If you work in a trauma center you will see injured children. Most of the serious injuries to children are blunt. Diagnostic workup often includes labs and imaging – but begins with a focused physical assessment underpinned by ATLS. The digital rectal exam can help assess for rectal tone in spinal cord injuries and gross blood in bowel injuries and thus, in severely injured children (think GCS <8) is a no-brainer. For others however, it can be invasive and downright scary. I was wondering whether or not it was absolutely necessary to perform a rectal exam would add any diagnostic utility. Let’s take a look at two studies shall we?

Lack of evidence to support routine digital rectal examination in pediatric trauma patients

Shlamovitz GZ. Mower WR. Bergman J. Crisp J. DeVore HK. Hardy D. Sargent M. Shroff SD. Snyder E. Morgan MT.
Pediatric Emergency Care Aug 2007; 23(8): 537-43

Shlamovitz et al conducted an observational chart review study to identify DRE findings followed by radiologic and operative reports, and discharge summaries to identify specific injuries. They noted the following:

  • Detection of spinal cord injury by decreased anal sphincter tone 33% sensitive (95% CI 6-79%) and 99% specific (95% CI 96-100%)
  • Presence of gross blood to diagnose bowel injuries on exam was 0% sensitive (95% CI 0-23%)
    and 98% specific (95% CI 95-99%)
  • Palpation of disrupted rectal wall integrity was 0% sensitive (95% CI 0-65%) and 100% specific 95% (95% CI 95-100%)
  • Palpation of bony fragments on exam to diagnose pelvic fracture 0% sensitive (95% CI 0-65%) and 100% specific (95% CI 95-100%)
  • Diagnosis of urethral injury by presence of abnormal position (high-riding) of prostate was 0% sensitive (95% CI 0-79%) and 100% specific  (95% CI 94-100)

So, it would seem that this study would lead us to conclude that the DRE can help “rule-in” injuries. But, it also relied on chart review, which is prone to missing data, was conducted at a Level 1 Trauma Center (not the place where most kids go after being injured), there was no blinding to results, no mention of interrupter reliability (which would I suppose require two DREs) and rectal exam was either deferred or not even recorded in a third of patients. Furthermore, the ethical issues were not addressed.

The digital rectal examination in pediatric trauma: A pilot study

Kristinsson G. Wall SP. Crain EF.
Journal of Emergency Medicine Vol. 32, No. 1, pp. 59–62, 2007

Kristinsson et al. conducted a pilot study of children 1-17 years to evaluate the utility of DRE to identify injuries by comparing physical exam during the secondary survey with and without rectal exam. Note that the majority of patients in this study were NOT comatose/obtunded (the mean GCS was 15) and that there weren’t many DRE identifiable injuries to begin with. This, statistically speaking, has the effect of widening the confidence intervals quite a bit. Nevertheless, here is what the authors noted:

  • Physical exam with DRE for detecting injury 87.5% sensitive (95%CI 47.3-99.7%)
    and 78.7% specific (95%CI 70.6-85.5%)
  • Physical exam without DRE for detecting injury 87.5% sensitive (95% CI 47.3-99.7%)
    and 87.4% specific (95% CI 80.3-92.6%)

Overall, these numbers need to be interpreted in the face of low injury prevalence and relatively well patients.

Let’s start with the fact that DRE isn’t necessarily evidence based in trauma. Even with prep from child life or other support personnel the rectal exam is traumatic for the child who was just strapped to a backboard and is still confined to a cervical collar, often surrounded by multiple people they don’t know. Overall these studies indicate that DRE isn’t necessarily accurate in children and a “false positive” result could expose kids to unnecessary CTs. Furthermore, in the very injuries obtunded child would a “negative” DRE really stop you from enacting spinal precautions and obtained advanced imaging? Overall, DRE likely has very limited utility in injured children. It should really be reserved for children with the following features:

  • Penetrating trauma near the rectum
  • Children with an obvious pelvic fracture
  • When spinal cord injury and spinal shock cant be excluded based on the exam
  • Those sick enough to be intubated and sedated (GCS ≤8-9)

Otherwise, for most kids with blunt trauma there isn’t enough justification. Anecdotally, I see the exam initiated by surgery most often. Thus, I recommend first and foremost you have a discussion with local personnel and make yourself aware of institutional practices.