Managing Sexual Assualt in Primary Care

Thanks to those who participated in a great discussion in AMR last week. I wanted to share some of what we talked about here…

Sexual assault is an unusal complaint inside of a primary care clinic.  Many victims head straight for the ER or a Rape Crisis Center, others never report their attack. But for many, their primary care doctor may seem like a trusted source for health care in a very scary and chaotic situation. Since it is also a scary and chaotic situation for the provider, I thought that an organized process may help you know what to do in such a scenario.


Legal Issues

The patient may need or want an exam in order to collect evidence for future charges against an attacker. There is a very specialized process that is used to collect evidence, and maintain the chain of custody.  I would recommend that you contact your Emergency Dept or Rape Crisis Center for help.  In Birmingham, the Crisis Center offers Sexual Assault Nurse Examiner (SANE) Exams in a safe and secure facility, and may be a more comfortable alternative to an ED.  They have a SANE nurse on call 24/7. Many times, this exam must be done within 72 hours of the attack.

Pregnancy Prevention

Most women should be offered post-coital contraception after a sexual assault.  The most effective oral option is Le
vonorgestrel, (Plan B is one brand name).  Ulipristal (Ella) is a newer form of emergency contraception that is effective up to 120 hours after unprotected sex.

 

STI Prevention

The CDC recommends antibiotic prophylaxis for GC, Chlamydia, and Trichomonas.  If your patient declines, you should see her back in a week for testing.  You need to give (all single dose therapies):

  • Ceftriaxone 250mg IM for Gonorrhea
  • Azithromycin 1g PO for Chlamydia
  • Metronidazole 2g PO for Trichomonas

Hepatitis B Prevention

If the Hepatitis B status of the attacker is not known, and the victim is not already immune, the victim should receive the Hepatitis B vaccine on first visit, and then at 1 and 6 months.  If the attacker has Hepatitis B, then you should offer HBIG.

HIV Prevention

There is some data that post-exposure prophylaxis with antiretroviral drugs prevents HIV transmission. Most of this data is in the healthcare setting, when folks like us are exposed with needles. The studies done in sexual exposure and IV drug users are all small and observational. Side effects with these medicines are fairly common, and usually of the GI variety.

Given limited data, and relatively low risk of transmission for a single sexual exposure (0.1% for consensual vaginal intercourse and 2% for consensual anal intercourse- transmission rates with nonconsensual sex are likely to be higher), the CDC only recommends post exposure prophylaxis (PEP) if:

  • The assailant is known to be HIV positive
  • The victim presents within 72 hours
  • There was exposure OF: eye, mouth, vaginal, rectum, other mucus membrane or nonintact skin
  • WITH: semen, vaginal fluid, blood, rectal secretions, milk, or other bodily fluids that are known to transmit HIV.

However, they do give you an option to treat other patients on a case-by-case basis. Many experts recommend that PEP is offered to all victims of sexual assault that present in the first 72 hours and have a chance at HIV exposure.  If you were going to prescribe, it should start within 72 hours (the earlier the better), and continue for 4 weeks. Three drug combinations are usually used, the same as in occupational HIV PEP.

  • Tenofovir/emtricitabine 300/200 plus Dolutegravir 50mg once daily
  • Tenofovir/emtricitabine 300/200 plus Raltegravir 400mg twice daily

Psychologic Support

Probably the most important thing that you can do. Your patient came to use because you were trusted, available, and supportive. You need to continue to be those things. After an assault, many victims will struggle with nightmares, anorexia, guilt, anxiety, and PTSD.  As a primary care doctor, you can gently ask about these issues, and guide your patients to helpful therapies and supportive environments. Again, rely on your local resources for crisis counseling and psychiatry, in addition to using all of your own talents.

Here is a NEJM article (subscription needed) if you are interested in reading more: NEngl J Med 2011; 365:834-841.

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Living in the Grey Zone: Back Pain

Thanks to all who participated and attended the Grey Zone: Acute Back Pain lecture last Tuesday.  I learned a lot, hope that you did as well.  As is often the case with grey zone lectures, we spend so much time talking with the panel that we miss some of the didactics at the end.  Here are some highlights that I wanted to be sure to cover.

99% of patients will acute back pain will get better, often without you doing much at all.  Gentle activity, NSAIDs, and time will take care of most.  If it goes on for two-week or so, add some formal PT. The activity is good, but PT will also use massage, heat, TENS and US to help get the muscles to relax.

Red flags aren’t all they are made out to be, but are definitely a clue to slow down your thinking about a patient with back pain.  You may not need to do more just because a patient has one red flag-  80% of patients will have at least one.

