The American Journal of Gastroenterology 107, 1157-1163 (August 2012) |

doi:10.1038/ajg.2012.23

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o Reuben K Wong

o Douglas A Drossman

o Adil E Bharucha

o Satish S Rao

o Arnold Wald

o Carolyn B Morris

o more authors of this article

The Digital Rectal Examination: A Multicenter Survey of

Physicians' and Students' Perceptions and Practice Patterns
Reuben K Wong, Douglas A Drossman, Adil E Bharucha, Satish S Rao, Arnold Wald, Carolyn B
Morris, Amy S Oxentenko, Karthik Ravi, Daniel M Van Handel, Hollie Edwards, Yuming Hu
and Shrikant Bangdiwala

Abstract

Objectives:

The digital rectal examination (DRE) may be underutilized. We assessed the frequency of DREs
among a variety of providers and explored factors affecting its performance and utilization.
Methods:

A total of 652 faculty, fellows, medical residents, and final-year medical students completed a
questionnaire about their use of DREs.

Results:

On average, 41 DREs per year were performed. The yearly number of examinations was
associated with years of experience and specialty type. Patient refusal rates were lowest among
gastroenterology (GI) faculty and highest among primary-care doctors. Refusal rates were
negatively correlated with comfort level of the physician in performing a DRE. More
gastroenterologists used sophisticated methods to detect anorectal conditions, and
gastroenterologists were more confident in diagnosing them. Confidence in making a diagnosis
with a DRE was strongly associated with the number of DREs performed annually.

Conclusions:

The higher frequencies of performing a DRE, lower refusal rate, degree of comfort, diagnostic
confidence, and training adequacy were directly related to level of experience with the
examination. Training in DRE technique has diminished and may be lost. The DRE's role in
medical school and advanced training curricula needs to be re-established.

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Abstract

Background

The digital rectal examination (DRE) has been reflexively performed to evaluate common chief
complaints in the Emergency Department without knowing its true utility in diagnosis.

Objective

Medical literature databases were searched for the most relevant articles pertaining to: the utility
of the DRE in evaluating abdominal pain and acute appendicitis, the false-positive rate of fecal
occult blood tests (FOBT) from stool obtained by DRE or spontaneous passage, and the
correlation between DRE and anal manometry in determining anal tone.

Discussion

Sixteen articles met our inclusion criteria; there were two for abdominal pain, five for
appendicitis, six for anal tone, and three for fecal occult blood. The DRE was shown to add no
additional diagnostic information and confounded the diagnosis in acute, undifferentiated
abdominal pain. The sensitivity, specificity, positive predictive value, negative predictive value,
and odds ratio for the DRE were too low to reliably diagnose acute appendicitis in children and
adults. No statistical differences in the number of colonic pathologies were found between stool
collection methods in those with positive FOBT. The DRE correlation with anal manometry in
determining resting and squeeze anal tone ranged from 0.405 to 0.82 and 0.52 to 0.97,
respectively.

Conclusion

We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal
pain and acute appendicitis. Stool obtained by DRE doesn't seem to increase the false-positive
rate of FOBTs, and the DRE correlated moderately well with anal manometric measurements in
determining anal sphincter tone.