Sexual assault

Background

Labeled vulva, showing external and internal views.

Pelvic anatomy including organs of the female reproductive system.

• Male victim in 10% of cases
• Toluidine blue: detects vulvar tears
• Wood's lamp: detects semen stains

Risks

• Pregnancy
  • Without contraception 1-5%
  • If mid-cycle (days 14-16) risk is higher
• STD (5-10%)
• HIV
  • Theoretically higher risk of transmission in sexual assault than consensual due to physiological factors
  • Consensual receptive vaginal intercourse 0.1-0.2%
  • Consensual receptive anal intercourse 0.5-3%

Clinical Features

• History of sexual exposure without consent
• May or may not have symptoms/signs of injury

Differential Diagnosis

Genitourinary Trauma

• Urinary system
  • Renal trauma
  • Ureter trauma
  • Bladder trauma
  • Urethral trauma
    • Traumatic foley catheter removal
• Genital
  • Penile trauma
    • Traumatic foley catheter removal
  • Testicular trauma
  • Vaginal trauma
• Other
  • Child abuse
  • Pelvic fracture (often accompanies)
  • Sexual assault

Evaluation

General

• Check for life threats, emergent medical needs, and injuries first
• If patient consents to forensic exam after medical evaluation
  • Ask patient not to change, shower, eat, drink, or wash hands
  • Do not give wet wipe and ask patient not to wipe when giving urine sample. Collect dirty catch urine
  • Defer GU examination if patient consents to SANE (sexual assault nurse examiner) exam
• Contact SANE (sexual assault nurse examiner) and police (if report not already filed and patient consents, or if required by law)

Labs

• Pregnancy test
• Rapid HIV
• Hepatitis panel
  • Hepatitis B surface antigen
  • Hepatitis C viral load
• RPR
• Urine GC/chlamydia, if not collected by SANE
• If considering HIV PEP, need baseline labs
  • CBC
  • Chemistry
  • LFTs

Management

• Consider emergency contraception if possibility of pregnancy

Empiric Antibiotics for STDs

HIV nonoccupational exposure algorithm

• Ceftriaxone 500mg IM in a single dose (1000mg if weight >= 150 kg) AND
• Doxycycline 100mg orally twice a day for 1 week AND
  • For pregnant patients, Azithromycin 1g orally in a single dose instead of doxycycline AND
• Metronidazole 500 mg PO BID for 1 week AND
• HIV post-exposure prophylaxis
  • Post-exposure prophylaxis (PEP) recommended as soon as possible if <= 72 hours since exposure AND
    • Assailant HIV positive
    • Assailant HIV status unknown, but patient's mucous membranes or non-intact skin exposed to blood, semen, vaginal secretions, or bloody body fluids

Pediatric Antibiotics for STDs

• If patient is pre-pubertal, only treat with antibiotics if they test positive rather than empirically.
• Pubertal patients should be given empiric antibiotics.
• For patients who weigh > 45 kg, same as adult medications above
• For patients who weigh <= 45 kg
  • Gonorrhea: Ceftriaxone 50 mg/kg IM (maximum dose 250 mg) in a single dose
  • Chlamydia: Doxycycline 2.2 mg/kg (maximum dose 100 mg) orally twice a day for 1 week
    • Doxycycline may be used in age < 8 for treatment durations <= 21 days
    • If patient is pregnant or liquid doxycycline is not available for patients who cannot swallow pills, can give Azithromycin 60 mg/kg (maximum dose 1000 mg) orally in a single dose
  • Trichomonas: Metronidazole 15 mg/kg (maximum dose 670 mg or 2000 mg/day) orally three times a day for 1 week

Vaccines

• Tetanus vaccine
• Hepatitis B post-exposure prophylaxis
  • Even if patient is vaccinated, give HBV vaccine booster shot, preferably within 24 hours of exposure
• HPV vaccine for female patients age 9-26 and male patients 9-21 if patient has not already completed series of 3 vaccines

Remember to attend to patient's emotional needs as well, consider social work consult and/or offering support resources such as [Rape, Abuse & Incest National Network] 800-656-HOPE

Disposition

• Typically outpatient

See Also

• HIV post-exposure prophylaxis
• Child abuse
• Occupational exposure

External Links

• https://www.cdc.gov/std/tg2015/sexual-assault.htm
• https://www.rainn.org/about-rainn