Basics
Description
Specific legal definition varies from state to state:
- Nonconsensual completed or attempted penetration between the penis and vulva or penis and anus
- Nonconsensual contact between the mouth and the penis, vulva, or anus
- Nonconsensual penetration of the anal or genital opening with a finger, hand, or object
- Nonconsensual intentional touching, directly or through clothing, of the genitalia, vagina, anus, groin, inner thigh, or buttocks
Etiology
- Lifetime prevalence of sexual assault in US is 18% in women, 5% in men
- 72% of female rape victims are raped by someone they know; however, men are primarily raped and physically assaulted by strangers and acquaintances, not intimate partners.
- Women who are disabled, pregnant, or attempting to leave their abusers are at increased risk of intimate partner rape.
- Prevalence of sexual assault in men is higher in those who are gay, bisexual, veterans, prison inmates or seeking mental health services
- Nearly 25% of women and 7% of men have been raped or sexually assaulted by a current or former partner.
Diagnosis
Signs and Symptoms
- Victims might not disclose assault:
- Most will reveal the history only in response to direct questions.
- Tachycardia or pounding heart beat
- Headaches
- Nausea
- Back pain
- Skin problems
- Menstrual symptoms
- Sudden weight change
- Sleeping disorders
- Abdominal pain
- Trouble breathing
- Associated injuries:
- Of those with injuries, 70% report no injury at presentation.
- Lacerations of perineum
- Vulvar trauma
- Laceration of vaginal wall (more common in younger patients, near introitus)
- Multiple contusions
- Abrasions
- Human bite
- Lacerations or puncture wound to extremity
- Burns
- Depressed skull fracture
- ¢ ¼54% of rapes of women occur before the age of 18.
- Must follow state laws regarding child abuse
- Most of the physical exams in child sexual abuse cases are normal
- In prepubertal children, an exam will most likely not require a speculum exam. If a speculum exam is warranted, it should be done under sedation; consider involving a sexual assault examiner.
- In interviewing the child, ask open-ended questions.
- Use toys and dolls to have the child explain what happened.
- Early psychiatric intervention is necessary.
Women who are pregnant have higher rates of abuse/assault
History
- Obtain complete history even if patient does not wish to file charges, including:
- Date, time, and place of assault
- Physical description of assailants
- Number of assailants
- Types of penetration: Vaginal, oral, rectal
- Assailant ejaculation: Ask if assailant used condom
- Any bodily fluid exchange
- Use of force, weapons, restraints, drugs, or alcohol
- Ask if victim has memory loss or loss of consciousness
- Victims activity since assault:
- Changed clothes
- Douched
- Bathed
- Urinated
- Defecated
- Eaten
- Tampon use
- Full gynecologic history
- Last voluntary intercourse
- Sperm may be mobile up to 5 days in cervix and 12 hr in vagina
- Address all physical complaints.
Physical Exam
- Use local evidence kit even if victim is unsure of reporting to police.
- Female chaperone required if male physician
- If clothes soiled, photograph prior to undressing, with patients consent.
- Note emotional state of victim.
- Note general appearance of clothes:
- Staining
- Tears
- Mud
- Leaves
- Wood lamp for seminal stains
- Have patient disrobe while standing on sheet and place all clothes in paper bag.
- Plastic causes mold and increases bacterial counts.
- Only the patient should handle the clothing.
- Arrange for change of clothes.
- Complete physical exam should be done with emphasis on:
- Abrasions
- Lacerations
- Bites
- Scratches
- Foreign bodies
- Ecchymosis
- Dried semen on skin
- Forensic collection:
- Fingernail scrapings
- Scalp or pubic hair samples
- If oral penetration, swab between teeth for acid phosphatase (assay for semen) and sperm.
- Throat culture for Gonococcus and Chlamydia if oral sex
- Gynecologic exam:
- Explain all steps and allow patient to pace exam.
- Comb and collect pubic hair per local protocol.
- Lubricate speculum with water (not lubricant).
- Look for genital trauma even in asymptomatic patients.
- May use toluidine blue to identify small pelvic lacerations from traumatic intercourse:
- Best applied to vaginal mucosa at introitus
- Special attention to hymen as 1 of the most common places for trauma
- Lacerations to vaginal wall near introitus more common in younger patients
- Aspirate secretions pooled in posterior fornix and place in sterile container to be examined for sperm and acid phosphates:
- If no secretions in posterior fornix, wipe with cotton tip.
- Swab and microscopically examine for sperm and acid phosphates.
- Swab for Gonococcus and Chlamydia:
- Controversial; evidence can be used by defense to show promiscuity.
- Colposcope allows visualization of small lesions and enables photography of findings (performed by many sexual assault nurse examiner [SANE] programs)
- Rectal exam and cultures for Gonococcus and Chlamydia if there was penetration or attempted penetration
Essential Workup
- Obtain written consent prior to any exam, test, or treatment.
- Allow patient to pause and proceed at comfortable pace.
- Allow advocate to stay with patient during exam with patients consent.
Diagnosis Tests & Interpretation
Lab
- Syphilis serology
- Hepatitis B and C panel
- HIV testing and counseling
- Drug testing (if suspect victim was drugged, can be used against victim if other agents detected)
- Blood type
- Pregnancy test
- Gonococcus culture
- Chlamydia culture
- Other labs as needed based on injuries
Imaging
As indicated by injuries
Diagnostic Procedures/Surgery
As indicated by injuries
Treatment
Pre-Hospital
- Treat patient in a kind, nonjudgmental manner.
