DIGITAL
RECTAL EXAMINATION FOR TRAUMA: DOES EVERY PATIENT NEED ONE?
Porter
JM, Ursic CM. Am Surg 2001 May;67(5):438-41.
BACKGROUND:
The digital rectal examination is widely accepted as an essential component in
the initial assessment of trauma. However, no data have been published that
justify its routine use in all seriously injured patients. The objective of
this study was to determine what if any impact on subsequent treatment and
management decisions the initial digital rectal examination had on injured
patients arriving at our emergency department (ED).
DESIGN:
We conducted a prospective observational study of all injured patients arriving
at a Level II trauma center over a period of 6 months. A digital rectal
examination was performed on all patients during the secondary survey phase of
their initial evaluation shortly after arrival to the ED. The results of the
rectal examination were noted for each patient with particular attention placed
on the presence or absence of gross blood, Hemoccult result, prostatic
examination, rectal vault integrity, and rectal sphincter tone. In addition the
patient's hemodynamic parameters while in the ED and the injuries that were
sustained were noted, as was their final disposition.
RESULTS:
Four hundred twenty-three patients were admitted to the ED after sustaining
serious injuries. The mean Injury Severity Score was 9.96. The prostatic
examination was normal in more than 99 per cent of patients; no high-riding or
nonpalpable prostate glands were noted. Twenty-two patients (5.2%) were
Hemoccult positive, but in none of these cases did the presence of occult blood
in the stool lead to a change in the initial management or diagnostic approach.
Three patients (0.7%) with penetrating injuries to the perineal/pelvic area had
gross blood on digital rectal examination that prompted operative exploration
to rule out a lower gastrointestinal injury. All three had rectal injuries
confirmed at surgery. Rectal sphincter tone was normal in 406 (96%) patients,
weak in 17 (4%), and absent in none. The only patient in whom the sphincter
tone influenced management was an individual complaining of complete paralysis
after a blunt mechanism of injury. He had normal rectal sphincter tone and
admitted to malingering shortly thereafter. Overall the rectal examination
influenced therapeutic decision making in five cases (1.2%).
CONCLUSION:
The digital rectal examination is unlikely to affect initial management when
applied indiscriminately to all seriously injured patients during the secondary
survey. Patients in whom the rectal examination may have a higher probability
of influencing management are those with penetrating injuries in proximity to
the lower gastrointestinal tract, questionable spinal cord damage, and severe
pelvic fractures with potential urethral disruption or open fractures in
continuity with the rectal vault. The Hemoccult test does not add useful
information and should be discontinued as part of the secondary survey of
injured patients.