BRIEF REPORT
Chlamydia trachomatis, sexual assault; Neisseria gonorrhoeae, sexual assault
T h e Prevalence of Neisseria Gonorrhoeae and Chlamydia Trachomatis in Victims of Sexual Assault The prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in 232 sexual assault victims who presented for examinations between August I, 1987, and July 31, 1988, was determined. Results are reported for cervical, rectal, and oropharyngeal NG cultures and for cervical and rectal CT smears. Results from a one-week follow-up are also reported. Cervical test results from the initial sexual assault examination were compared with cervical tests on 399 randomly selected female emergency department patients who presented for other gynecological conditions or lower abdominal pain. The victims of sexual assault had ten of 210 positive cervical N G cultures (4.76%), and 13 of 213 positive cervical CT smears (6.1%) at the first visit. These prevalence rates were not significantly different (P = .3058). There were none of 28 positive rectal NG cultures (0%) and one of 22 positive rectal CT smears (4.34%) (P = .451). None of the 43 oral NG cultures was positive. Seventy-three victims returned for follow-up examination. No follow-up cervical, rectal, or oral NG cultures were positive. However, one of 53 follow-up cervical smears for CT was positive, but this was not significantly different than for cervical N G (P = .461). Sexually assaulted patients had ten of 210 (4.76%) cervical N G cultures positive, and nonassaulted patients showed 53 of 393 positives (13.4%) (P < .001). Assaulted patients had 13 of 213 (6.1%) cervical CT smears positive, and nonassaulted patients showed 33 of 352 (913%) positives (P = .11). Two of 203 victims (1.03%) who had both cervical NG and cervical CT tests performed had both reported as positive; in the nonassaulted group, six of 377 (1.6%) who had both tests done showed both positive (P = .455). We conclude that NG or CT each occur in about 5% of our female sexual assault population on initial examination, are isolated with nearly equal frequencies, and occur together in the cervical area in less than 2% of patients. Furthermore, cervical N G occurs more commonly in ED patients who present for other gynecological problems or abdominal pain. [Sturm JT, Carr ME, Luxenberg MG, Swoyer JK, Cicero JJ: The prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of sexual assault. Ann Emerg Med May 1990;19:587-590.]
James T Sturm, MD Mary E Carr, MD Michael G Luxenberg, PhD Jacqueline K Swoyer James J Cicero, MD St Paul, Minnesota From the Department of Emergency Medicine, Ramsey Clinic, and the St PauI-Ramsey Medical Center, St Paul, Minnesota. Received for publication March 7, 1989. Revision received December 11, 1989. Accepted for publication January 18, 1990. This study was supported by the St PaulRamsey Medical Education and Research Foundation. Address for reprints: James Sturm, MD, 640 Jackson Street, St Paul, Minnesota 55101.
INTRODUCTION The prevalence of Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT) in women presenting to emergency departments has been reported to be 10% to 21%Y -s Coinfection with these two organisms has been reported to be 26% to 33% in symptomatic women,67 and 0.2% to 2% in asymptomatic female patients. 8-1t The prevalence of these organisms in victims of sexual assault has been reported to be as low as 2.5% and as high as i5~/o.12-I4 It is impossible to determine with certainty whether pathological organisms recovered at a sexual assault examination are the result of the sexual assault or a reflection of the prevalence in the general population. Our study sought to determine the prevalence of NG and CT in female victims of sexual assault. We tested the following null hypotheses: in our ED population, the prevalence of NG and CT in female sexual assault victims is no different than in other female patients who require NG and CT tests for evaluation of their gynecological problems or abdominal pain; and NG and CT prevalence does not differ in our female sexual assault victims.
19:5 May 1990
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SEXUAL ASSAULT VICTIMS Sturm et al
The purpose of the first comparison w a s n o t to c o n d u c t a c o n t r o l l e d study to determine if sexual assault victims have different N G and C T prevalences w h e n compared with the general population. T h e comparison was undertaken to determine if differences existed between victims of sexual assault and other ED Patients requiring evaluation of gynecological problems or abdominal pain.
