Digital rectal examination for trauma: Does every patient need one?

The digital rectal examination is widely accepted as an essential component in the initial assessment of trauma. However, no data have been published that justify its routine use in all seriously injured patients. The objecti ve of this study was to determine what if any impact on subsequent treatmen t and management decisions the initial digital rectal examination had on in jured patients arriving at our emergency department (ED). We conducted a pr ospective observational study of all injured patients arriving at a Level I I trauma center over a period of 6 months. A digital rectal examination was performed on all patients during the secondary survey phase of their initi al evaluation shortly after arrival to the ED. The results of the rectal ex amination were noted for each patient with particular attention placed on t he presence or absence of gross blood, Hemoccult result, prostatic examinat ion, rectal vault integrity, and rectal sphincter tone. In addition the pat ients hemodynamic parameters while in the ED and the injuries that were sus tained were noted, as was their final disposition. Four hundred twenty-thre e patients were admitted to the ED after sustaining serious injuries. The m ean Injury Severity Score was 9.96. The prostatic examination was normal in more than 99 per cent of patients; no high-riding or nonpalpable prostate glands were noted. Twenty-two patients (5.2%) were Hemoccult positive, but in none of these cases did the presence of occult blood in the stool lead t o a change in the initial management or diagnostic approach. Three patients (0.7%) with penetrating injuries to the perineal/pelvic area had gross blo od on digital rectal examination that prompted operative exploration to rul e out a lower gastrointestinal injury. All three had rectal injuries confir med at surgery. Rectal sphincter tone was normal in 406 (96%) patients, wea k in 17 (4%), and absent in none. The only patient in whom the sphincter to ne influenced management was an individual complaining of complete paralysi s after a blunt mechanism of injury. He had normal rectal sphincter tone an d admitted to malingering shortly thereafter. Overall the rectal examinatio n influenced therapeutic decision making in five cases (1.2%). The digital rectal examination is unlikely to affect initial management when applied in discriminately to all seriously injured patients during the secondary surve y. Patients in whom the rectal examination may have a higher probability of influencing management are those with penetrating injuries in proximity to the lower gasstrintestinal tract, questionable spinal cord damage, and sev ere pelvic fractures with potential urethral disruption or open fractures i n continuity with the rectal vault. The Hemoccult test does not add useful information and should be discontinued as part of the secondary survey of i njured patients.