UROGENITAL TRAUMA

Reasons to Omit Digital Rectal Exam in Trauma Patients: No Fingers, No Rectum, No Useful Additional Information
Esposito TJ, Ingraham A, Luchette FA, Sears BW, Santaniello JM, Davis KA, Poulakidas SJ, Gamelli RL
Division of Trauma, Critical Care and Burns, Department of Surgery, The Burn and Shock Trauma Institute, Loyola University Medical Center, Maywood, Illinois, USA
J Trauma. 2005; 59: 1314-9

• Background: Performance of digital rectal examination (DRE) on all trauma patients during the secondary survey has been advocated by the Advanced Trauma Life Support course. However, there is no clear evidence of its efficacy as a diagnostic test for traumatic injury. The purpose of this study is to analyze the value of a policy mandating DRE on all trauma patients as part of the initial evaluation process and to discern whether it can routinely be omitted.
• Methods: Prospective study of patients treated at a Level I trauma center. Clinical indicators other than DRE (OCI) denoting gastrointestinal bleeding (GIB), urethral disruption (UD), or spinal cord injury (SCI) were sought and correlated with DRE findings suggesting the same. Impression of the examining physician as to the need and value of DRE was also studied. Patients with a Glasgow Coma Scale Score (GCS) of 3 and pharmacologically paralyzed were excluded from the SCI analyses. UD analysis included only males.
• Results: In all, 512 cases were studied (72% male, 28% female) ranging in age from 2 months to 102 years. Thirty index injuries were identified in 29 patients (6%), 17 SCI (3%), 11 GIB (2%), and 2 UD (0.4%). DRE findings agreed positively or negatively with one or more OCI of index injuries in 93% of all cases (92% seeking SCI, 90% seeking GIB, 96% seeking UD). Overall, negative predictive value of DRE was the same as that of OCI, 99% (SCI 98% versus 99%, GIB, 97% versus 99%, UD both 100%). Positive predictive value for DRE was 27% and for OCI 24% (SCI 47% versus 44%, GIB 15% versus 18%, UD 33% versus 6%). Efficiency of DRE was 94% and OCI was 93%. For confirmed index injuries, indicative DRE findings were associated with 41% and OCI 73% (SCI 36% versus 79%, GIB 36% versus 73%, UD 50% versus 100%). OCIs were present in 81% of index injury cases. In all index injury cases where OCIs were absent, positive DRE findings were also absent. DRE was felt to give additional information in 5% of all cases and change management in 4%. In cases where the clinician felt DRE was definitely indicated (29%) it reportedly gave no additional information in 85% and changed management in 11%.
• Conclusion: DRE is equivalent to OCI for confirming or excluding the presence of index injuries. When index injuries are demonstrated, OCI is more likely to be associated with their presence. DRE rarely provides additional accurate or useful information that changes management. Omission of DRE in virtually all trauma patients appears permissible, safe, and advantageous. Elimination of routine DRE from the secondary survey will presumably conserve time and resources, minimize unpleasant encounters, and protect patients and staff from the potential for further harm without any significant negative impact on care and outcome.
  
  
• Editorial Comment
  The old teaching mantra in trauma management is that the only trauma patient who should not get a digital rectal exam (DRE) is either the patient who has no rectum or the doctor who has no fingers. This interesting paper by Esposito et al questions the overall value (yield) of the trauma DRE. Traditionally, the trauma DRE assesses for signs that suggest either rectal injury, urethral disruption injury or spinal cord injury. Rectal injury is suggested on DRE by occult blood (hemoccult test positive) in the rectal vault or loss of rectal wall integrity. Urethral disruption injury is suggested by a “high riding prostate”. Spinal cord injury is suggested by loss of or decreased rectal sphincter tone, and thus disruption of the S4-S5 spinal arc. The authors contend that related clinical findings and signs, such as blood at the urethral meatus, scrotal hematoma, perineal hematoma, and type of pelvic fracture are more reliable as positive predictors of injury then the DRE. In this study, DRE was found to add information in only 5% of cases and changed management in only 4%; and this was only significant for rectal tone (SCI) and rectal bleeding (rectal injury) and not for urethral injury. I have always felt that a labeled “high riding prostate” was a misnomer. Usually the trauma DRE is performed by the most inexperienced examiner and to them, all prostates feel high riding. The issue of poor inter-rater reliability to prostate DRE has been addressed by Smith & Catalona (1). With pelvic fracture and urethral disruption the pelvis fills with blood, the planes are obliterated and the prostate can be difficult to palpate. Thus a non-palpable prostate would seem to be more predictive of possible urethral injury (2). A well designed multi-institution study would put this issue at rest.

References
1. Smith D, Catalona W: Inter examiner variability of digital rectal examination in detecting prostate cancer. Urology 1995; 45: 70-74.
2. Brandes SB, Yu M: Urologic Trauma. In Hanno PM, Wein AJ (eds), Clinical Manual of Urology. 3rd ed., New York, McGraw Hill. 2001.

Dr. Steven B. Brandes
Associate Professor, Division of Urologic Surgery
Washington University in St. Louis
St. Louis, Missouri, USA