Yellow Lights mean “slow down and prepare to stop” according to my 5-year-old, and that is just what these should signs and symptoms should make you do.

  • Age >70
  • History of cancer, not active malignancy
  • IV drug use
  • Osteoporosis, use of steroids
  • Immunosuppression

On the other hand, the red lights should make you stop and seriously consider more imaging, consultation, or other workup. You may still be justified in delaying imaging if there are one of these present, but you need to be extra sure that it is the right thing to do.

  • Known metastatic cancer
  • Trauma
  • Recent spinal surgery
  • Bowel/Bladder incontinence
  • Fever (without another reason)
  • Weight loss (without another reason)
  • Saddle anesthesia, decreased rectal tone
  • Progressive motor or sensory loss

If you do need to do more workup, let your differential diagnosis be your guide as to what needs to happen.  Here are some suggestions:

  • Vertebral Fracture: either from osteoporosis or trauma.  Plain films are quite helpful, CT is important for traumatic fractures- will give a better idea of the extent of the fracture and the mechanism.
  • Metastatic disease: Plain films are a place to start.  MRI would be quick to follow if there are neurologic findings.  Bone scan may be useful in a high risk patient with a less clear picture.
  • Cauda Equina Syndrome: Think this if there is saddle anesthesia, bowel/bladder incontinence. MRI if you are concerned, with quick referral to NSGY.
  • Spinal Stenosis: Pseudoclaudication is the classic sx here: predictable pain with standing or walking, better with rest.  Vascular claudication gets better quickly with rest, pseudoclaudication takes 20-30 minutes or more. Plain films may show misalignment, but the MRI is going to clinch the diagnosis.
  • Epidural abcess: Unexplained fever and weight loss in a high risk patient: IV drugs, recent spinal surgery, recently septic, decubital ulcers all are all risks. MRI is the imaging test.

Here’s a great patient centered video about low back pain to bring these points home to your patients.

Contraception Myths

Some highlights from my contraception mythbusting crusade.  If only I could get to the Supreme Court…

“The good thing about science is that it’s true whether or not you believe in it.” Neil deGrasse Tyson

For combined Estrogen and Progesterone contraceptives: These prevent ovulation, primarily with the progesterone.  The normal menstrual cycle is below, the cyclic fall and rise of progesterone triggers the LH surge. By keeping this high, negative feedback to the hypothalamus is washed out. No LH surge, no ovulation.  The estrogen is there to recruit more progesterone receptors (so less progesterone is needed), and stabilize the endometrium (less breakthrough bleeding).

menstrual cycle

Ovulation happens at the LH surge. LH is surging because progesterone is low.

Large doses of progesterone only contraceptives (DepoProvera, the MiniPill, and Implants) is enough progesterone to prevent ovulation.  The lower dose progesterone only contraceptives (Mirena/Skyla IUDs, the MiniPill) work by thickening cervical mucus, reduce fallopian tube motility, and thinning the endometrium.

IUDs are not abortifacients.  They actually prevent conception from ever happening: the IUD creates a sterile inflammatory response that is toxic to sperm and ova.  This has been shown in vivo with tubal flushing studies.  Women who are not on contraception can be found to have sperm, non fertilized eggs, and even fertilized, but nonviable eggs in the tubes.  Women with IUDs have fewer of all three: the sperm never get there and fertilization doesn’t happen.

IUDs do not increase the risk of STIs or PID.  There is a slightly higher risk of infection in the first 20 days after insertion. This is either from incompletely sterile technique or if the woman is already infected when the IUD is placed. So make sure your patient is free from cervicitis before inserting an IUD. After that, the risk is no different.  This myth comes from an old IUD, the Dalkon Shield (that parasite-looking thing in the picture below), which DID increase the risk of PID, because it had a multifilament string that acted as a bacterial superhighway.   IUDs

Emergency Contraception is not an abortifacient either.  The EC pills are mostly large doses of progesterone- which works to prevent ovulation, thicken cervical mucus, and impair motility in the fallopian tubes.  Women do not get pregnant if they have had intercourse after ovulation. Sperm lives in the female reproductive tract for up to 6 days after intercourse, and all that time it is making its way up to the fallopian tubes, where fertilization happens.  EC pills prevent ovulation, and are more effective the sooner after unprotected intercourse they are taken (this is why it is helpful for a woman to have it at home before something goes wrong).  If a woman does get pregnant despite taking EC, the pills will not harm the pregnancy.  

Here’s a great table to use when talking about contraception with your patients. Aim to pick a method from the top row: these are the most effective with typical use (because they don’t require the woman to think about anything once in place).  As you move down the rows, preventing pregnancy gets closer and closer to just luck.  And we can do better than that!

contraception effectiveness