What is the appropriate initial workup for a patient who has been sexually assaulted?

Initial Workup for Sexual Assault Patient (SANE Examination)

The initial workup for a sexual assault patient should include forensic evidence collection (if within 4-7 days of assault), comprehensive STI testing from all sites of penetration, pregnancy testing and emergency contraception, baseline serology for HIV/hepatitis B/syphilis, prophylactic antimicrobial therapy, hepatitis B and HPV vaccination, and immediate psychological assessment with trauma-informed counseling. 1, 2

Forensic Evidence Collection

Timing is critical for forensic examination:

• Evidence collection is most useful within 4 days of assault and possibly longer with DNA amplification techniques 1
• Between 4-7 days, contact local authorities to determine if evidence collection remains useful 1
• After 1 week, proceed with medical examination and treatment without forensic collection 1

Before examination, advise patients to:

• Not wash clothes, bathe, or shower until examined 1
• Store clothes in paper (not plastic) bags 1

STI Testing at Initial Visit

Nucleic acid amplification tests (NAATs) should be performed from all sites of penetration or attempted penetration with sensitivity 86.1%-100% and specificity 97.1%-100% 2:

• Gonorrhea and Chlamydia NAATs from pharynx, rectum, vagina (in females), and urethra (in males) 1, 2
• Wet mount examination of vaginal swab for Trichomonas, bacterial vaginosis, and yeast if discharge or malodor present 1, 2
• Baseline serology for HIV, hepatitis B, and syphilis 1

Important caveat: Initial testing may be negative if performed too soon after assault, as organisms may not have reached sufficient concentrations 1

Prophylactic Treatment (Administered at Initial Visit)

The CDC recommends empiric antimicrobial prophylaxis for all patients with vaginal, anal, or oral penetration (with ejaculation) 1:

Recommended Regimen:

• Ceftriaxone 250 mg IM (single dose) 1
• PLUS Azithromycin 1 g orally (single dose) 1
• PLUS Metronidazole 2 g orally (single dose) OR Tinidazole 2 g orally 1

Clinical pearl: If alcohol recently ingested or emergency contraception provided, metronidazole/tinidazole can be taken at home to minimize side effects and drug interactions 1

Pregnancy Prevention

Emergency contraception should be offered to all females with vaginal penetration or genital contact with ejaculate 1:

• Perform baseline urine pregnancy test 1
• Levonorgestrel 1.5 mg orally (both 0.75 mg tablets taken together) is more effective with fewer adverse effects than older regimens 1

Vaccination

Hepatitis B vaccination should be administered at initial visit if not previously vaccinated, with follow-up doses at 1-2 months and 4-6 months 1:

• If assailant known to be HBsAg-positive, give both vaccine and HBIG 1

HPV vaccination recommended for females aged 9-26 years and males aged 9-21 years (through age 26 for MSM), with follow-up doses at 1-2 months and 6 months 1

HIV Post-Exposure Prophylaxis (PEP)

HIV PEP should be individualized based on risk assessment 1:

• Consult HIV specialist for high-risk exposures 1
• Discuss risks/benefits and toxicity 1
• Provide 3-7 days medication initially until tolerance assessed 1
• Baseline CBC, chemistry panel, and HIV testing required 1

Physical Examination Findings

Visual inspection should document 1:

• Genital, perianal, and oral areas for discharge, bleeding, irritation, warts, ulcerative lesions 1
• Common injury patterns in assault victims: posterior fourchette, labia minora, hymen, fossa navicularis with tears, abrasions, and ecchymosis 3
• 68% of assault victims show genital trauma at mean 3.1 sites 3

Psychological Assessment

Immediate psychological support is critical 1:

• Screen for suicidal ideation and self-harm behavior 1
• Up to 80% of rape victims develop post-traumatic stress disorder 1
• Assess for acute symptoms: disbelief, anxiety, fear, emotional lability, guilt 1
• Refer to trauma-focused cognitive behavioral therapy 1
• Male victims require specific counseling regarding masculinity and sexual orientation concerns 1

Follow-Up Schedule

1-2 week follow-up 1:

• Assess injury healing and medication adherence 1
• Repeat STI testing if prophylaxis not given or symptoms develop 1
• Mental health assessment and counseling arrangement 1

2-week follow-up 1:

• Pregnancy testing 1
• Repeat physical examination 1

6 weeks, 3 months, and 6 months follow-up 1:

• Repeat HIV and syphilis serology if initial tests negative and assailant infection status unknown 1
• Complete vaccination series 1

Critical pitfall: Follow-up compliance is often poor in emergency department patients, so referral to medical home or specialty sexual assault center with patient consent improves outcomes 1