eMedicine Specialties > Emergency Medicine > Psychosocial
Sexual Assault: Treatment & Medication
Updated: Feb 29, 2008
- Overview
- Differential Diagnoses & Workup
- Treatment & Medication
- Follow-up
Treatment
Prehospital Care
If EMS is involved in transporting the patient, their primary focus should be on stabilization of life-threatening injuries and providing emotional support for the victim. Evidence collection and crisis intervention should be handled by the ED team.
Emergency Department Care
The responsibilities of the ED physician are more complex than in routine patients. The examiner must provide psychological support and referral to the appropriate resources, treat physical injuries, collect legal evidence, document pertinent history, perform a thorough head-to-toe physical examination, give prevention of unwanted pregnancy, and provide prevention of and screening for STDs.
- Even in areas where SANE team support is readily available, the clinician must be mindful that the ED record also constitutes legal evidence. Treatment and documentation must be accurate and meticulous.
- At present, CDC guidelines for postsexual assault prophylaxis are as follows1 :
- Ceftriaxone 125 mg IM in a single dose, metronidazole 2 g PO in a single dose, and azithromycin 1 g PO in a single dose; or doxycycline 100 mg PO twice a day for 7 days
- Offer pregnancy prophylaxis if the pregnancy test results are negative. The current regimen of choice is 2 Ovral tablets PO in the ED, then 2 more tablets 12 hours later.
- Update tetanus status when necessary.
- Evaluate the patient's hepatitis B immunization status.
- Postexposure hepatitis B vaccination, without hepatitis B immunoglobulin, should adequately protect against the hepatitis B virus.
- Hepatitis B vaccine should be administered to sexual assault victims at the time of the initial examination if they have not been previously vaccinated. Follow-up doses of vaccine should be administered 1-2 months and 4-6 months after the first dose.
- If available, offer a consultation with a sexual assault counselor in the ED. Further, refer the patient to a sexual assault center for aftercare and community resources. Given the long-term emotional and psychosocial impact of sexual assault on the victim, aftercare is vital. Community-based sexual assault centers are essential to such efforts; they serve not only as headquarters for SANE teams but also as aftercare clinics and resource centers for patients dealing with the aftermath of the assault. If such a center is not available, consultation with social services can provide access to such services that may exist in the region.
- Provide reassurance and emotional support.
Consultations
- Refer to either the sexual assault center or the OB/GYN for follow up on laboratory tests and to discuss subsequent HIV surveillance and completion of hepatitis B prophylaxis (when necessary).
- If the assailant is known to be HIV seropositive or is a high-risk contact, HIV prophylaxis should be considered at the time of ED contact if the patient is seen within the appropriate time window to initiate therapy.
- Immediate discussion with the OB/GYN and/or infectious diseases services is indicated in such cases.
- Risk of contracting HIV from a single sexual encounter is somewhere between 1:500 for known seropositivity and 1:5,000,000 for a low-risk assailant.
Medication
Medical intervention in sexual assault is focused on prevention of unwanted pregnancy and STDs. The recommendations below follow the most recent CDC guidelines, dated August 2006.
Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.
Ceftriaxone (Rocephin)
Current DOC for prophylaxis against gonorrheal infection. Third-generation cephalosporin with broad-spectrum, gram-negative activity; lower efficacy against gram-positive organisms; higher efficacy against resistant organisms. Bactericidal activity results from inhibiting cell wall synthesis by binding to 1 or more penicillin-binding proteins. Exerts antimicrobial effect by interfering with synthesis of peptidoglycan, a major structural component of the bacterial cell wall. Bacteria eventually lyse because of the ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested.
Highly stable in presence of beta-lactamases and both penicillinase and cephalosporinase of gram-negative and gram-positive bacteria. Approximately 33-67% of dose is excreted unchanged in urine and remainder is secreted in bile and ultimately in feces as microbiologically inactive compounds. Reversibly binds to human plasma proteins and bindings have been reported to decrease from 95% bound at plasma concentrations <25 mcg/mL to 85% bound at 300 mcg/mL.
Adult
125 mg IM once
Pediatric
25-50 mg/kg IM as single dose (maximum 125 mg)
Probenecid may increase levels; coadministration with ethacrynic acid, furosemide, and aminoglycosides may increase nephrotoxicity
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in severe renal insufficiency (high doses may cause CNS toxicity); superinfections and promotion of nonsusceptible organisms may occur with prolonged use or repeated therapy; caution in breastfeeding women
Cefixime (Suprax)
Former DOC for broad-spectrum prophylaxis of gonorrhea and syphilis. Inhibits bacterial cell wall synthesis, and the bacteria eventually lyse because of ongoing activity of cell wall autolytic enzymes while cell wall assembly is arrested. No longer readily available; hence, no longer CDC recommended. FDA has approved Lupin Ltd to renew production, but they have yet to do so.
Adult
400 mg PO once
Pediatric
Administer as in adults
Coadministration of aminoglycosides increase nephrotoxicity; probenecid may increase effects of cefixime
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose with renal impairment
Metronidazole (Flagyl)
Active against various anaerobic bacteria and protozoa. Appears to be absorbed into cells. Intermediate-metabolized compounds formed bind DNA and inhibit protein synthesis, causing cell death.
