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Digital rectal exam: side view of the male reproductive and urinary anatomy, including the prostate, rectum and bladder
rectal examination, commonly called a prostate exam, is an internal examination of the rectum, performed by a healthcare provider.
- 1 Usage
- 2 Usage as a screening tool
- 3 Procedure
- 4 Society and culture
- 5 Veterinary medicine
- 6 See also
- 7 References
- 8 External links
This examination may be used:
- for the diagnosis of rectal tumors and other forms of cancer;
- for the diagnosis of prostatic disorders, notably tumors and benign prostatic hyperplasia. Its utility as a screening method for prostate cancer however is not supported by the evidence.
- for the diagnosis of appendicitis or other examples of an acute abdomen (i.e. acute abdominal symptoms indicating a serious underlying disease). Although a Journal of Emergency Medicine paper concludes: "We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis."
- for the estimation of the muscle tone of the anal sphincter, which may be useful in case of fecal incontinence or neurologic diseases, including traumatic spinal cord injuries;
- in females, for gynecological palpations of internal organs;
- for examination of the hardness and color of the feces (i.e. in cases of constipation, and fecal impaction);
- prior to a colonoscopy or proctoscopy;
- to evaluate hemorrhoids although internal hemorrhoids are often too soft to be felt, a visual inspection may be more useful;
- in newborns to exclude imperforate anus.
- through the insertion of medical devices including thermometers or specialized balloons; to identify digestion problems, parasites, organ damage, anal bruising, and foreign objects in the rectal cavity
- the DRE (digital rectal examination) is frequently combined with an FOBT (fecal occult blood test), which may be useful for diagnosing the cause of anemia or confirming a gastrointestinal bleed in an emergency care setting. The American Journal of Medicine published a paper in which a Dallas Hospital eliminated the FOBT in their emergency room for anemia and overt gastrointestinal bleeding. It concluded: "It has been more than 17 years since studies confirmed the futility of in hospital fecal occult blood tests and initiated its long demise. We have waited long enough. It is time to write the obituary for in-hospital fecal occult blood tests."
Usage as a screening tool
In colorectal cancer screening of asymptomatic adults aged 50 to 75
- Even though 1 in 4 colorectal cancers (CRC) is located in the rectum, little evidence supports the effectiveness of using the DRE for rectal cancer detection and it is not recommended in the colorectal cancer screening guidelines. The DRE is inadequate as a screening tool for colorectal cancer because it examines less than 10% of the colorectal mucosa; sigmoidoscopy is preferred.
- Although the DRE is commonly used as a way to obtain a stool sample for a FOBT (fecal occult blood test) in an office based setting, this is an insufficient way of screening for colorectal cancer and is not recommended. A single office-based FOBT (fecal occult blood test) performed following a digital rectal examination (DRE) is not an adequate screen due to low sensitivity for advanced tumor and colorectal cancer. A paper published in the Journal of Internal Medicine states, "While FOBT done appropriately (taken home and used according to the instructions) is an important screening option, in-office FOBT may be worse than no screening at all because it misses 95% of cases of advanced tumor, giving many patients a false sense of reassurance."
In prostate cancer screening of asymptomatic men aged 55 to 69
- In men aged 55-69 who have been counseled on the known harms and potential benefits of prostate cancer screening, the U.S. Preventive Service Task Force (USPSTF) May 2018 statement states, "The use of digital rectal examination as a screening modality is not recommended because there is a lack of evidence on the benefits." The American Academy of Family Physicians (AAFP) states, "Digital Rectal Exam does not improve detection of prostate cancer and should not be performed as a part of screening." The American Urology Association (AUA) 2013 (reviewed and validity confirmed 2018) guideline panel states, "The literature supporting the efficacy of digital rectal exam (DRE) for screening with the goal of reducing prostate cancer mortality provide limited evidence to draw conclusions." "The guideline panel could find no evidence to support the continued use of DRE as a first-line method of 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.
- A meta-analysis published in the Annals of Family Medicine concluded: "Given the considerable lack of evidence supporting its efficacy, we recommend against routine performance of DRE to screen for prostate cancer in the primary care setting."
Using the digital rectal exam as a screening tool
The old adage, "If you don't put your finger in it, you might put your foot in it" rings true even though the research evidence and guidelines by every major organization of US medicine do not support it. On the June 18, 2018 Pri-med podcast, "Frankly Speaking" Episode 73 entitled, "Put That Finger Down! The End of the Screening Rectal Exam." they state,
"One of the big challenges people have about not doing rectal exams, is the worry about liability. And so I say, "Document that you've had this discussion offering the pros, and cons, and alternatives to screening, and making sure that the patient is aware." Will that protect you from being named in a lawsuit down the road? Probably not. Will it protect you from being found negligent or guilty of malpractice? Absolutely."
The digital rectal examination (DRE; Latin: palpatio per anum, PPA) is a relatively simple medical procedure. The patient undresses and is then placed in a position where the anus is accessible (lying on the side, squatting on the examination table, bent over it, or lying down with feet in stirrups). If the patient is lying on his/her side, the physician will usually have him/her bring one or both legs up to his/her chest. If the patient bends over the examination table or the back of a chair, the physician will have him place his elbows on the table and squat down slightly; generally a man having his prostate examined can expect it to be examined in the bending position, as it is easier to conduct the examination with a man standing. If the patient uses the supine position, the physician will ask the patient to slide down to the end of the examination table until their buttocks are positioned just beyond the end. The patient then places his/her feet in the stirrups. The physician spreads the buttocks apart and will usually examine the external area (anus and perineum) for any abnormalities such as hemorrhoids, lumps, or rashes. Then, as the patient relaxes, the physician slips a lubricated finger into the rectum through the anus and palpates the insides for a short time.
Society and culture
Due to the taboos surrounding the anus and the potential for discomfort and embarrassment, the rectal exam is a common comedic device, including in episodes of Saturday Night Live, Impractical Jokers, Futurama, Family Guy, South Park and the movie Fletch, with M. Emmet Walsh as the general practitioner and Chevy Chase as the patient being examined. Similar activities to the rectal exam are attributed to extraterrestrials in video games such as Saints Row IV, Gaia Online and Destroy All Humans!. The practice of rectal exams without prior consent by medical students has been an area of concern. A number of medical students in Australia and the United Kingdom were instructed by consultant physicians to perform a rectal exam on patient without acquiring informed consent.
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In veterinary medicine rectal examination is useful in dogs for analysis of the prostate (as in men), pelvic urethra, sublumbar lymph nodes, and anal glands. In horses it is a vital component of the clinical examination for colic, to determine the presence or absence of bowel torsion, impaction, or displacement. When horses undergo a rectal examination there is a small risk of a rectal tear occurring, which can be a life-threatening event, rapidly leading to peritonitis and septic shock. It is also a common procedure in cattle, and is one method of diagnosing pregnancy in both the horse and the cow.
The procedure in dogs and cats is similar to humans. For the horse, the patient stands in a stock and may be sedated. The examiner puts on a long glove that extends to the shoulder. The examiner inserts the hand and arm into the rectum as far as necessary.
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