)	Erythema of skin or mucosa; non-specific finding	Anywhere in the anogenital region	High false-positive rate; redness alone carries little evidential weight without supporting findings
Swelling (S)	Localised oedema; often paired with other TEARS findings	Labia, perineum	Swelling resolves quickly; document urgently; alone is non-specific

Injury frequency: what the research says

Most patients with a valid assault history have no detectable anogenital injury.

This is the most clinically important and most misunderstood fact in anogenital forensic examination. 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.

Normal variants and the anatomy of misidentification

A forensic nurse who misidentifies normal anatomy as injury causes significant harm.

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

Normal anogenital variants versus injury look-alikes.

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.

Posterior fourchette and common injury patterns

Knowing where injuries cluster helps focus the examination.

When anogenital injuries do occur after sexual assault, they are not randomly distributed. Studies using colposcopy consistently identify the posterior fourchette as the most frequent single injury site. The anatomy is biomechanically straightforward: the fourchette 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 anogenital injury

Male patients are examined on the same principles but with different anatomy.

Male sexual assault is underreported and underexamined. Training programmes have historically focused on female anatomy, but forensic nursing practice must include competency in male anogenital examination. The same TEARS framework applies; the anatomy differs.

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.

Worked example

Applying TEARS to a reported penetrative assault with minimal findings

What a largely negative examination looks like on paper.

A 22-year-old woman presents 18 hours after a reported penetrative vaginal assault by an acquaintance. She reported no use of condom and consented to forensic examination.

TEARS screening (labia majora): no tears, no ecchymosis, no abrasions, mild erythema on the left labia majora consistent with minor friction, no swelling.
TEARS screening (posterior fourchette): 0.5 cm superficial abrasion at the posterior midline, no active bleeding. Documented by location, size, and category (Abrasion). Photographed with scale.
TEARS screening (hymen): colposcopic examination reveals a 0.3 cm partial-thickness tear at 6 o'clock with slightly irregular margins. Documented as Tear, noting location, depth (partial thickness), and appearance.
Overall impression documented: 'Two acute anogenital findings (posterior fourchette abrasion and hymenal tear at 6 o'clock), consistent with recent penetrating trauma. A negative or minimal-injury examination would also be consistent with the described assault. Evidence swabs collected from vaginal vault, cervix, and ectocervix.'

The documentation records the two positive findings precisely and frames the clinical significance correctly: the findings are consistent with the history, but a negative examination would also have been consistent. Neither overstatement ('clearly corroborates assault') nor understatement ('minor findings, probably nothing') serves the patient or the justice system.

Check your understanding

Question 1 of 4· 0 answered

What does the 'E' in the TEARS mnemonic stand for?

Key Takeaways

TEARS (Tears, Ecchymosis, Abrasions, Redness, Swelling) provides a systematic five-category framework for documenting anogenital findings, improving consistency and inter-examiner reliability.
A substantial proportion of sexual assault patients have no detectable anogenital injury; absence of injury does not exclude assault and must not be communicated as doing so.
Consensual sexual activity can also produce anogenital injury; injury presence alone cannot confirm non-consent, and must be interpreted alongside the full clinical picture.
Normal variants (vestibular papillomatosis, hymenal notches, median raphe, Fordyce spots) are commonly misidentified as injury by less experienced examiners; recognition of these variants is a core competency.
The posterior fourchette is the most frequently documented injury site in penetrative vaginal assault; male anogenital examination follows the same TEARS framework applied to different anatomy.

What does TEARS stand for?

TEARS stands for Tears, Ecchymosis, Abrasions, Redness, and Swelling. It is a systematic mnemonic for categorising and communicating anogenital findings during a forensic examination. Using it ensures consistent documentation across examiners and improves the reliability of inter-rater comparison.

Is the absence of anogenital injury evidence that a sexual assault did not occur?

No. Research consistently shows that a significant proportion of people who have experienced penetrative sexual assault have no detectable anogenital injury. The absence of injury does not rule out assault. Examiners must document findings accurately and resist the pressure to over-interpret a negative examination as exculpatory.

What is the most common site of anogenital injury in female patients after sexual assault?

The posterior fourchette (the posterior midline junction of the labia minora) is the most consistently reported site of anogenital injury after penetrative vaginal assault in research studies. Fossa navicularis and lateral vaginal walls are also frequently documented injury sites.

Can consensual sexual activity cause anogenital injury?

Yes. Research by Sommers et al. and others has demonstrated that anogenital injuries, including abrasions and lacerations, occur following consensual intercourse. Injury alone does not distinguish consensual from non-consensual contact. The presence or absence of injury must be interpreted alongside the full clinical and contextual picture.

What normal anatomical variants can be mistaken for injury?

Several anatomical variants are commonly misidentified as injury. These include hymenal notches (naturally occurring), hymenal remnants, median raphe (midline perineal ridge), vestibular papillomatosis (normal micropapillary projections of the vestibule), and Fordyce spots (sebaceous glands). An experienced forensic nurse learns to distinguish these from traumatic findings.

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Key Takeaways

Key Takeaways