Sexual assault


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


  • 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



  • 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)


  • 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


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


  • 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


  • Typically outpatient

See Also

External Links


  1. Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020.
  2. CDC Research on doxycycline and tooth staining.
  3. American Academy of Pediatrics Summary of Major Changes in the 2018 Red Book.
  4. CDC 2015 Sexually Transmitted Diseases Treatment Guidelines.