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
- Urinary system
- Genital
- 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[1]
- 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
- Post-exposure prophylaxis (PEP) recommended as soon as possible if <= 72 hours since exposure AND
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
- ↑ Update to CDC’s Treatment Guidelines for Gonococcal Infection, 2020. http://dx.doi.org/10.15585/mmwr.mm6950a6
- ↑ CDC Research on doxycycline and tooth staining. https://www.cdc.gov/rmsf/doxycycline/index.html
- ↑ American Academy of Pediatrics Summary of Major Changes in the 2018 Red Book. https://redbook.solutions.aap.org/chapter.aspx?sectionid=189639927&bookid=2205
- ↑ CDC 2015 Sexually Transmitted Diseases Treatment Guidelines. https://www.cdc.gov/std/tg2015/sexual-assault.htm