Sexual Assault Workup

Updated: Nov 10, 2015
  • Author: William Ernoehazy, Jr, MD, FACEP; Chief Editor: Gil Z Shlamovitz, MD, FACEP  more...
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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 may be problematic in EDs because of laws in some states that stipulate mandatory counseling and follow-up care. However, the CDC recommends HIV screening for patients in all healthcare settings after the patient is notified that testing will be performed unless the patient declines (ie, opt-out screening). [9, 10] Policy and guidelines should be established in advance with local sexual assault aftercare groups and OB/GYN services in accordance with prevailing law and CDC guidelines.
  • 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. [11] 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.

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Imaging Studies

Imaging studies are only indicated for evaluation of comorbid trauma.

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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.

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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.

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