It has been taught for many years that a rectal examination should be done to assess a high-riding prostate as possible evidence of urethral injury. However, a 2009 study by Ball et al demonstrated that the rectal examination has a sensitivity of only two percent for detecting urethral injury. The authors conclude that the rectal examination “appears to be insensitive for detecting blunt urethral injuries.”3
Explore This Issue
ACEP Now: Vol 41 – No 11 – November 2022Following an abstract, PubMed provides a section of “related articles.” Using this function, you may also find several published articles that question the clinical utility of the rectal examination. A study by Schlamovitz et al in 2007 studied 213 pediatric trauma patients and concluded that the digital rectal examination, “has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. Our findings suggest that the DRE should not be routinely used in pediatric trauma patients.”4
Another study of 1,401 ED trauma patients found that, “the digital rectal examination has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries.”5
A 2006 study by Guldner et al included 1,032 adult patients with blunt trauma who had a DRE. The sensitivity, specificity, positive predictive value, and negative predictive value were 50, 93, 27, and 97 percent, respectively. The authors conclude, “The DRE is insensitive to spinal cord injury and has a poor positive predictive value.”6
Conclusions
The literature includes several important studies that demonstrate the low sensitivity of the DRE in the setting of trauma. In this case, the trauma of the digital rectal examination was exacerbated by the lack of communication about the reasons, expectations, and description of the examination. This may have contributed to the patient’s distrust of the medical team and reluctance to consent to a chest tube.
In summary, a digital rectal examination has limited clinical value in the setting of trauma without specific rectal trauma. If clinically indicated, clear communication with the patient about its importance and expectations will enhance trust in the physician-patient relationship.
Dr. Marco is professor of emergency medicine at Penn State Health-Milton S. Hershey Medical Center and associate editor of ACEP Now.
References
- Ahl R, Riddez L, Mohseni S. Digital rectal examination for initial assessment of the multi-injured patient: Can we depend on it? Ann Med Surg (Lond). 2016;9:77-81. doi: 10.1016/j.amsu.2016.07.006.
- Porter JM, Ursic CM. Digital rectal examination for trauma: does every patient need one? Am Surg. 2001;67(5):438-41. PMID: 11379644.
- Ball CG, Jafri SM, Kirkpatrick AW, et al. Traumatic urethral injuries: does the digital rectal examination really help us? Injury. 2009;40(9):984-6.
- Shlamovitz GZ, Mower WR, Bergman J. Lack of evidence to support routine digital rectal examination in pediatric trauma patients. Pediatr Emerg Care. 2007;23(8):537-43.
- Shlamovitz GZ, Mower WR, Bergman J, et al. Poor test characteristics for the digital rectal examination in trauma patients. Ann Emerg Med. 2007;50(1):25-33,33.e1.
- Guldner GT, Brzenski AB. The sensitivity and specificity of the digital rectal examination for detecting spinal cord injury in adult patients with blunt trauma. Am J Emerg Med. 2006;24(1):113-7.
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