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Utility of the Digital Rectal Examination in the Emergency Department: a Review

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Utility of the Digital Rectal Examination in the Emergency Department: a Review The Journal of Emergency Medicine, Vol. 43, No. 6, pp. 1196–1204, 2012 Published by Elsevier Inc. Printed in the USA 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2012.06.015 Clinical Reviews UTILITY OF THE DIGITAL RECTAL EXAMINATION IN THE EMERGENCY DEPARTMENT: A REVIEW Chad Kessler, MD, MHPE*† and Stephen J. Bauer, MD† *Department of Emergency Medicine, Jesse Brown VA Medical Center and †University of Illinois-Chicago College of Medicine, Chicago, Illinois Reprint Address: Chad Kessler, MD, MHPE, Department of Emergency Medicine, Jesse Brown Veterans Hospital, 820 S Damen Ave., M/C 111, Chicago, IL 60612 , Abstract—Background: The digital rectal examination abdominal pain and acute appendicitis. Stool obtained by (DRE) has been reflexively performed to evaluate common DRE doesn’t seem to increase the false-positive rate of chief complaints in the Emergency Department without FOBTs, and the DRE correlated moderately well with anal knowing its true utility in diagnosis. Objective: Medical lit- manometric measurements in determining anal sphincter erature databases were searched for the most relevant arti- tone. Published by Elsevier Inc. cles pertaining to: the utility of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive , Keywords—digital rectal; utility; review; Emergency rate of fecal occult blood tests (FOBT) from stool obtained Department; evidence-based medicine by DRE or spontaneous passage, and the correlation be- tween DRE and anal manometry in determining anal tone. Discussion: Sixteen articles met our inclusion criteria; there INTRODUCTION were two for abdominal pain, five for appendicitis, six for anal tone, and three for fecal occult blood. The DRE was The digital rectal examination (DRE) has a longstanding shown to add no additional diagnostic information and con- history as a mainstay component in a complete physical founded the diagnosis in acute, undifferentiated abdominal examination (1–3). However, evidence is rarely cited to pain. The sensitivity, specificity, positive predictive value, support its use or to substantiate the validity of the negative predictive value, and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children findings. The purpose of this review article is to search and adults. No statistical differences in the number of and review the literature for the utility of the DRE colonic pathologies were found between stool collection in evaluating acute, undifferentiated abdominal pain, methods in those with positive FOBT. The DRE correlation suspected appendicitis, fecal occult blood, and anal with anal manometry in determining resting and squeeze sphincter tone. The use of the DRE in colorectal neo- anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97, plasm and benign prostatic hyperplasia screenings is be- respectively. Conclusion: We found the DRE to have yond the scope of this article and will not be included. a limited role in the diagnosis of acute, undifferentiated Acute, undifferentiated abdominal pain is a vague yet common chief complaint in the Emergency Department (ED). Some physicians routinely perform the DRE The work was previously presented at the 2011 Council of Emergency Medicine Residency Directors Scientific Assembly when evaluating abdominal pain even though the DRE in San Diego in February 2011. has been shown to be of little diagnostic value. Similarly, No grants or additional funding were associated with this the DRE has a history as a mainstay in diagnosing sus- article. pected appendicitis in children and adults with right RECEIVED: 2 August 2011; FINAL SUBMISSION RECEIVED: 2 February 2012; ACCEPTED: 28 June 2012 1196 Rectal Examination in the ED 1197 lower quadrant pain (4). However, its use for diagnosing Table 1. Search Terms suspected appendicitis has come into scrutiny. After per- Digital rectal examination NOT prostate NOT neoplasms forming a DRE, fecal occult blood testing (FOBT) by Digital rectal examination AND abdominal pain guaiac cards has become common practice throughout Digital rectal examination AND acute appendicitis Digital rectal examination AND appendicitis all medical services, such as in the ED to look for occult Digital rectal examination AND anal tone gastrointestinal (GI) bleeding (5). Testing for fecal occult Digital rectal examination AND anal manometry blood in DRE-obtained stool has been argued to be Digital rectal examination AND fecal occult blood Digital rectal examination AND hematochezia a ‘‘knee-jerk procedure’’ of little value (6). Longstreth Digital rectal examination AND bright red blood per rectum proposed that trauma to the anus or hemorrhoids during Digital rectal