Tag Archives: rectal exam

Technique

Update: The Rectal Exam In Trauma Continues to “Pass”?

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This topic continues to come up from time to time. I still see trauma programs that perform the good, old-fashioned digital rectal exam on nearly every trauma patient. But is it really necessary?

In the not so distant past, it was standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief had always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from this exam.

Unfortunately, a finger in the bum also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal exam that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

And what is the best patient position for the exam? I continue to see people try to do it when the patient is in the logroll position! This is substandard for two reasons:

  • It is not a stable position, and no one likes a finger in their butt. Awake patients will squirm and withdraw, defeating any attempt at spinal precautions.
  • It’s not ideal for the examiner, either.  Access to the male prostate is subpar because the examiner’s finger is generally pointed posteriorly, away from this organ. In order to rotate anteriorly, the examiner must spin around, putting “reverse English” (billiards reference) on their arm.

To do a proper rectal exam when indicated, make sure the patient is supine, warn them that you are going to do it, and use the same hand as the side of the patient you are standing on. Right side, right hand to avoid the “reverse English” thing again.

Bottom line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent and effective exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position. 

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.

General

The Rectal Exam In Trauma Continues to “Pass”?

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This topic continues to come up from time to time. I still see trauma programs that perform the good, old-fashioned digital rectal exam on nearly every trauma patient. But is it really necessary?

In the not so distant past, it was standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief had always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from this exam.

Unfortunately, a finger in the bum also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal exam that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

Bottom line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position. No patient likes a rectal exam, so they’ll do their best to defeat your puny attempt at spine precautions if you have them on their side. Supine, frog-leg only.

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.

Philosophy

Don’t Ignore The Naughty Bits

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A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position.

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

General

The “Passing” Of The Rectal Exam In Trauma

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It has long been standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief has always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from the exam.

Unfortunately, the exam also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

The Bottom Line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position. No patient likes a rectal exam, so they’ll do their best to defeat your attempt at spine precautions if you have them on their side. Supine, frog-leg only.

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.

General

Don’t Ignore The Naughty Bits

Leave a comment

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

image

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis – Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum – Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina – external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum – Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus – Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft – Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position. 

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

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