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Clinical Summary

Comprehensive care of victims of sexual assault must address both acute medical and psychosocial needs of the patient and must happen in concert with forensic and legal requirements. Ideally, this care is provided by a specially trained sexual assault examiner when available. Thorough collection and preservation of all potential evidence and careful documentation of any physical findings are imperative. Chain of custody must be established and maintained for all samples collected in order for them to be used in later legal proceedings. Meticulous general and genital examination may reveal injuries to the perineum, rectum, vaginal fornices, vagina, and cervix as well as associated injuries to other areas of the body. Toluidine staining and colposcopy are useful in enhancing less apparent injuries such as those to the posterior fourchette and perianal area. Tears to the posterior fourchette are most commonly found in the distribution between the 3- and 9-o’clock positions when the patient is examined in dorsal lithotomy. Perianal lacerations are more evident with toluidine staining and appear as linear tears.

Management and Disposition

Forensic evidence collection should precede treatment other than pain relief. Forensic evaluation should include Wood lamp examination to identify semen for collection, pubic hair sampling and combing, vaginal and cervical smears (air-dried), a cervical and vaginal wet mount to identify sperm, vaginal aspirate to test for acid phosphatase, and rectal or buccal swabs for sperm. A prepackaged kit with directions may be available to facilitate the collection of evidence. Consult your state’s laws for requirements.

FIGURE 10.14

Genital Trauma (Posterior Fourchette). (A) Linear tears of the posterior fourchette consistent with sexual assault. (B) Findings enhanced by toluidine blue staining. (Photo contributors: Hillary J. Larkin, PA-C, and Joshua Luftig, PA-C.)

FIGURE 10.15

Genital Trauma (Posterior Fourchette). (A) Linear midline tear of posterior fourchette. (B) Findings enhanced by toluidine blue staining. (Photo contributors: Hillary J. Larkin, PA-C, and Joshua Luftig, PA-C.)

Obtain cervical cultures for Chlamydia and N gonorrhoeae as well as serum testing for syphilis, hepatitis, and HIV. Provide empiric antibiotic coverage against STIs and offer an oral contraceptive to prevent unwanted pregnancy where applicable.

Pearls

  1. Victims of sexual assault may initially be reluctant to disclose their history and often present with an unrelated chief complaint. A thorough sexual history is necessary for proper identification and treatment.

  2. Normal physical examination and lack of sperm on wet preparation do not exclude the possibility of assault.

  3. Perineal injuries from accidental trauma may be indistinguishable from those of sexual assault and ...

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