eMedicine Specialties > Emergency Medicine > Psychosocial

Sexual Assault: Differential Diagnoses & Workup

Author: William Ernoehazy Jr, MD, FACEP, Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida
Coauthor(s): Heather Murphy-Lavoie, MD, FAAEM, Assistant Professor, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine, New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine
Contributor Information and Disclosures

Updated: Dec 3, 2009

Differential Diagnoses

Abdominal Trauma, Blunt
Cervical Strain
Abdominal Trauma, Penetrating
Chancroid
Abruptio Placentae
Compartment Syndrome, Extremity
Acute Coronary Syndrome
Corneal Abrasion
Alcohol and Substance Abuse Evaluation
Corneal Laceration
Ankle Injury, Soft Tissue
Costochondritis
Anxiety
Depression and Suicide
Asthma
Diaphragmatic Injuries
Back Pain, Mechanical
Dislocations, Ankle
Bartholin Gland Diseases
Dislocations, Elbow
Bites, Human
Dislocations, Foot
Burns, Thermal
Dislocations, Hand
Candidiasis
Dislocations, Hip
Cellulitis
Dislocations, Interphalangeal

Other Problems to Be Considered

The above list, protean in its extent, reflects the overwhelming number of co-injuries that can occur during sexual assault, as well as the potential sequelae of such assaults.

Workup

Laboratory Studies

  • Obtain urine or serum pregnancy tests in women of childbearing age.
  • Preexisting pregnancy may complicate management of coexisting injuries and is a contraindication to providing Ovral for pregnancy prevention.
  • Baseline screening for STDs includes the following:
    • Serologic tests for syphilis, hepatitis B, and HIV: HIV testing is problematic in EDs because of state and federal laws that stipulate mandatory counseling and follow-up care. Policy and guidelines should be established in advance with local sexual assault aftercare groups and OB/GYN services in accordance with prevailing law.
    • Cultures of exposed body sites (eg, oral, throat, vaginal, rectal) as appropriate: Current Centers for Disease Control and Prevention (CDC) guidelines consider Food and Drug Administration (FDA)–approved nucleic acid amplification tests an acceptable substitute for culture, as long as positive test results are confirmed by a second study.3 Other tests (EIA, nonamplified probes, direct fluorescent antibody tests) are not considered acceptable alternatives by the CDC because of unacceptable false-negative and false-positive result rates.
    • Wet mount and culture of a vaginal swab specimen to evaluate for Trichomonas vaginalis, bacterial vaginosis, and candidiasis
  • Recently, controversy has arisen concerning the usefulness of baseline STD testing of sexual assault victims. Opponents note the following:
    • Patients are offered antibiotic prophylaxis regardless of results from the preliminary screening.
    • The presence of STD baseline testing in the medical record invites defense attorneys to bring the victims to the witness stand, thereby opening prolonged interrogation of victims regarding their sexual histories in efforts to impeach the creditability of their stories. Many jurisdictions now forbid such inquiries into victims' personal lives, unless the victims' other sexual life experiences are somehow brought into the body of evidence before the court. These legal protections can, however, sometimes be breached, to the detriment of the victim. 
    • These points are vigorously disputed by advocates of routine baseline testing. The CDC, in its most recent guidelines for the treatment and prevention of STDs, discusses the pros and cons of testing at some length.

Imaging Studies

  • Imaging studies are only indicated for evaluation of comorbid trauma.

Other Tests

  • To collect evidence, most hospitals have a prepackaged rape kit with the necessary equipment and detailed instructions. However, if the sexual assault victim presents 72 hours after the event, the evidence collection kit is no longer needed for legal documentation of the case.

Procedures

  • Colposcopy, where available, may have considerable value in documentation because it allows photographic recording of injuries. Anoscopy may be performed in male victims, and it may be combined with colposcopy in female victims.
  • Evidence suggests that if speculum examination is performed before toluidine blue application to the posterior fourchette (to enhance small lesions that may occur during forceful genital penetration), the speculum itself may cause small lesions that will take up the dye. These iatrogenic lesions will be seen on colposcopy. Clinicians should consider deferring speculum examination until after external colposcopy if toluidine blue is to be used.

More on Sexual Assault

Overview: Sexual Assault
Differential Diagnoses & Workup: Sexual Assault
Treatment & Medication: Sexual Assault
Follow-up: Sexual Assault
References
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References

  1. Avegno J, Mills TJ, Mills LD. Sexual assault victims in the emergency department: analysis by demographic and event characteristics. J Emerg Med. Oct 2009;37(3):328-34. [Medline].

  2. Jones JS, Rossman L, Diegel R, Van Order P, Wynn BN. Sexual assault in postmenopausal women: epidemiology and patterns of genital injury. Am J Emerg Med. Oct 2009;27(8):922-9. [Medline].

  3. [Guideline] Centers for Disease Control and Prevention, Workowski KA, Berman SM. Sexually transmitted diseases treatment guidelines, 2006. MMWR Recomm Rep. Aug 4 2006;55(RR-11):1-94. [Medline].

  4. [Guideline] New York State Department of Health. HIV prophylaxis following non-occupational exposure including sexual assault. Jan 2008;[Full Text].

  5. Braun GR. Sexual assault. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St. Louis: Mosby-Year Book; 1992:2003-12.

  6. Ciancone AC, Wilson C, Collette R, et al. Sexual Assault Nurse Examiner programs in the United States. Ann Emerg Med. Apr 2000;35(4):353-7. [Medline].

