Gynecology: Sexual Assault

Guest · **posting in usmle forum about Obstetrics & Gynecology**

1. Rape-Trauma Syndrome:
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1. Acute phase. May last for hours to days and is characterized by a distortion or paralysis of the individual’s coping mechanism. Generalized body pain, eating and sleeping disturbances, vaginal discharge, itching and rectal pain, depression, anxiety, and mood swings may be present.

2. Delayed or organizational phase. Characterized by flashbacks, nightmares, phobias, and a need for reorganization of thought processes, as well as the gynecologic and menstrual complaints noted above. This phase may occur months or years after the event. Mood disorders and posttraumatic stress syndrome may develop.

3. Counseling. Should be phase specific.

2. Prophylactic Therapy After Rape:
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Treat presumptively for Chlamydia and gonorrhea. The patient should be instructed to return for repeat STD testing in 3 to 4 weeks. The patient should be counseled about possible HIV infection and offered prophylactic therapy. HIV serologic analysis should be obtained at the time of assault and repeated in 6 months. If the patient is at risk for pregnancy, a postcoital contraceptive regimen should be offered (see section on contraception), and a pregnancy test should be performed during the return visit. If the patient becomes pregnant, she should be counseled about all available options. Arrange for follow-up medical care and counseling.

3. Child Sexual Abuse:
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1. Babies, children, handicapped people, and the elderly can be victims of sexual assault. A high index of suspicion is needed for diagnosis.

2. Symptoms. Behavioral: anxiety, sleep disturbances, withdrawal, somatic complaints, increased sex play, inappropriate sexual behavior, school problems, acting-out behaviors, self-destructive behaviors, depression, low self-esteem. Physical: unexplained vaginal or rectal injuries, unexplained vaginal or rectal bleeding, bruising, bites, scratches, pregnancy, sexually transmitted disease, recurrent vaginal infections, pain in the anal or genital area, recurrent atypical abdominal pain.

3. Physical findings

1. Colposcopy allows a detailed magnified inspection of the vulva to search for physical signs of abuse that may have escaped detection by unaided examination. However, most findings are visible to the naked eye. Take pictures and document any findings well. Videocolposcopy is the standard of care.

2. Nonspecific. Redness of external genitalia, increased vascular pattern of the vestibule and labia, presence of purulent discharge from the vagina, small skin fissures or lacerations in the area of the posterior fourchette, and agglutination of the labia minora after trauma.

3. Specific findings. Recent or healed lacerations of the hymen and vaginal mucosa may indicate abuse. An enlarged hymenal opening of 1 cm or more is non-specific. Procto-episiotomy and indentations in the skin indicating teeth marks (bite marks) or laboratory confirmation of a venereal disease may indicate abuse.

4. Definitive findings. Any presence of sperm.