MATERIALS A N D M E T H O D S From August 1, 1987, through July 31, 1988, all victims of sexual assault w h o suffered penile p e n e t r a t i o n or t h o u g h t they m i g h t have incurred penile penetration had cultures taken for N G and smears sent for direct fluorescent a n t i b o d y d e t e c t i o n of C T from the involved orifices (cervix or vagina, r e c t u m , oropharynx). However, CT testing was not done from the oropharynx because during the study period the Food and Drug Administration had not approved the direct a n t i b o d y test for use in oropharyngeal smears. Currently, the test is licensed for oropharyngeal use. N G was cultured on Thayer-Martin agar. CT was detected by the direct fluorescent antibody technique, MicroTrak ® (Syva Company, Palo Alto, California). 1s, 16 D u r i n g this period, 239 patients were seen for sexual assault and had or were suspected of having penile p e n e t r a t i o n ; 232 w e r e f e m a l e patients and seven were male patients. This study involved the 232 female patients. The study protocol called for both N G cultures and CT smears to be taken from each orifice; this was not done with 100% uniformity and, as a result, the numbers of N G cultures and C T smears were n o t equal. The 232 female victims of sexual assault were compared with a series of 399 randomly selected female patients who presented to the ED for the assessment of other gynecological conditions i n c l u d i n g lower abdominal pain. None of the sexual assault victims was s y m p t o m a t i c for pelvic inflammatory disease, and none was treated for N G or CT without a positive N G culture or CT smear. The frequencies of occurrence of cervical and rectal N G and CT were compared for statistical significance. It is our sexual offense protocol to have victims return one week after the initial e x a m i n a t i o n for repeat 142/588
N G and CT testsJ 7 This is done to ensure that evidence not recovered initially m i g h t be discovered at a later date. The results from the first examination and second examination were analyzed separately. In addition , the prevalences of cervical N G and CT were compared between the sexual assault and nonassault patients. Lastly, the frequency of cervical coinfection with both organisms was compared between assault and nonassault patients. The X2 method was used for statistical analysis. Fisher's exact test was used if the number of patients in any cell of the 2 x 2 contingency table was five or less.
ycycline twice a day for one week and did not return for a scheduled third examination. Seven rectal swabs were sent for CT on the second visit and all were negative (Table 1). In the group of patients not sexually assaulted, 53 of 393 p a t i e n t s (13.5%) had positive N G cultures of the cervix. This was significantly different from the sexually assaulted patients (ten of 210 positive, 4.76%, P < .001). In the group of patients not sexually assaulted, the incidence of positive CT cervical smears was 33 o f 352 {9.4%). This was not significantly different from the prevalence in sexually assaulted patients (13 of 213, 6.10%, P = .11)(Table 2).
RESULTS The 232 female patients ranged in age from 3 to 94 years, with a mean age of 23.5 + 11.7 years. Of the 232 patients, 210 underwent pelvic examination with cultures for N G taken from the cervix (or from the vaginal vault in ten children). There were ten positive N G cultures, an incidence of 4.76%. Two hundred thirteen female patients had smears from the cervix (or vaginal vault in ten children) for CT; 13 of these were positive, an incidence of 6.1%. The proportion of patients with positive cervical N G and w i t h positive cervical CT was not significantly different (P - .358). Twenty-eight female patients had cultures for N G taken from the rectum; none was positive. Twenty-two patients had smears t a k e n for CT from the rectum; one was positive (4.34%). To our knowledge, this is the first report of a positive rectal CT s m e a r in a female sexual assault victim. The difference b e t w e e n rectal N G and CT occurrence was not significant (P = .451). Forty-three fem a l e patients had oral cultures for N G and none was positive. Two of the 203 patients who had both cervical N G culture and cervical CT smear done had both reported as positive, an incidence of 1.03%. Seventy-three of the 232 patients (31.5%) returned for their scheduled second e x a m i n a t i o n . A m o n g these patients, there were 62 cervical, ten rectal, and 14 oral specimens sent for N G culture; all were negative. Fiftythree cervical specimens were sent for CT, and one was positive (1.9%). The initial cervical CT s m e a r had been negative on this patient. This patient was treated with 100 mg dox-
