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?

26 comments:

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.

Harold said...

Ten years ago my PSA went from 2.8 to 4.1 and I was referred by my very competent PCP (translation: family doctor) to a very competent urologist. On DRE he felt a nodule and ordered a prostate biopsy. The biopsy result was a Gleason score of 6 (translation: cancerous but treatable). Accordingly I underwent a radical prostatectomy. As a result of those events I am alive today, and in good health. Absent those events I would very possibly not be alive. I would very probably not be in good health. As for the urologist, Satish was dismissive, indeed scornful, of those who recommend against routine PSA testing. Alas he is no longer among us. A generation of urology patients and residents don't what they are missing.

Skeptical Scalpel said...

Harold, I'm glad you are OK. There are countless stories like yours. They are what are called anecdotes.

It is just as possible that you had the type of prostatic cancer that grows very slowly and would never have troubled you.

Regarding the DRE, your PSA spiked. You would have been referred to a urologist anyway. Other than causing you discomfort, I don't see what the PCP's DRE accomplished.

Kimberlyd said...

The chest x-ray in the background is backwards....

Skeptical Scalpel said...

Kimberlyd, good pickup. That mistake is pretty common in movies and on TV.

Harold said...

The DRE was done by my excellent urologist. His positive finding led to a prostate biopsy, in turn to a radical prostatectomy. I feel he saved my life. After five years of negative PSAs, the cancer returned with a vengeance: the PSA was doubling every six months. My oncologist did a series of radiation treatments, followed by five more cancer-free years (Thanks, Doc).

I'll be clear: Men, if you're over a certain age, your PCP should do regular PSAs. If the PSA is elevated, you should be seeing a urologist who will do routine PSAs and DREs. If anyone questions the value of these procedures, my reply is "What is your life worth?" If I didn't have an appropriately aggressive PCP and urologist, I probably wouldn't be alive to write this comment, and certainly would not be enjoying robust health. DREs aren't fun, but when you've had as many as I have, it's just routine. Preventive medicine is like putting out the garbage. It's not fun, but if you don't the consequence is disaster. Avoiding or delaying PSA and DRE procedures is courting disaster.
I make no comment about routine DREs, that is for your PCP to decide. But there is a voice speaking out against against routine PSAs for men above a certain age. I loudly defend them. Routine PSA was a life saver for me.
I would further note that if you want to enjoy a robust old age you should undergo colonoscopy, but thank you Skeptical Scalpel. You've generously allowed me to express myself so I won't push your hospitality.

Anonymous said...

Routine rectal exam is intrusive, uncomfortable, and for me at least - distressing, due to assaults with objects in early teen years. I have avoided them all my life when conscious. I requested one when "out" for laser kidney stone treatment, which was done - "enlarged but normal for age" 4 years ago. PSA 3.8. I finally agreed to one from a female GP PSA 3.9 this year - just as bad as I thought - "seems smooth, but I can't tell any more than that". So what was the point?

My wife has a bowel problem - no piles, no fissures, no fresh blood, no dark stools, no fecal blood detected, no ribbon stools, appendix. caecum and ileal valve removed 5 years ago - no cancer. Periodic bloating and constipation are issues, senitivity to certain foods. She had a total hysterectomy 20 years ago. Our GP wants a referral. 1st on his agenda is a rectal exam, then proctoscope, then sigmoidoscope, then colonoscope, then other investigations. She has refused this torture by 100 probes. She wants an abdominal scan and discussion of SIBO and irritable bowel.

Skeptical Scalpel said...

Well, a smooth prostate means no nodules which is good. But of course, it’s your PSA that’s important, not your rectal exam. While we’re on the subject is screening, what is the role of PSA? Lots of controversy.

Your wife is probably correct.

Harold said...

"Well, a smooth prostate means no nodules which is good."

Sounds like you just affirmed the value of Anonymous' DRE.

"but I can't tell any more than that".

His GP sounds like she agrees with my PCP: A DRE would be more definitive if performed by a skilled urologist.

Skeptical Scalpel said...

Please read the rest of my response. A palpable nodule would be concerning. The absence of a nodule means nothing. If you believed in screening, either way you would still need a PSA.

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