Case

A 38-year-old man presents after a 15-foot fall from a ladder. He notes right chest pain and dyspnea. Vital signs are: blood pressure, 110/78; heart rate, 140; respiratory rate, 36; oxygen saturation, 91 percent on 10L non-rebreather mask. He is in moderate respiratory distress and severe pain with any movement. Lung examination reveals decreased breath sounds on the right. The emergency medicine team manages the airway, which is intact on initial assessment. The trauma team rolls him to his side, and, without any explanation, performs a digital rectal examination. The patient yells out, “Ahh, stop!” A chest radiograph reveals multiple fractured ribs on the right with a moderate hemothorax. As the trauma team sets up to perform a chest tube, the patient refuses, and states, “I don’t want any tubes!”

Question

This case raises an important question about the clinical value of a digital rectal examination (DRE) in the setting of trauma. Rectal examinations have been a longstanding tradition in the physical examination of the trauma patient. Many institutions and experts continue to recommend the routine performance of a rectal examination. The traditional teaching is that a DRE should be performed to assess for the presence of blood, and to assess the prostate for possible evidence of urethral injury. However, after decades of experience, I cannot recall a single case where the findings of a rectal examination changed management or were helpful in any way. Nearly all patients with severe trauma will receive CT scans of the head, neck, chest, abdomen, and pelvis. What does the literature say about this question?

An initial literature search on PubMed for the last five years using terms “digital rectal examination” and “trauma” yielded 15 results, none of which address the sensitivity or specificity of this physical examination test. Expanding the search criteria to include articles from the past 10 years yielded several relevant abstracts. One specific article appears related to our clinical question: Ahl et al found that among 253 multi-system trauma patients, 160 had a documented digital rectal examination, with abnormal findings in 48 percent. Subsequent management was not altered in any case due to rectal examination findings. The authors conclude that “DRE in trauma settings has low sensitivity and does not change subsequent management.”¹

A study by Porter et al found that among 423 trauma patients, in only five cases (1.2 percent), did the rectal examination influence therapeutic decision making. The authors conclude that there is a higher probability of findings influencing management among patients with penetrating injuries in proximity to the lower GI tract, possible spinal cord damage, or severe pelvic fractures.²