DISCUSSION This study was undertaken to evaluate our ED protocol for testing of sexually transmitted diseases in victims of sexual assault. The data obtained are specifically relevant only to our patient population. However, the study is relevant to other patient populations in a general way because it shows that there can be substantial differences between results obtained in a specific population of patients and those reported in the literature. The lesson to be learned here is that EDs that treat sexual assault victims should monitor the prevalence of N G and CT and evolve treatment protocols that take into account the local p r e v a l e n c e s and local rates of coinfection. Our data take on additional relevance when the emergency medicine literature is searched for articles dealing with sexual assault. A search of Annals of Emergency Medicine from 1980 through June 1989 revealed only seven full-length articles on sexual assault, and n o n e of these s e v e n touched on the subject of sexually t r a n s m i t t e d diseases in sexual assank. A search of The American fourhal of Emergency M e d i c i n e w a s made for the years 1984 through June 1989; only one article on sexual assault was located and it did not deal with sexually transmitted diseases. We hope that our study will give impetus to further clinical research and publication in the important area of emergency medicine. O u r present s t u d y d e m o n s t r a t e d that the prevalences of N G and CT were 4.76% and 6.1%, respectively, in cervical specimens taken from our
Annals of Emergency Medicine
19:5 May 1990
TABLE 1. S u m m a r y of results in sexual assault v i c t i m s
Examination First Cervix Rectum Oropharynx Second Cervix Rectum Oropharynx
NG (%)
CT (%)
10/210 (4.76) 0/28 (0) 0/43 (0)
13/213 (6.1) 1/22 (4.34)
.3058 .451
1/53 0/7
.461 NS
0/62 (0)
O/lO (o) 0/14 (0)
(1.9)
(o)
P
TABLE 2. Comparison of sexual assault and nonassault patients
Examination Cervix NG CT NG and CT
Sexual Assault (%)
Nonassault (%)
10/210 (4.76) 13/213 (6.1) 2/203 (1.03)
53/393 (13.4) 33/352 (9.3) 6/377 (1.6)
p o p u l a t i o n of f e m a l e sexual a s s a u l t victims. The differences between these two prevalences were not stat i s t i c a l l y s i g n i f i c a n t . In a d d i t i o n , there was no statistically significant difference b e t w e e n the prevalence of N G and CT in rectal specimens. The coinfection rates of these two organisms were n o t significantly different b e t w e e n sexually assaulted and nonassaulted patients. These results fall w i t h i n the range of results reported by other investigators3,2,1s, 19 Our investigation delves into areas n o t covered by p r e v i o u s studies in t h a t w e r e p o r t t h e p r e v a l e n c e rates for N G and C T of the r e c t u m and N G of the oropharynx in sexually assaulted patients. T h e n u m b e r of rectal and oropharyngeal studies we report is small, 28 w o m e n (12.1% of t h e total) w i t h r e c t a l N G c u l t u r e s done, 22 (9.5% of the total) w i t h CT smears done, and 43 (18.5% of the total) w i t h oral N G cultures performed. However, these are the largest n u m b e r s of t h e i r k i n d r e p o r t e d a n d t h e r e i n lies t h e i r s i g n i f i c a n c e . T h e additional relevance of the rectal and oral data is that, in the small n u m b e r of cases reported, the n u m b e r of positive rectal and oropharyngeal N G or C T tests is low. We hope our data will encourage other investigators to report their findings.
