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

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

Following 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

1. 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.
2. Porter JM, Ursic CM. Digital rectal examination for trauma: does every patient need one? Am Surg. 2001;67(5):438-41. PMID: 11379644.
3. 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.
4. 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.
5. 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.
6. 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.