  7. da Silva DA, Goes AC, de Carvalho JJ, de Carvalho EF. DNA typing from vaginal smear slides in suspected rape cases. Sao Paulo Med J. Mar 4 2004;122(2):70-2. [Medline].

  8. Das S, Huengsberg M. An audit on the management of female victims of sexual assault attending a genitourinary medicine clinic. Int J STD AIDS. Jul 2004;15(7):484-5. [Medline].

  9. Elliott DM, Mok DS, Briere J. Adult sexual assault: prevalence, symptomatology, and sex differences in the general population. J Trauma Stress. Jun 2004;17(3):203-11. [Medline].

  10. Ernst AA, Green E, Ferguson MT, et al. The utility of anoscopy and colposcopy in the evaluation of male sexual assault victims. Ann Emerg Med. Nov 2000;36(5):432-7. [Medline].

  11. Higgins SD, Schwartz GR. The sexually assaulted patient. Sexual assault evidence collection protocol, Office of the Attorney General. In: Principles and Practice of Emergency Medicine. 3rd ed. Williams & Wilkins; 1992:2418-31.

  12. Humphrey JA, White JW. Womens' vulnerability to sexual assault from adolescence to young adulthood. J Adolesc Health. Dec 2000;27(6):419-24. [Medline].

  13. Jones JS, Dunnuck C, Rossman L, et al. Significance of toluidine blue positive findings after speculum examination for sexual assault. Am J Emerg Med. May 2004;22(3):201-3. [Medline].

  14. Kenworthy T, Adams CE, Bilby C, et al. Psychological interventions for those who have sexually offended or are at risk of offending. Cochrane Database Syst Rev. 2004;CD004858. [Medline].

  15. Kintz P, Villain M, Ludes B. Testing for the undetectable in drug-facilitated sexual assault using hair analyzed by tandem mass spectrometry as evidence. Ther Drug Monit. Apr 2004;26(2):211-4. [Medline].

  16. Linden JA, Oldeg P, Mehta SD, et al. HIV postexposure prophylaxis in sexual assault: current practice and patient adherence to treatment recommendations in a large urban teaching hospital. Acad Emerg Med. Jul 2005;12(7):640-6. [Medline].

  17. Littel, K. Sexual Assault Nurse Examiner (SANE) Programs: Improving the Community Response to Sexual Assault Victims. US Department of Justice, Office of Justice Programs, Office for Victims of Crime; April 2001. [Full Text].

  18. Mancino P, Parlavecchio E, Melluso J, et al. Introducing colposcopy and vulvovaginoscopy as routine examinations for victims of sexual assault. Clin Exp Obstet Gynecol. 2003;30(1):40-2. [Medline].

  19. Rand M, Catalano S. Criminal Victimization, 2006. U.S. Department of Justice, Bureau of Justice Statistics; Dec 2007. [Full Text].

  20. Reznic MF, Nachman R, Hiss J. Penile lesions -- reinforcing the case against suspects of sexual assault. J Clin Forensic Med. Apr 2004;11(2):78-81. [Medline].

  21. Sachs CJ. How To Convict A Rapist: Sexual Assault Response Teams. ACEP Scientific Assembly Proceedings. 1999.

  22. Sievers V, Murphy S, Miller JJ. Sexual assault evidence collection more accurate when completed by sexual assault nurse examiners: Colorado's experience. J Emerg Nurs. Dec 2003;29(6):511-4. [Medline].

  23. Stermac L, Del Bove G, Addison M. Stranger and acquaintance sexual assault of adult males. J Interpers Violence. Aug 2004;19(8):901-15. [Medline].

  24. Testa M, Vanzile-Tamsen C, Livingston JA. The role of victim and perpetrator intoxication on sexual assault outcomes. J Stud Alcohol. May 2004;65(3):320-9. [Medline].

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Further Reading

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Keywords

sexual assault, sexual assault victim, domestic violence, rape, posttraumatic stress disorder, pregnancy, sexually transmitted diseases, STDs, male victims of sexual assault, female victims of sexual assault, Sexual Assault Nurse Examiner, SANE

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Contributor Information and Disclosures

Author

William Ernoehazy Jr, MD, FACEP, Medical Director, Emergency Department, Ed Fraser Memorial Hospital, Florida
William Ernoehazy Jr, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Heather Murphy-Lavoie, MD, FAAEM, Assistant Professor, Section of Emergency Medicine and Hyperbaric Medicine, Louisiana State University School of Medicine, New Orleans; Clinical Instructor, Department of Surgery, Tulane University School of Medicine
Heather Murphy-Lavoie, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Society for Academic Emergency Medicine, and Undersea and Hyperbaric Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Francis Counselman, MD, Program Director, Chair, Professor, Department of Emergency Medicine, Eastern Virginia Medical School
Francis Counselman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Association of Academic Chairs of Emergency Medicine (AACEM), Norfolk Academy of Medicine, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Robert Harwood, MD, MPH, FACEP, FAAEM, Program Director, Department of Emergency Medicine, Advocate Christ Medical Center; Assistant Professor, Department of Emergency Medicine, University of Illinois at Chicago College of Medicine
Robert Harwood, MD, MPH, FACEP, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, Council of Emergency Medicine Residency Directors, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Pamela L Dyne, MD, Professor of Clinical Medicine/Emergency Medicine, David Geffen School of Medicine at UCLA; Attending Physician, Department of Emergency Medicine, Olive View-UCLA Medical Center
Pamela L Dyne, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

 
 
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