19:5 May 1990
P
.001 .11 .455
This low rate of p a t i e n t follow-up m a y s k e w t h e r e s u l t s reported, and the reader should interpret the findings a c c o r d i n g l y . A t t h e o n e - w e e k follow-up e x a m i n a t i o n n o n e of t h e N G c u l t u r e s was positive, but one cervical CT s m e a r was positive after being i n i t i a l l y negative. Thus, o n l y one of the 73 patients w h o returned was positive. A l t h o u g h one positive test result among 73 p a t i e n t s is a num e r i c a l l y low yield, we c o n t i n u e to b e l i e v e t h a t s e x u a l l y a s s a u l t e d patients should be re-evaluated soon after t h e i n i t i a l v i s i t to p r e v e n t t h e c o n s e q u e n c e s of u n r e c o g n i z e d sexua l l y t r a n s m i t t e d i n f e c t i o n s . 17 T h e low yield obtained at one-week follow-up e x a m i n a t i o n raises the question of the cost effectiveness of this protocol; however, we believe that it is in the best interest of the p a t i e n t to p e r f o r m f o l l o w - u p c u l t u r e s a n d smears, recognizing the difficulty of justifying the expenses involved. O u r study differs from previous reports in that w e compared the prevalence of N G and CT in the sexual assault p o p u l a t i o n to the prevalence of the s a m e organisms in patients presenting for other gynecological conditions, i n c l u d i n g l o w e r a b d o m i n a l pain. There was a s t a t i s t i c a l l y significant difference in the occurrence of N G in s y m p t o m a t i c n o n a s s a u l t e d pa-
Annals of Emergency Medicine
tients. However, there was not a difference in the prevalence of CT bet w e e n assaulted and n o n a s s a u l t e d pat i e n t s . A p l a u s i b l e e x p l a n a t i o n for these facts m i g h t be that c h l a m y d i a l i n f e c t i o n s are m o r e often c l i n i c a l l y silent for longer periods t h a n gonorrheal infections, and patients who are s y m p t o m a t i c are m o r e l i k e l y to harbor N G t h a n CT. Alternatively, this s t a t i s t i c m a y m e r e l y reflect our patient population. T h e c o i n f e c t i o n rates in b o t h the a s s a u l t e d and the n o n a s s a u l t e d patients were low. W h e n e v e r one venereal disease is diagnosed, it is m o r e likely that another sexually transm i t t e d d i s e a s e w i l l also be found. Previous reports s t a t e t h a t the N G and CT infections occur concomit a n t l y in 21% to 40% of m e n and 40% to 60% of women.11,18, 2o Coi n f e c t i o n rates reflect the degree to w h i c h p a t i e n t s are s y m p t o m a t i c at presentation. 2o CONCLUSION NG or CT were isolated from about 5% of our f e m a l e sexual assault p o p u l a t i o n on initial examination. N G was not isolated from any p a t i e n t w h o r e t u r n e d for follow-up examination, but C T occurred once. There was an u n e x p l a i n e d difference in the prevalence of N G , but not CT, in cervical s p e c i m e n s from the nonassaulted patients c o m p a r e d w i t h the s e x u a l l y a s s a u l t e d p a t i e n t s . T h e sim u l t a n e o u s recovery of N G and CT was less than 2% in both groups. The authors thank Ms Lynn Gilsrud for her editorial assistance in the preparation of this manuscript.
REFERENCES
1. Jensen KA, Hevesy GZ: Study of Chlamydia traehomatis pelvic inflammatory disease in women undergoing pelvic examination in an emergency department setting (abstract). Ann Emerg Med 1987;16:477-478. 2. O'Hare PA, Fiumara NJ, McCormack WM: Pelvic inflammatory disease among women presenting to the emergency room of hospitals in Massachusetts. Am J Obstet Gynecol 1980;138: 909-912. 3. Hochbaum SR: The evaluation and treatment of the sexually assaulted patient. Emerg Med Clin North Am 1987;5:601-623. 4. Schwartz RH: Sexually transmitted diseases, in Pitkin RM, Scott JR (eds): Clinical Obstetrics and Gynecology. Philadelphia, Harper and Row Publishers, Inc, 1983, p 109-213. 5. Thompson JL: Pelvic inflammatory disease: Diagnosis and management. Female Patient 1984;9:38-56.
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6. Stamm WE, Guinan ME, Johnson C, et al: Effect of treatment regimens for Neisseria gonorr h o e a e on s i m u l t a n e o u s i n f e c t i o n w i t h Chlamydia trachomatis. N Engl J Med 1984; 310: 545-549. 7. Brunham RG, Kuo CC, Stevens CE, et ah Treatment of concomitant Neisseria gonorrhoeae and Chlamydia trachomatis infections in women: Comparison of trimethoprim-sulfamethozole with ampicillin-probencid. Rev Infect Dis 1982;4:491-494. 8. Fraser JJ, Rettig PJ, Kaplan DW: Prevalence of cervical Chlamydia trachomatis and Neisseria gonorrhoeae in female adolescents. Pediatrics 1983; 71:333-336. 9. Saltz GR, Linnemann CC, Brookman RR, et ah Chlamydia trachomatis cervical infections in female adolescents. J Pediatr 1981;98:981-984. 10. Wiesmeier E, Lovett MA, Forsythe AB: Chlamydia trachomatis isolation in a symptomatic university student population. Obstet
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Gynecol 1984~63:81-84.
J Clin Microbiol 1977;6:285-292.
