or genital pain or other complaint, bleeding, or discharge If that is not the case, it may be preferable to refer the child/adolescent for an outpatient medical evaluation with a specialist in child sexual assault As stated previously, the vast majority of children have normal anogenital examinations, in part due to the rapid healing of the mucosa as well as the nonviolent nature of most child sexual abuse A normal physical examination does not rule out sexual assault Many studies have documented the examination findings that are indicative of sexual abuse, including lacerations of posterior aspect of the hymen and posterior fourchette, ecchymosis of the hymen, or perianal lacerations Other acute genital injuries are concerning, though not diagnostic of sexual abuse, and include bruising or lacerations of the vulva, penis, scrotum, or perineum These injuries can be caused by accidental mechanisms, but the history provides the context for interpretation of these types of injuries Management/Diagnostic Testing Acute Medical Management Medical or surgical treatment of associated injuries follows standard procedure with immediate consultation by specialty services as indicated (Chapter A General Approach to the Ill or Injured Child ) During initial medical evaluation and stabilization, make all reasonable attempts to preserve potential evidence, if possible Avoiding cutting through holes found in clothing; collect all clothing and place in paper bags and keep it with the patient until chain of custody can be confirmed Avoid washing away potential DNA evidence The management of serious coexisting injuries or other acute medical conditions takes precedence over preservation of forensic evidence If needed, a forensic examination can be completed in the operating room, prior to prepping the injured area for surgery, and in concert with the surgeon managing the serious injury Weighing the risk/benefit of forensic evidence collection to providing medical/surgical treatment is a collaborative decision of the treatment team Forensic Evidence Collection Studies in prepubertal children have shown that the yield of forensic evidence collection diminishes rapidly with time and is low for children presenting more than 24 hours after assault However, a few recent studies