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Three Part Question

In [pediatric trauma patients] does [routine digital rectal exams] have [adequate diagnostic accuracy]?

Clinical Scenario

A 7 yr old boy presents to the trauma bay in the emergency department after a high speed motor vehicle collision. He is alert, talking, and moving all extremities. During his secondary survey, you wonder if a digital rectal exam would be of any prognostic or diagnostic utility.

Search Strategy

Medline 1948-06/11 using OVID interface, Cochrane Library (2011), PubMed clinical queries
[(exp digital rectal examination OR rectal examination.mp) AND (exp “wounds and injuries” OR trauma.mp)]. Limit to English language and all children (0 to 18 years).

Search Outcome

22 papers were identified, only 2 prospective clinical trials were relevant to the clinical question

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Shlamovitz GZ et al 2007 USA	Pediatric trauma patients that the trauma team was activated between 1/2003 to 2/2005 who received a digital rectal exam(DRE).	A nonconcurrent, observational, chart review study to identify DRE findings followed by radiologic and operative reports, and discharge summaries to identify specific injuries.	Detection of spinal cord injury (presence of decreased anal spincter tone):	95% CI	Chart review is vulnerable to missing data. Potential workup bias- not definitive testing for all and physicians were not blinded to the DRE findings, coding bias- in DRE findings; spectrum bias- level 1 trauma center. DRE was deferred or not recorded in 31% of patients. Inability to calculate interrater reliability. Did not address costs, ethical or legal issues.
			Sens	33%(6-79)
			Spec	99%(96-100)
			Diagnosis of bowel injuries (presence of gross blood on exam):	95% CI
			Sens	0%(0-23)
			Spec	98%(95-99)
			Diagnosis of rectal injuries (disruption of rectal wall integrity):	95% CI
			Sens	0%(0-65)
			Spec	100%(95-100)
			Diagnosis of pelvic fractures (presence of bony fragments on exam):	95% CI
			Sens	0%(0-65)
			Spec	100%(95-100)
			Diagnosis of urethral injury (presence of abnormal position of prostate):	95% CI
			Sens	0%(0-79)
			Spec	100%(94-100
George Kristinsson, MD et al 2007 USA	Patients 1 to 17 years of age presenting to the pediatric emergency department of an urban level I trauma center with a history of trauma to the spine or trunk.	Pilot study: To evaluate the utility of the DRE(digital rectal exams) in detecting DRE-identifiable injuries using two-sample tests of proportions and compared the test performance characteristics of the physical examination during the secondary survey with and without the DRE.	Physical Exam with DRE (mean GCS 15)		Low incidence of comatose or obtunded children in study. Small number of DRE-identifiable injuries leading to wide confidence intervals. No inter-rater agreement.
			Sens(95%CI)	87.5%(47.3-99.7)
			Spec(95%CI)	78.7%(70.6-85.5)
			Physical Exam without DRE (mean GCS 15)
			Sens(95%CI)	87.5%(47.3-99.7)
			Spec(95%CI)	87.4%(80.3-92.6)

Comment(s)

ATLS(Advanced Trauma Life Support) course has been subject to change recently regarding some of the non evidence-based recommendations, one being the digital rectal exam(DRE). DRE can be confusing, painful, and frightening for a child, so it is important to evaluate the usefulness of routine use of the DRE in children. One prospective clinical trial from the Pediatric Emergency Care by Shlamovitz et al., proves that DRE is not accurate and could expose patients to further studies, a costly work-up, and additional risks. Also, negative results may produce undue confidence in providers of patients with potential false-neg DRE. This study concludes that DRE has poor sensitivity for the diagnosis of spinal cord, bowel, rectal, bony pelvis, and urethral injuries. A pilot study in The Journal of Emergency Medicine by Kirstinsson et al., found that the specificity of the physical exam without the digital rectal exam tended to be better than theat of the physical exam with the DRE. The study concludes that routine performance of the DRE may not improve the identification of serious injury during the secondary survey in alert pediatric trauma patients. Both of these studies were prospective clinical trials, yet both had small sample sizes given the rarity of these pediatric injuries.

Clinical Bottom Line

At least two studies have shown that DRE should not be routinely utilized in pediatric trauma patients. To increase the diagnostic accuracy, some studies suggest limiting the use of DRE to patients with: penetrating trauma in proximity to the rectum or pelvic fractures, those likely to have rapid-sequence intubation, and when spinal cord injury and neurogenic shock cannot be excluded based on the general physical exam.

References

1. Shlamovitz GZ. Mower WR. Bergman J. Crisp J. DeVore HK. Hardy D. Sargent M. Shroff SD. Snyder E. Morgan MT. Lack of evidence to support routine digital rectal examination in pediatric trauma patients Pediatric Emergency Care Aug 2007; 23(8): 537-43
2. Kristinsson G. Wall SP. Crain EF. THE DIGITAL RECTAL EXAMINATION IN PEDIATRIC TRAUMA: A PILOT STUDY Journal of Emergency Medicine Vol. 32, No. 1, pp. 59–62, 2007