11. Shafer MA, Beck A, Blain B, et ah Chlamydia traehomatis: Important relationships to race, contraception, lower genital tract infection and Papnicolaou smear. J Pediatr 1984; 104:141-146.
16. Munday PE, Johnson AP, Thomas BJ, et ah A comparison of the sensitivity of immun o f l u o r e s c e n c e and G i e m s a for s t a i n i n g Chlamydia trachomatis inclusions in cyclohexamide-treated McCoy cells. J Clin Pathol 1980;33:197-199.
12. Dattel BJ, Landers DV, Couherk K, et ah Isolation of Chlamydia trachomatis from sexually abused female adolescents. Obstet Cyneco] 1988; 72:240-242. 13. Forester GE, Pritchard J, Munday PE, et ah Incidence of sexually transmitted diseases in rape victims during 1984. Cenitourin Med 1986;62:267-269. 14. Hayman CR, Lanza C: Sexual assault in women and girls. A m J Obstet Gynecol 1971; 109:480-485. 15. Thomas BJ, Evans RT, Hutchinson GR, et ah Early detection of chlamydial inclusions combining the use of cycloheximide-treated McCoy cells and immunofluorescence staining.
Annals of Emergency Medicine
17. Glaser JB, Hammerschlag MR, McCormack WM: Epidemiology of sexually transmitted diseases in rape victims. Rev Infect Diseases 1989; 11:246-254. 18. Glaser JB, Hammerschlag MR, McCormack WM: Sexually transmitted diseases in victims of sexual assault. N Engl J M e d 1986;345: 625-627. 19. Richmond SJ, Oriel JD: Recognition and management of genital Chlamydial infection. Br Med J 1978~2:480-484. 20. Judson FN: Treatment of uncomplicated gonorrhea w i t h ceftriaxone: A review. Sex Transm Dis 1986;13(Suppl 3):209-211.
19:5 May 1990
Chlamydia trachomatis, sexual assault; Neisseria gonorrhoeae, sexual assault
T h e Prevalence of Neisseria Gonorrhoeae and Chlamydia Trachomatis in Victims of Sexual Assault The prevalence of Neisseria gonorrhoeae (NG) and Chlamydia trachomatis (CT) in 232 sexual assault victims who presented for examinations between August I, 1987, and July 31, 1988, was determined. Results are reported for cervical, rectal, and oropharyngeal NG cultures and for cervical and rectal CT smears. Results from a one-week follow-up are also reported. Cervical test results from the initial sexual assault examination were compared with cervical tests on 399 randomly selected female emergency department patients who presented for other gynecological conditions or lower abdominal pain. The victims of sexual assault had ten of 210 positive cervical N G cultures (4.76%), and 13 of 213 positive cervical CT smears (6.1%) at the first visit. These prevalence rates were not significantly different (P = .3058). There were none of 28 positive rectal NG cultures (0%) and one of 22 positive rectal CT smears (4.34%) (P = .451). None of the 43 oral NG cultures was positive. Seventy-three victims returned for follow-up examination. No follow-up cervical, rectal, or oral NG cultures were positive. However, one of 53 follow-up cervical smears for CT was positive, but this was not significantly different than for cervical N G (P = .461). Sexually assaulted patients had ten of 210 (4.76%) cervical N G cultures positive, and nonassaulted patients showed 53 of 393 positives (13.4%) (P < .001). Assaulted patients had 13 of 213 (6.1%) cervical CT smears positive, and nonassaulted patients showed 33 of 352 (913%) positives (P = .11). Two of 203 victims (1.03%) who had both cervical NG and cervical CT tests performed had both reported as positive; in the nonassaulted group, six of 377 (1.6%) who had both tests done showed both positive (P = .455). We conclude that NG or CT each occur in about 5% of our female sexual assault population on initial examination, are isolated with nearly equal frequencies, and occur together in the cervical area in less than 2% of patients. Furthermore, cervical N G occurs more commonly in ED patients who present for other gynecological problems or abdominal pain. [Sturm JT, Carr ME, Luxenberg MG, Swoyer JK, Cicero JJ: The prevalence of Neisseria gonorrhoeae and Chlamydia trachomatis in victims of sexual assault. Ann Emerg Med May 1990;19:587-590.]
