Let’s get personal: Digital rectal exams

Residents, let’s get serious for a minute. How often are you performing digital rectal exams (DRE)  for patients that have an indication? An informal poll of the audience revealed that even some gastroenterologists, let alone medical residents, were skipping the rectal exam despite having patients with lower gastrointestinal (GI) symptoms. I know that during a busy day in the hospital or clinic doing a rectal exam may seem like the last thing on your checklist, but your finger may provide very useful information quickly.

In 2012, Nature published a multicenter survey looking at the utility of perceptions and practice patterns of rectal exams. They found that only 33.6% of healthcare practitioners felt confident in their training to perform an DRE. This is unacceptable! There is minimal training in medical school and no training in residency. Medical schools usually bring a standardized patient who sits through has each person does a rectal exam once. While I can’t imagine doing this job, kudos to them for being a pivotal role in medical education. However, it clearly isn’t enough training if only one third of all practitioners are comfortable in their training!

Indications for a DRE are:

  1. Bleeding (hemorrhoids, fissures, malignancy, determine source of bleeding, Iron deficiency anemia)
  2. Changes in bowel habits (constipation, fecal incontinence, malignancy, Pelvic floor disease)
  3. Urinary changes in men (prostate hypertrophy or malignancy)
  4. Bowel dysfunction (Pelvic floor disease, Spinal disease)
  5. Anal lump (HPV, hemorrhoids, rectal prolapse, malignancy)
  6. Trauma

 

How you can properly do a rectal exam:

Consent: Always ask before performing a rectal exam. Please do not surprise patients with this maneuver. Make sure you have a chaperone. Have the patient lie in the left lateral position. You will need to double glove, prepare your finger with lubricant, have the patient take a deep breath in and out.

Observe the Skin: Spread the buttocks, and observe the skin for hemorrhoids, fissures, blood, skin tags, rectal prolapse, anal warts, or fecal soiling.

Ask the patient to strain: Look for leakage of stool, ability to strain, prolapse of internal hemorrhoids, rectal prolapse. Inability might mean lower resting pressures on manometry. Patients with rectal prolapse will have a dark red mass at the anal verge appear during straining.

Anal wink testing: stroke a cotton pad in all 4 quadrants around the anus. You should see the anus contract each time. This means the patient has intact sacral nerve pathways. If this is missing, patients need neurologic examinations.

Palpation: Ask the patient to take a deep breathe, place tip of your gloved finger over and into the anus. Observe for worsening pain which suggests an anal fissure or thrombosed external hemorrhoids, ischiorectal abscess, active proctitis, or anal ulceration. Next palpate the rectal walls. Anterior wall for the prostate gland in men and cervix in women. Rotate finger clockwise to lateral and posterior walls.

Sphincter tone: as you move your finger through the rectum, assess the resting tone. Once inside notice the rectal sphincter tone around your proximal interphalangeal joint. Low pressures can suggest sphincter tear and a high resting tone can suggest difficulty evacuating.

Pelvic floor Evaluation: there are some special tests to check for pelvic floor dysfunction (PFD).  

The first test is ask the patient to strain and push out your finger. The normal mechanism allows the anal sphincter and puborectalis to relax and the perineum descends 1-3.5 cm. If anything other than this happens, it suggests paradoxical external anal sphincter and puborectalis contraction. Essentially this leads to abnormal defecation. These patients benefit from a dynamic MRI for better assessment of movement.

For the Second test, look for pain when palpating the posterior rectal wall. This can also suggest PFD.

Third, ask the patient to contract or squeeze the pelvic floor muscles. The anal sphincter and the puborectalis should contract. How do you know if this random muscle contracted? The muscle should lift your finger towards the umbilicus.

Lastly, place your hand on the anterior abdominal wall while asking the patient to strain allowing you to assess excessive or inadequate contractions of the abdominal wall.

Finishing up: Remove your finger and assess the tip for stool and blood. Note the color of the feces. The anal canal should be closed. Failure might indicate external anal sphincter or neurological defect.

So what do we need to do? Residents encourage your interns and medical students to perform rectal exams. Attending physicians, drive home the importance of performing rectal exams when indicated. Gastroenterology fellows, urge primary teams to perform and report rectal exams while calling consults. Gastroenterology attending physicians, review rectal exam results in detail with your fellows. Every level of the medical hierarchy has a role in the education and performance of rectal exams. There should be no reason a rectal exam is not performed if a patient has indications, so get in there and get dirty!

I would love to hear below if you have tips or tricks for performing rectal exams!

 

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