Sexual assault: Difference between revisions

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==Workup==
==Background==
[[File:Vulva Figure 28 02 02.jpg|thumb|Labeled vulva, showing external and internal views.]]
[[File:Blausen 0400 FemaleReproSystem 02b.png|thumb|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%


Check life threats
==Clinical Features==
*History of sexual exposure without consent
*May or may not have symptoms/signs of injury


Don’t change, shower, etc. pt
==Differential Diagnosis==
{{Lower GU trauma DDX}}


Consent obtained
==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)


Contact SANE (sexual assault nurse examiner)
===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


==Riskfactors ==
===Empiric Antibiotics for [[STDs]]<ref>Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. http://dx.doi.org/10.15585/mmwr.mm6950a6</ref>===
[[File:Nonoccupational HIV algorithm.png|thumb|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<ref>CDC Research on doxycycline and tooth staining. https://www.cdc.gov/rmsf/doxycycline/index.html</ref><ref>
American Academy of Pediatrics Summary of Major Changes in the 2018 Red Book. https://redbook.solutions.aap.org/chapter.aspx?sectionid=189639927&bookid=2205</ref>
***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


Risk of pregnancy without contraception 1-5%; if mid-cycle (days 14-16) risk is higher
===Vaccines<ref>CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. https://www.cdc.gov/std/tg2015/sexual-assault.htm</ref>===
*[[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


Risk of STD 5-10%


Risk of HIV: consensual vaginal intercourse 0.1-0.2%; receptive anal intercourse 0.5-3%
;''Remember to attend to patient's emotional needs as well, consider social work consult and/or offering support resources such as [[https://www.rainn.org/ Rape, Abuse & Incest National Network]] 800-656-HOPE''


==Disposition==
 
*Typically outpatient
==W/U==
 
 
ABO, RPR, Hep B, HIV, EtOH, icon, Utox, G&C/wet mount
 
HIV test now, 6wk, 3months, 6months
 
CBC, Chem 10 if HIV PPx
 
 
==Treatment ==
 
 
===Pregnancy===
 
 
Yuzpe ethinyl estradiol 100macg po plus levonorgestral 0.5mg po; repeat in 12h
 
OR
 
Plan B levonorgestrel 0.75mg po q12h x2
 
 
===STD===
 
 
Gonorrhea: Ceftriaxone 125mg IM or Cipro 500mg po x1 or Ofloxacin 400mg po x1
 
PLUS
 
Chlaymdia: Azithromycin 1g PO x1 or Doxycyclin 100mg po bid x7d
 
PLUS
 
Trich: Metronidazole 2g PO x1 or 500mg po bid x 7d
 
Syphilis: Pen G benzathine 2.4million U IM x1
 
 
===Hepatitis B===
 
 
Virus vaccine 1.0mL IM now, 1-2 months and in 4-6months if pt unimmunized
 
Hep B Immune Globulin for high-risk exposure (IV drug user or multiple assailants)
 
 
===HIV===
 
 
Initiate within 72h (best within 36h) x 28d
 
Zidovudine 300mg bid or 200mg tid
 
PLUS
 
Lamivudine 150mg bid;
 
 
OR
 
 
Tenofovir
 
PLUS
 
Emtricitabine
 


==See Also==
==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


ID:  HIV Prophylaxis (Non-Occupational)
==References==
 
<references/>
 
==Source ==
 
 
DeBonis 12/1/08 adapted from the CDC 2006 guidelines
 
 
 
 


[[Category:OB/GYN]]
[[Category:ID]]
[[Category:OBGYN]]
[[Category:Trauma]]

Latest revision as of 20:11, 3 August 2022

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

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[1]

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[2][3]
      • 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[4]

  • 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

External Links

References

  1. ↑ Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. http://dx.doi.org/10.15585/mmwr.mm6950a6
  2. ↑ CDC Research on doxycycline and tooth staining. https://www.cdc.gov/rmsf/doxycycline/index.html
  3. ↑ American Academy of Pediatrics Summary of Major Changes in the 2018 Red Book. https://redbook.solutions.aap.org/chapter.aspx?sectionid=189639927&bookid=2205
  4. ↑ CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. https://www.cdc.gov/std/tg2015/sexual-assault.htm
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