James T Sturm, MD Mary E Carr, MD Michael G Luxenberg, PhD Jacqueline K Swoyer James J Cicero, MD St Paul, Minnesota From the Department of Emergency Medicine, Ramsey Clinic, and the St PauI-Ramsey Medical Center, St Paul, Minnesota. Received for publication March 7, 1989. Revision received December 11, 1989. Accepted for publication January 18, 1990. This study was supported by the St PaulRamsey Medical Education and Research Foundation. Address for reprints: James Sturm, MD, 640 Jackson Street, St Paul, Minnesota 55101.
INTRODUCTION The prevalence of Neisseria gonorrhoeae (NG) or Chlamydia trachomatis (CT) in women presenting to emergency departments has been reported to be 10% to 21%Y -s Coinfection with these two organisms has been reported to be 26% to 33% in symptomatic women,67 and 0.2% to 2% in asymptomatic female patients. 8-1t The prevalence of these organisms in victims of sexual assault has been reported to be as low as 2.5% and as high as i5~/o.12-I4 It is impossible to determine with certainty whether pathological organisms recovered at a sexual assault examination are the result of the sexual assault or a reflection of the prevalence in the general population. Our study sought to determine the prevalence of NG and CT in female victims of sexual assault. We tested the following null hypotheses: in our ED population, the prevalence of NG and CT in female sexual assault victims is no different than in other female patients who require NG and CT tests for evaluation of their gynecological problems or abdominal pain; and NG and CT prevalence does not differ in our female sexual assault victims.
19:5 May 1990
Annals of Emergency Medicine
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SEXUAL ASSAULT VICTIMS Sturm et al
The purpose of the first comparison w a s n o t to c o n d u c t a c o n t r o l l e d study to determine if sexual assault victims have different N G and C T prevalences w h e n compared with the general population. T h e comparison was undertaken to determine if differences existed between victims of sexual assault and other ED Patients requiring evaluation of gynecological problems or abdominal pain.
MATERIALS A N D M E T H O D S From August 1, 1987, through July 31, 1988, all victims of sexual assault w h o suffered penile p e n e t r a t i o n or t h o u g h t they m i g h t have incurred penile penetration had cultures taken for N G and smears sent for direct fluorescent a n t i b o d y d e t e c t i o n of C T from the involved orifices (cervix or vagina, r e c t u m , oropharynx). However, CT testing was not done from the oropharynx because during the study period the Food and Drug Administration had not approved the direct a n t i b o d y test for use in oropharyngeal smears. Currently, the test is licensed for oropharyngeal use. N G was cultured on Thayer-Martin agar. CT was detected by the direct fluorescent antibody technique, MicroTrak ® (Syva Company, Palo Alto, California). 1s, 16 D u r i n g this period, 239 patients were seen for sexual assault and had or were suspected of having penile p e n e t r a t i o n ; 232 w e r e f e m a l e patients and seven were male patients. This study involved the 232 female patients. The study protocol called for both N G cultures and CT smears to be taken from each orifice; this was not done with 100% uniformity and, as a result, the numbers of N G cultures and C T smears were n o t equal. The 232 female victims of sexual assault were compared with a series of 399 randomly selected female patients who presented to the ED for the assessment of other gynecological conditions i n c l u d i n g lower abdominal pain. None of the sexual assault victims was s y m p t o m a t i c for pelvic inflammatory disease, and none was treated for N G or CT without a positive N G culture or CT smear. The frequencies of occurrence of cervical and rectal N G and CT were compared for statistical significance. It is our sexual offense protocol to have victims return one week after the initial e x a m i n a t i o n for repeat 142/588
N G and CT testsJ 7 This is done to ensure that evidence not recovered initially m i g h t be discovered at a later date. The results from the first examination and second examination were analyzed separately. In addition , the prevalences of cervical N G and CT were compared between the sexual assault and nonassault patients. Lastly, the frequency of cervical coinfection with both organisms was compared between assault and nonassault patients. The X2 method was used for statistical analysis. Fisher's exact test was used if the number of patients in any cell of the 2 x 2 contingency table was five or less.
ycycline twice a day for one week and did not return for a scheduled third examination. Seven rectal swabs were sent for CT on the second visit and all were negative (Table 1). In the group of patients not sexually assaulted, 53 of 393 p a t i e n t s (13.5%) had positive N G cultures of the cervix. This was significantly different from the sexually assaulted patients (ten of 210 positive, 4.76%, P < .001). In the group of patients not sexually assaulted, the incidence of positive CT cervical smears was 33 o f 352 {9.4%). This was not significantly different from the prevalence in sexually assaulted patients (13 of 213, 6.10%, P = .11)(Table 2).
