28 A practical guide to the Istanbul Protocol – for medical doctors II. GASTROINTESTINAL Acute torture-related symptoms have been described after having a foreign body inserted into the anus. Lesions of the anus and rectum have been described as a consequence of the torture. The lesions give rise to pain and bleeding. Obstipation is often a secondary symptom to anal pain. On examination of the anus, the following findings should be looked for and documented (Allden et al., 2001): 1. Fissures tend to be non-specific findings as they may occur in a number of “normal” situations (constipation, poor hygiene). However, when seen in an acute situation (i.e. within 72 hours), fissures are a more specific finding and may be considered evidence of penetration. 2. Rectal tears with or without bleeding may be noted. 3. Disruption of the rural pattern may manifest as smooth fan-shaped scarring. When these scars are seen out of midline (i.e. not at 12 or 6 o’clock), they may be an indication of penetrating trauma. 4. Skin tags, which may be the result of healing trauma. 5. Purulent discharge from the anus. Cul- tures should be taken for gonorrhoea and chlamydia in all cases of alleged rectal penetration, regardless of whether a discharge is noted. Acute gastroduodenal haemorrhage has been reported by a small number of torture victim survivors, and may be explained by the extreme stress. Acute gastrointestinal symptoms such as abdominal pain, epigastric discomfort, diarrhoea, vomiting, etc., are associated with torture and imprisonment. These symptoms must be considered to be of mixed aetiology, in which mechanisms caused by the stressful situation may be a factor. Insufficient or unappetising food, restriction of liquids and lack of exercise may also be factors related to these gastrointestinal symptoms during imprisonment. The incidence of gastrointestinal symptoms in the torture victims at the time of medical examination was the same as that of control groups and of the population at large. (Rasmussen, 1990). (See § 202 in the Istanbul Protocol.) III. UROLOGICAL Severe beating to the kidney region may give rise to the development of haematoma in and/or around the kidney. In many cases, the lesion is accompanied by haematuria. Direct trauma to the urethal mucous membrane, either by beating or electric torture in the urethra, also produces haematuria. Beating at the scrotum may injure testis with subsequent atrophia (Abildgaard et al., 1984).