Health Column: Beware of digital rectal exams
MOHLER’S MEDICATION MAXIMS
Free Press Health Columnist
I remember being taught the importance of the rectal exam in medical school, “One out of every four colon cancers is within the reach of your finger … The DRE is part of every complete physical exam.” I don’t remember my first time, but I apologize to those early patients who endured my awkward, “this is taking forever, doc“ rectal exams.
In the last 40 years, my fingers must have shrunk and I have been the butt of lots of jokes while administering this procedure.
“Doc, find Amelia Earhart yet?”
“Can you hear me now?”
“Hey doc, let me know if you find my dignity.”
Recent studies demonstrate increasing evidence that DRE, once proof that you were a very thorough physician, has evolved into an unnecessary, often painful, embarrassing, dreaded adventure.
As previously discussed in this column, there is no evidence that general physical “annual” exams pay any dividends in terms of better health outcomes or happier, more contented patients. If however, you and your doc are slaves to tradition (it takes physicians about seven years to incorporate new evidence into their everyday practice), then remind your caregiver that most major national professional organizations — representing both adult women and men, as well as children — recommend against routine rectal exams.
Only the American Cancer Society (ACS), equivocates, arguing that rectal exams may be part of prostate cancer screening. The ACS, with their head in the clouds or someplace else south of their belly buttons, describes the rectal exam as “ uncomfortable (especially in men with hemorrhoids), but it isn’t painful and it only takes a short time.” Au contraire, ACS! Seventy- eight of 100 patients in one English study ranked their rectal exam as “painful.”
Recall that the United States Preventive Services Task Force (the U.S. agency that is the most reliable and unbiased) has recommended against prostate cancer screening by PSA and DRE.
Today, we know that one of four colon cancers is not in the reach of anyone’s finger and DRE is not one of the accepted modalities for colon cancer screening, nor is a single stool sample obtained with a rectal exam. The accepted screening modalities are three stool samples obtained at home and tested with a high sensitivity fecal occult blood test, a sigmoidoscopy or a colonoscopy.
Is there ever a good reason for a digital rectal exam? If you develop urinary or fecal incontinence, a rectal exam may reveal a fecal impaction (a blockage of stool) as the culprit. In cases of spinal injury, evaluation of the tone of the rectal sphincter may give important information. Multiple studies now show, however, that DRE is not useful in sorting out the causes of abdominal pain. The American Academy of Pediatrics, in particular, has voiced the advice that children suspected of having appendicitis should not have a rectal exam.
So, if you hear the snap as your physician dons an exam glove, remind him or her of the evidence against routine rectal exams and that he or she can be a thorough physician without going anal.
GJ Free Press health columnist Dr. Mohler has practiced family medicine in Grand Junction for 39 years. He has a particular interest in pharmaceutical education. Phil works part-time for Rocky Mountain Health Plans. Email him at firstname.lastname@example.org.
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