RESULTS The 232 female patients ranged in age from 3 to 94 years, with a mean age of 23.5 + 11.7 years. Of the 232 patients, 210 underwent pelvic examination with cultures for N G taken from the cervix (or from the vaginal vault in ten children). There were ten positive N G cultures, an incidence of 4.76%. Two hundred thirteen female patients had smears from the cervix (or vaginal vault in ten children) for CT; 13 of these were positive, an incidence of 6.1%. The proportion of patients with positive cervical N G and w i t h positive cervical CT was not significantly different (P - .358). Twenty-eight female patients had cultures for N G taken from the rectum; none was positive. Twenty-two patients had smears t a k e n for CT from the rectum; one was positive (4.34%). To our knowledge, this is the first report of a positive rectal CT s m e a r in a female sexual assault victim. The difference b e t w e e n rectal N G and CT occurrence was not significant (P = .451). Forty-three fem a l e patients had oral cultures for N G and none was positive. Two of the 203 patients who had both cervical N G culture and cervical CT smear done had both reported as positive, an incidence of 1.03%. Seventy-three of the 232 patients (31.5%) returned for their scheduled second e x a m i n a t i o n . A m o n g these patients, there were 62 cervical, ten rectal, and 14 oral specimens sent for N G culture; all were negative. Fiftythree cervical specimens were sent for CT, and one was positive (1.9%). The initial cervical CT s m e a r had been negative on this patient. This patient was treated with 100 mg dox-
DISCUSSION This study was undertaken to evaluate our ED protocol for testing of sexually transmitted diseases in victims of sexual assault. The data obtained are specifically relevant only to our patient population. However, the study is relevant to other patient populations in a general way because it shows that there can be substantial differences between results obtained in a specific population of patients and those reported in the literature. The lesson to be learned here is that EDs that treat sexual assault victims should monitor the prevalence of N G and CT and evolve treatment protocols that take into account the local p r e v a l e n c e s and local rates of coinfection. Our data take on additional relevance when the emergency medicine literature is searched for articles dealing with sexual assault. A search of Annals of Emergency Medicine from 1980 through June 1989 revealed only seven full-length articles on sexual assault, and n o n e of these s e v e n touched on the subject of sexually t r a n s m i t t e d diseases in sexual assank. A search of The American fourhal of Emergency M e d i c i n e w a s made for the years 1984 through June 1989; only one article on sexual assault was located and it did not deal with sexually transmitted diseases. We hope that our study will give impetus to further clinical research and publication in the important area of emergency medicine. O u r present s t u d y d e m o n s t r a t e d that the prevalences of N G and CT were 4.76% and 6.1%, respectively, in cervical specimens taken from our
Annals of Emergency Medicine
19:5 May 1990
TABLE 1. S u m m a r y of results in sexual assault v i c t i m s
Examination First Cervix Rectum Oropharynx Second Cervix Rectum Oropharynx
NG (%)
CT (%)
10/210 (4.76) 0/28 (0) 0/43 (0)
13/213 (6.1) 1/22 (4.34)
.3058 .451
1/53 0/7
.461 NS
0/62 (0)
O/lO (o) 0/14 (0)
(1.9)
(o)
P
TABLE 2. Comparison of sexual assault and nonassault patients
Examination Cervix NG CT NG and CT
Sexual Assault (%)
Nonassault (%)
10/210 (4.76) 13/213 (6.1) 2/203 (1.03)
53/393 (13.4) 33/352 (9.3) 6/377 (1.6)
p o p u l a t i o n of f e m a l e sexual a s s a u l t victims. The differences between these two prevalences were not stat i s t i c a l l y s i g n i f i c a n t . In a d d i t i o n , there was no statistically significant difference b e t w e e n the prevalence of N G and CT in rectal specimens. The coinfection rates of these two organisms were n o t significantly different b e t w e e n sexually assaulted and nonassaulted patients. These results fall w i t h i n the range of results reported by other investigators3,2,1s, 19 Our investigation delves into areas n o t covered by p r e v i o u s studies in t h a t w e r e p o r t t h e p r e v a l e n c e rates for N G and C T of the r e c t u m and N G of the oropharynx in sexually assaulted patients. T h e n u m b e r of rectal and oropharyngeal studies we report is small, 28 w o m e n (12.1% of t h e total) w i t h r e c t a l N G c u l t u r e s done, 22 (9.5% of the total) w i t h CT smears done, and 43 (18.5% of the total) w i t h oral N G cultures performed. However, these are the largest n u m b e r s of t h e i r k i n d r e p o r t e d a n d t h e r e i n lies t h e i r s i g n i f i c a n c e . T h e additional relevance of the rectal and oral data is that, in the small n u m b e r of cases reported, the n u m b e r of positive rectal and oropharyngeal N G or C T tests is low. We hope our data will encourage other investigators to report their findings.
