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 objective of this study was to determine what if any impact on subsequent treatment and management decisions the initial digital rectal examination had on injured patients arriving at our emergency department (ED). We conducted a prospective observational study of all injured patients arriving at a Level II trauma center over a period of 6 months. A digital rectal examination was performed on all patients during the secondary survey phase of their initial evaluation shortly after arrival to the ED. The results of the rectal examination were noted for each patient with particular attention placed on the presence or absence of gross blood, Hemoccult result, prostatic examination, rectal vault integrity, and rectal sphincter tone. In addition the patient's hemodynamic parameters while in the ED and the injuries that were sustained were noted, as was their final disposition. Four hundred twenty-three patients were admitted to the ED after sustaining serious injuries. The mean 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 to a change in the initial management or diagnostic approach. Three patients (0.7%) with penetrating injuries to the perineal/pelvic area had gross blood on digital rectal examination that prompted operative exploration to rule out a lower gastrointestinal injury. All three had rectal injuries confirmed at surgery. Rectal sphincter tone was normal in 406 (96%) patients, weak in 17 (4%), and absent in none. The only patient in whom the sphincter tone influenced management was an individual complaining of complete paralysis after a blunt mechanism of injury. He had normal rectal sphincter tone and admitted to malingering shortly thereafter. Overall the rectal examination influenced therapeutic decision making in five cases (1.2%). The digital rectal examination is unlikely to affect initial management when applied indiscriminately to all seriously injured patients during the secondary survey. Patients in whom the rectal examination may have a higher probability of influencing management are those with penetrating injuries in proximity to the lower gastrointestinal tract, questionable spinal cord damage, and severe pelvic fractures with potential urethral disruption or open fractures in continuity with the rectal vault. The Hemoccult test does not add useful information and should be discontinued as part of the secondary survey of injured patients.