Adult
2 g PO once
Pediatric
40 mg/kg PO once
May increase toxicity of anticoagulants, lithium, and phenytoin; cimetidine may increase toxicity of metronidazole; disulfiram reaction may occur with orally ingested ethanol
Documented hypersensitivity
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Adjust dose in hepatic disease; monitor for seizures and development of peripheral neuropathy
Azithromycin (Zithromax)
Treats mild to moderate infections caused by susceptible strains of microorganisms. Indicated for prophylaxis of chlamydial infections of the genital tract.
Adult
1 g PO once
Pediatric
5-12 mg/kg/d PO for 15 d
May increase toxicity of theophylline, warfarin, and digoxin; effects are reduced with coadministration of aluminum and/or magnesium antacids; nephrotoxicity and neurotoxicity may occur when coadministered with cyclosporine
Documented hypersensitivity; hepatic impairment; do not administer with pimozide
Pregnancy
B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions
Site reactions can occur with IV route; bacterial or fungal overgrowth may result with prolonged antibiotic use; may increase hepatic enzymes and cholestatic jaundice; caution in patients with impaired hepatic function, prolonged QT intervals, or pneumonia; caution in hospitalized, geriatric, or debilitated patients
Doxycycline (Bio-Tab, Doryx, Vibramycin, Vibra-Tabs)
Alternate to azithromycin in STD prophylaxis regimens. Broad-spectrum, synthetically derived bacteriostatic antibiotic in the tetracycline class. Almost completely absorbed, concentrates in bile, and is excreted in urine and feces as a biologically active metabolite in high concentrations.
Inhibits protein synthesis and, thus, bacterial growth by binding to 30S and possibly 50S ribosomal subunits of susceptible bacteria. May block dissociation of peptidyl tRNA from ribosomes, causing RNA-dependent protein synthesis to arrest.
Adult
100 mg PO bid for 7 d
Pediatric
<8 years: Not recommended
>8 years: Administer as in adults
Bioavailability decreases with antacids containing aluminum, calcium, magnesium, iron, or bismuth subsalicylate; tetracyclines can increase hypoprothrombinemic effects of anticoagulants; tetracyclines can decrease effects of oral contraceptives, causing breakthrough bleeding and increased risk of pregnancy
Documented hypersensitivity; severe hepatic dysfunction
Pregnancy
D - Fetal risk shown in humans; use only if benefits outweigh risk to fetus
Precautions
Photosensitivity may occur with prolonged exposure to sunlight or tanning equipment; reduce dose in renal impairment; consider drug serum level determinations in prolonged therapy; tetracycline use during tooth development (last one half of pregnancy through age 8 y) can cause permanent discoloration of teeth; Fanconilike syndrome may occur with outdated tetracyclines
Oral contraceptives
These agents are used to prevent unwanted pregnancies after sexual assault.
Estradiol and norgestrel (Ovral)
Inhibits ovulation by suppressing FSH and LH. Alterations that take place in the genital tract, including cervical mucus and the endometrium, may contribute to the effects of contraceptives.
Adult
2 tab PO in ED, then 2 tab PO 12 h after first dose
Pediatric
Administer as in adults
Onset of acetaminophen effect may be delayed or decreased slightly; hepatic metabolism of TCAs, caffeine, corticosteroids, benzodiazepines, beta-blockers, and theophylline may be decreased with increased therapeutic effects
Documented hypersensitivity; thrombophlebitis; known or suspected breast carcinoma or estrogen-dependent neoplasia; thromboembolic disorders; myocardial infarction; coronary artery disease; carcinoma of the endometrium; other hepatic adenomas/carcinomas
Pregnancy
X - Contraindicated; benefit does not outweigh risk
Precautions
Caution in hepatic impairment, migraine, seizure disorders, cerebrovascular disorders, breast cancer, or thromboembolic disease; progestins may elevate LDL levels and decrease HDL levels, making hyperlipidemia control more difficult; depression may occur, attributed to a deficiency in pyridoxine; caution in patients with conditions that may be aggravated by fluid retention
More on Sexual Assault |
| Overview: Sexual Assault |
| Differential Diagnoses & Workup: Sexual Assault |
 Treatment & Medication: Sexual Assault |
| Follow-up: Sexual Assault |
| References |
| « Previous Page | Next Page » |
References
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].
Braun GR. Sexual assault. In: Emergency Medicine: Concepts and Clinical Practice. 3rd ed. St. Louis: Mosby-Year Book; 1992:2003-12.
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].
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].
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].
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].
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].
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.
Humphrey JA, White JW. Womens' vulnerability to sexual assault from adolescence to young adulthood. J Adolesc Health. Dec 2000;27(6):419-24. [Medline].
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].
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].
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].
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].
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].
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].
Rand M, Catalano S. Criminal Victimization, 2006. U.S. Department of Justice, Bureau of Justice Statistics; Dec 2007. [Full Text].
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].
Sachs CJ. How To Convict A Rapist: Sexual Assault Response Teams. ACEP Scientific Assembly Proceedings. 1999.
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].
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].
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].
Further Reading
Keywords
sexual assault, domestic violence, rape, impulse control disorders, post-assault emotional stress, posttraumatic stress disorder, post-traumatic stress disorder, PTSD, pregnancy, sexually transmitted diseases, STDs, male victims of sexual assault, female victims of sexual assault, Sexual Assault Nurse Examiner, SANE, Trichomonas vaginalis, T vaginalis