- C-spine immobilization for patients with head/neck trauma
Initial Stabilization/Therapy
Treat life-threatening injuries.
Ed Treatment/Procedures
- Place patient in quiet, private room.
- Assure patient of confidentiality regarding name and reason for visit.
- Regularly assure patient of safety.
- Enforce nonjudgmental behavior by staff.
- Designate nursing and medical provider for entire stay who is familiar with evidence collection kit.
- Have SANE perform exam if available.
- Contact community or in-hospital advocate to stay with patient while in ED.
- Alert hospital security to possibility of assailant presenting to ED.
- Contact police if patient consents or local law requires.
- Collect evidence as outlined above and according to local law.
- Offer pregnancy prophylaxis if not currently pregnant
- Administer prophylactic therapy for Gonococcus, Chlamydia, Trichomonas
- Consider prophylactic HIV treatment
- Consider prophylactic therapy or vaccine for hepatitis B
Medication
Risk of pregnancy after rape is ¢ ¼5%
Pregnancy Prophylaxis
Hormonal therapy if within 72 hr:
- Levonorgestrel 0.75 mg PO 1st dose stat and repeat in 12 hr (preferred) or Levonorgestrel 1.5 mg PO, single dose
- Ethinyl estradiol 100 ¼g PO and levonorgestrel 0.5 mg PO 1st dose stat, repeat in 12 hr (less side effects but less effective)
All patients should be offered prophylaxis for STIs
STI Prophylaxis
- Ceftriaxone 250 mg IM once or Cefixime 400 mg PO single dose (Gonococcus)
- Doxycycline 100 mg PO BID for 7 days or azithromycin 1 g PO, single dose (Chlamydia)
- Metronidazole (Flagyl) 2 g PO, 1 dose (Trichomonas)
If PCN allergic, treat with Azithromycin 2 gm po single dose for Gonococcus and Chlamydia
Hepatitis B
If not already immunized, start hepatitis B vaccination in the ED, HBIG is not required unless assailant is known hepatitis B positive
HIV Prophylaxis
If within 72 hr
- High-risk exposures (source known to be HIV+ or is an intravenous drug user [IVDU], or history of men having sex with men) " Lopinavir/ritonavir (Kaletra) 200 mg/50 mg 2 tablets twice daily plus emtricitabine/tenofovir (Truvada) 200 mg/300 mg once daily for 28 days
- Emtricitabine/tenofovir (Truvada) 200 mg/300 mg once daily for exposures from persons other than those noted above, or lamivudine plus zidovudine (Combivir) 1 tab po twice a day for 28 days
- If HIV prophylaxis medications are started, baseline CBC, BMP, and LFTs should be obtained.
Follow-Up
Disposition
Admission Criteria
Serious traumatic injury
Discharge Criteria
- Medical follow-up for culture and HIV test results and monitoring of HIV prophylactic medication side effects (if applicable)
- Psychological follow-up
- Safe place for patient to go to
Issues for Referral
- Mental health services and counseling
- For all pediatric cases, the Department of Children and Family Services should be contacted.
Followup Recommendations
Follow-up should be provided for repeat HIV testing at 6 wk, 3 mo, and 6 mo
Pearls and Pitfalls
- ¢ ¼70% of rape victims do not tell their doctors or seeking mental health services
- Most victims will not disclose assault, unless in response to direct questions.
- Most of the pediatric exams in alleged sexual assault cases will be normal (80 " 96%)
- Extragenital trauma may be more common than genital
- Over 600 SANE/SART(specially trained forensic examiners) programs exist in US; use of a SANE, if available, may improve medical, legal, and psychological care of sexual assault victims
Additional Reading
- Campbell R, Patterson D, Lichty LF, et al. The effectiveness of sexual assault nurse examiner (SANE) programs: A review of psychological, medical, legal, and community outcomes. Trauma Violence Abuse. 2005;6:313 " 329.
- Linden JA. Clinical practice. Care of the adult patient after sexual assault. 2011;365(9):834 " 841.
- Sommers MS. Defining patterns of genital injury from sexual assault: A review. Trauma Violence Abuse. 2007;8:270 " 280.
- Tjaden P, Thoennes N. Extent, nature, and consequences of rape victimization: Findings from the National Violence Against Women. Washington DC: U. S. Department National Institute of Justice and the Centers for Disease Control and Prevention; 2006.
Codes
ICD9
- 995.53 Child sexual abuse
- 995.83 Adult sexual abuse
- V71.5 Observation following alleged rape or seduction
- 922.4 Contusion of genital organs
- 878.6 Open wound of vagina, without mention of complication
ICD10
- T74.21XA Adult sexual abuse, confirmed, initial encounter
- T74.22XA Child sexual abuse, confirmed, initial encounter
- Z04.41 Encounter for exam and obs following alleged adult rape
- S30.202A Contusion of unspecified external genital organ, female, initial encounter
- S30.201A Contusion of unspecified external genital organ, male, initial encounter
- S31.41XA Laceration w/o foreign body of vagina and vulva, init encntr
- T76.22XA Child sexual abuse, suspected, initial encounter
- Z04.42 Encounter for exam and obs following alleged child rape
SNOMED
- 242952005 sexual assault and rape (event)
- 95922009 Child sex abuse
- 171403008 examination for alleged rape (procedure)
- 77233005 Contusion of female genital organs (disorder)
- 242957004 Attempted rape of female (event)
- 36160007 Contusion of male genital organs (disorder)
- 410062001 Laceration of vagina (disorder)
- 444557007 Sexual abuse of adult