Wednesday, April 4, 2018

The decline and fall of the rectal exam

For almost 20 years, the value of the digital rectal exam (DRE), a long time staple of the complete examination of the trauma patient, has been questioned. Performing a rectal examination on all trauma patients is no longer advocated except for a few specific indications.

As recently as two months ago, trauma surgeon Michael McGonigal blogging at The Trauma Pro reinforced the message. Because a rectal examination is so uncomfortable for patients already traumatized and its yield is so minimal, he advocates doing it in only patients with spinal cord injury, pelvic fracture, and penetrating abdominal trauma. For a more extensive discussion of the topic, see Life in the Fastlane, an emergency medicine blog.

A systematic review and meta-analysis of the role of DRE in prostate cancer screening done by primary care physicians was just published in Annals of Family Medicine. Seven studies including 9241 patients who had both DRE and biopsy comprised the study. The authors found the sensitivity of DRE was only 0.51 and the specificity was 0.59. The positive predictive value was 0.41 and the negative predictive value was 0.64. In other words, it was similar to flipping a coin.

The quality of the included papers was low and the heterogeneity between the studies was high. In reviewing other relevant literature, the authors found that about half of graduating students from Canadian medical schools had never performed a digital rectal examination. A previous survey of Canadian primary care physicians revealed that only half of them felt confident in their ability to feel prostatic nodules on DRE. Another study found when two urologists examined the same patient, “the interexaminer agreement among urologists was only fair.”

The paper’s conclusion was “Given the findings of our analysis and appraisal of available studies, we do not recommend routine screening for prostate cancer using DRE in primary care.”

In a 2011 BMJ editorial, Des Spence, a general practitioner in Glasgow, wrote “Rectal examination is unpleasant, invasive, and as an investigation has unknown sensitivity and specificity.” In young patients with rectal symptoms, cancer is unlikely, and in symptomatic older patients, a negative DRE would not preclude further workup. Spence raised similar concerns about the role of DRE in screening for prostate cancer or in patients with lower urinary tract symptoms.

UpToDate does not recommend DRE for prostate or colorectal cancer screening because there are no studies showing performance of DRE reduces mortality rates for either tumor.

What do you think? Is the digital rectal examination no longer valid in the digital age?


gretchen kromer's blog said...

My doctor told me more than ten years ago that the American College of Gastroenterology said DREs were of no medical value.

Skeptical Scalpel said...

Changes in medicine take at least a generation.

Anonymous said...

"Is the digital rectal examination no longer valid in the digital age?"

Pun intended?

Skeptical Scalpel said...

Of course.

deniz said...

What about internal hemorrhoids?

Skeptical Scalpel said...

Other than possibly pain, I'm not sure what a DRE adds to the diagnosis of internal hemorrhoids. If you are going to stick something in there, make it something useful.

From the Mayo Clinic website: "Because internal hemorrhoids are often too soft to be felt during a rectal exam, your doctor may also examine the lower portion of your colon and rectum with an anoscope, proctoscope or sigmoidoscope."

Old FoolRN said...

After perusing your link to the article in The Annals of Family Medicine, I thought maybe they should change their name to "Anals of Family Medicine."

Anonymous said...

Anonymous Europe: Just finished my urology rotation. The guys there still perform DRE. Besides, we also do that in pediatric surgery if it is necessary. I personally think it is important to perform it in select cases. No machine can ever substitute us, phyisicans.

Skeptical Scalpel said...

Old, thanks for the smile.

Anon Europe, what are the indications for a DRE in pediatric surgery?

Unknown said...

Low sensitivity or not i cant see how it would be defensible to omit it as an examination in someone with symptoms suggestive of prostatic or rectal pathology, obstruction or trauma. In my view the old saying thaat if you dont put your finger in it you might put your foot in it will always be true

medaholic said...

Internist's view - In general, I don't do a DRE for any screening purposes. I don't see much value for prostate checking or for rectal cancers. However to say it's no longer valid would be an huge disservice.

There's still a role for them in specific cases - diagnosis of rectal cancers, confirmation of bleeding/melena, ruling out other etiologies. Often times you don't even have to do the digital exam, just looking at the rectum can help figure out a lot of things (fissues, hemorrhoids etc)

Skeptical Scalpel said...

I think maybe the title of my post is misleading. I take full responsibility for that.

I am not advocating eliminating a rectal exam for patients with specific symptoms. I was simply pointing out a few instances where a routine rectal exams have been determined by evidence to not be of value.

Another area I should have mentioned is omitting a DRE during a yearly physical exam, which BTW also has been found to not be useful.

Anonymous said...

Rectal exams are very uncomfortable for the practitioner, and any excuse to get rid of them is likely to get good press. Urologists do not fear the DRE, and it is useful for clinical staging. Now...lets bring up the PSA controversy!

William Reichert said...

The positive predicted value of the DRE was .41. That means that if a urologist examined you and felt you had a prostate that had the DRE findings of cancer, you would have a 41% chance of a positive biopsy . Would you want a biopsy or not?

Skeptical Scalpel said...

I'm not sure the DRE is that useful for clinical staging.

Men referred to urologists are already suspected of having prostate cancer. The exam is bound to find more tumors because those with out elevated PSAs are not likely to see a urologist.

Here is the direct quote from the UpToDate chapter on prostate cancer screening:

"We suggest not performing digital rectal examination (DRE) for prostate cancer screening either alone or in combination with prostate-specific antigen (PSA) screening. Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age.

There are inherent limitations to the DRE. It can detect palpable abnormalities (eg, nodules, asymmetry, or induration) in the posterior and lateral aspects of the prostate gland where the majority of cancers arise; however, other areas of the prostate where cancer occurs are not reachable by a finger examination. Furthermore, the majority of cancers detected by DRE alone are clinically or pathologically advanced, and stage T1 prostate cancers are nonpalpable by definition."

Anonymous said...

Anonymous Europe: Indications for Dre at least at our institution are: rectal bleeding, suspected Hirschprung,who gets presented at our outpatient unit for the first time, any kind of rectoanal pathology, constipation. Some old pediatric surgeons still use it to feel Douglas abscesses or pelvic masses... not me.:)

Skeptical Scalpel said...

If it's bright red blood, taking a look with an anoscope or sigmoidoscope will be necessary anyway and will be more revealing. If it's melena, it's not coming from the rectum.

Also, a digital rectal exam has no value in a patient who has an anal fissure you can see by spreading the the buttocks. And A DRE is extremely painful.

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