examination AND melena the DRE and the lack of dietary restrictions before stool Digital rectal examination AND gastrointestinal hemorrhage collection can cause potential false-positive results of FOBT, prompting needless, invasive investigations (6). In the emergent setting, assessing anal tone by DRE can agreement between the two authors for inclusion or ex- be performed during the trauma survey and during neuro- clusion of articles, we discussed the articles and more logic examination, yet it has largely been assumed that strictly applied the inclusion and exclusion criteria to the DRE provides good estimation of anal tone. reach an agreement. Methods RESULTS We identified four inclusion criteria to apply to the data- A total of 380 articles were found after searching all da- base searches. First, the study participants must have been tabases. Duplicate search results were not excluded in the adults, children, or both. Second, the participants must final counts of the articles found from the database have had symptoms of, or a chief complaint of abdominal searches. Some articles were found with more than one pain, acute appendicitis, anal sphincter tone, or fecal oc- search and on more than one database. After applying cult blood. Third, the participants had to have a digital the inclusion and exclusion criteria, 332 articles were ex- rectal examination performed with the outcome docu- cluded, leaving 48 articles. The bibliographies of the 48 mented. Fourth, the DRE had to be the major outcome included articles were searched, yielding an additional in the article and had to be compared to a true or final di- 65 articles. A total of 113 articles were included for full agnosis or compared to another reported outcome. Ran- text review with further application of inclusion criteria. domized controlled trials, meta-analyses, observational Ninety-seven articles were excluded for failing to meet studies, clinical guidelines, editorials, and letters to the inclusion criteria or for the DRE not being the major out- editor were considered for inclusion. Review articles, come of the study. Of the 16 articles left for inclusion, case reports, and abstracts were not considered for inclu- there were two for abdominal pain, five for appendicitis, sion. The exclusion criteria were any study using the DRE six for anal tone, and three for fecal occult blood. A flow to screen for benign prostatic hyperplasia or colorectal diagram of the search strategy can be found in Figure 1, neoplasia. and a summary of the included articles can be found in The following electronic databases were searched us- Table 2 (3,7–21). ing multiple phrases (Table 1) to ensure a comprehensive search of the literature: MEDLINE (PubMed; 1950 to Abdominal Pain present), EMBASE (1988 to present), Cochrane Library, and National Guidelines Clearinghouse. If a search term Two studies were found investigating physicians’ use of was not available in the Medical Subject Headings the DRE in medical management of acute, undifferenti- (MeSH) search function in PubMed, then PubMed was ated abdominal pain in the ED (7,8). The evaluating searched without using MeSH terms. Only the EMBASE physicians performed DREs at their discretion and database was searched; MEDLINE was not researched completed evaluation forms indicating whether the using the EMBASE search function. All of the searches DRE results altered their diagnosis (7,8). Quaas et al. from PubMed were searched in EMBASE, with no new found that the DRE results altered management of articles. The limits for the searches were: English and Hu- acute abdominal pain in only 7% of patients, in which man. No publication date restrictions were applied. The the alteration of management was as likely to bibliographic references of all the articles identified by diagnostically help (either indicate correct diagnosis or the database screening were examined to identify new ar- refute incorrect diagnosis) as it was to diagnostically ticles not identified in the searches. Although review arti- harm (either indicate incorrect diagnosis or refute cles and case reports were excluded, their bibliographies correct diagnosis) (7). Similarly, Manimaran and Galland were searched for applicable articles. If there was a dis- showed that the DRE did not change management of 1198 C. Kessler and S. J. Bauer Literature Search diagnostic information to the evaluation of RLQ pain (11). Databases: PubMed, EMBASE, Dickson et al. found a 90% diagnostic accuracy of acute The Cochrane Library, The National Guidelines Clearing House appendicitis based on history and physical examination Limits: Humans, English alone (12). Right-sided rectal tenderness or mass was present in 61 of 103 children with histologically proven appendicitis and in 12 of 98 children without appendicitis Search results combined (n = 380) (12). Similarly,
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