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This low rate of p a t i e n t follow-up m a y s k e w t h e r e s u l t s reported, and the reader should interpret the findings a c c o r d i n g l y . A t t h e o n e - w e e k follow-up e x a m i n a t i o n n o n e of t h e N G c u l t u r e s was positive, but one cervical CT s m e a r was positive after being i n i t i a l l y negative. Thus, o n l y one of the 73 patients w h o returned was positive. A l t h o u g h one positive test result among 73 p a t i e n t s is a num e r i c a l l y low yield, we c o n t i n u e to b e l i e v e t h a t s e x u a l l y a s s a u l t e d patients should be re-evaluated soon after t h e i n i t i a l v i s i t to p r e v e n t t h e c o n s e q u e n c e s of u n r e c o g n i z e d sexua l l y t r a n s m i t t e d i n f e c t i o n s . 17 T h e low yield obtained at one-week follow-up e x a m i n a t i o n raises the question of the cost effectiveness of this protocol; however, we believe that it is in the best interest of the p a t i e n t to p e r f o r m f o l l o w - u p c u l t u r e s a n d smears, recognizing the difficulty of justifying the expenses involved. O u r study differs from previous reports in that w e compared the prevalence of N G and CT in the sexual assault p o p u l a t i o n to the prevalence of the s a m e organisms in patients presenting for other gynecological conditions, i n c l u d i n g l o w e r a b d o m i n a l pain. There was a s t a t i s t i c a l l y significant difference in the occurrence of N G in s y m p t o m a t i c n o n a s s a u l t e d pa-
Annals of Emergency Medicine
tients. However, there was not a difference in the prevalence of CT bet w e e n assaulted and n o n a s s a u l t e d pat i e n t s . A p l a u s i b l e e x p l a n a t i o n for these facts m i g h t be that c h l a m y d i a l i n f e c t i o n s are m o r e often c l i n i c a l l y silent for longer periods t h a n gonorrheal infections, and patients who are s y m p t o m a t i c are m o r e l i k e l y to harbor N G t h a n CT. Alternatively, this s t a t i s t i c m a y m e r e l y reflect our patient population. T h e c o i n f e c t i o n rates in b o t h the a s s a u l t e d and the n o n a s s a u l t e d patients were low. W h e n e v e r one venereal disease is diagnosed, it is m o r e likely that another sexually transm i t t e d d i s e a s e w i l l also be found. Previous reports s t a t e t h a t the N G and CT infections occur concomit a n t l y in 21% to 40% of m e n and 40% to 60% of women.11,18, 2o Coi n f e c t i o n rates reflect the degree to w h i c h p a t i e n t s are s y m p t o m a t i c at presentation. 2o CONCLUSION NG or CT were isolated from about 5% of our f e m a l e sexual assault p o p u l a t i o n on initial examination. N G was not isolated from any p a t i e n t w h o r e t u r n e d for follow-up examination, but C T occurred once. There was an u n e x p l a i n e d difference in the prevalence of N G , but not CT, in cervical s p e c i m e n s from the nonassaulted patients c o m p a r e d w i t h the s e x u a l l y a s s a u l t e d p a t i e n t s . T h e sim u l t a n e o u s recovery of N G and CT was less than 2% in both groups. The authors thank Ms Lynn Gilsrud for her editorial assistance in the preparation of this manuscript.
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Annals of Emergency Medicine
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