Spare your next patient the discomfort of the DRE unless there is obvious indication.
For those of us who have taken Advanced Trauma Life Support (ATLS), performing the digital rectal exam (DRE) has been ingrained as an essential part of the examination. However, two recent studies by Shlamovitz and his colleagues from UCLA Medical Center refute this assumption, suggesting that physicians can spare their patients the discomfort of the DRE unless there is obvious indication.
The first study, published in the August 2007 issue of Annals of Emergency Medicine, was a retrospective chart review looking at 1,401 patients seen in the ED of a level one trauma center with trauma team activation between January 2003 and February 2005. 72% of the study enrollees were male, and the age range for these patients was from 1 month to 94 years with a mean age of 36.2 years. 91% of these were from blunt trauma. All of these patients had a DRE as part of their secondary survey. Patients were excluded if they were transferred from another facility, were not seen by the trauma team, refused the DRE, did not have a DRE, those with direct anal trauma, those that died in ED before any studies were performed, those pharmacologically paralyzed before a DRE could be performed, and those with pre-existing spinal cord injuries.
The overall sensitivity of the DRE for detecting any injury was 22.9% with a 94.7% specificity. 63% of spinal cord injuries were missed by the DRE, along with 94% of bowel injuries, 100% of pelvic fracture, 80% of urethral injuries, and 67% of rectal wall injuries.
A subset of this data was analyzed for pediatric patients and published in the August 2007 issue of Pediatric Emergency Care. 213 patients from the same study population and time period were included in this analysis. Patients were included if they were less than 18 years old and excluded with the same criteria already mentioned. 69% were male with a mean age of 12.6 years and 91% were involved in blunt trauma.
While no overall sensitivity and specificity were provided in this second study, the DRE failed to detect 66% of spinal cord injuries, 100% of pelvic fractures, 100% of urethral injuries, 100% of rectal wall injuries, and 100% of bowel injuries.
Given the retrospective nature of both of these studies, there are many inherent limitations in the methodology. However, these studies add to growing body of evidence that the DRE has a limited, if any, role in the evaluation of the general trauma patient. The specificities of the exam were overall high, meaning that an abnormal exam is a good indication of pathology, but its utility as the screening exam ATLS intended it to be is not supported. The question remains: what threshold needs to be surpassed in the literature to prompt removal of the recommendation of this procedure from the ATLS guidelines? Only time will tell, but until then, the enlightened emergency physician should spare the discomfort of the DRE for their patients unless there is obvious indication.