Sexual assault

Background
  • 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

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

Empiric Antibiotics for STDs
HIV nonoccupational exposure algorithm
  • Ceftriaxone 250mg IM in a single dose AND
  • Azithromycin 1g orally in a single dose AND
  • Metronidazole 2g orally in a single dose OR
  • 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

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

References
  1. CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. https://www.cdc.gov/std/tg2015/sexual-assault.htm
  2. CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. https://www.cdc.gov/std/tg2015/sexual-assault.htm
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