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Why Are We Still Doing DRE in Trauma Patients?

December 14, 2022

Written by Vivian Lei

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Use of the digital rectal exam (DRE) in trauma patients has repeatedly demonstrated poor sensitivity for injuries and has little impact on clinical management, with a high false negative rate in pediatric populations.

Why does this matter?
In trauma patients, performing a DRE is still recommended by the American College of Surgeons Advanced Trauma Life Support (ATLS) course. However, the exam’s diagnostic validity and clinical relevance are questionable.

Time to forget about DRE?
This was a systematic review investigating the sensitivity of the DRE for spinal cord, gastrointestinal, and urethral injuries and whether performing the exam changed the treatment or management of adult or pediatric trauma patients. Nine studies were ultimately included, with a total of 3,775 patients. In adults, DRE had an overall sensitivity for injuries ranging from 6.67% to 51%. Sensitivity for spinal cord injuries, gastrointestinal injuries, and urethral injuries ranged from 8.3% to 50%, 0 to 51%, and 0 to 50%, respectively. Other clinical indicators, such as wounds around the umbilicus, penetrating wounds to the abdomen, buttock, or perineum, blood at the urethral meatus, neurologic deficits, scrotal hematoma, and unstable pelvis were more sensitive for detecting injuries at 73%, compared to DRE at 41%. A DRE changed clinical management in only 11% of cases in one study.

In pediatric trauma patients, a physical examination without DRE was as sensitive for detecting injuries as a physical exam with DRE. In a study of 213 pediatric patients with DRE performed, DRE missed 66% of spinal injuries and 100% of urethral injuries, bowel injuries, rectal wall injuries, and pelvic fractures.  

This evidence suggest that future trauma assessment guidelines can omit the DRE or provide situation-specific indications for its use.

The benefits and clinical application of the digital rectal exam in trauma populations: Towards enhancing patient safety and quality outcomes. Am J Emerg Med. 2022 Nov 8;63:132-137. doi: 10.1016/j.ajem.2022.11.004. Online ahead of print.

What are your thoughts?