Tuesday, February 28, 2012

The View From the Other Side of the Glove

I have been out to discredit the routine use of the screening digital rectal exam (DRE) for years. My first experience was vivid and eye opening. The setting: England Air Force base in Louisiana. The circumstances: getting my pre-training Air Force physical. I was young (20), and I had no idea what I was about to go through. I was vigorous, healthy, and had absolutely no symptoms of anything, except perhaps too much cockiness.  A pre-flight physical before flight school – sure, no problem! I remember very few events about this exam other than one – after completing a myriad of forms, I was ushered into a room where a bored doctor asked me to drop pants and bend over. I was too shocked to not comply, and before I knew it I was in a world of hurt.

Fast forward to today. Now I know better – there is basically no screening value to performing DRE on healthy young men. Because I have some knowledge of military culture, I’m sure that traditional exam was a vestige of days gone by when “one size fits all”-medicine was the rule.

As a medical student learning the art of physical exam and the importance of being thorough, we were taught that everybody needed a DRE—well, almost everybody. The only clinic where this was not a required part of the medical database was the psychiatry ward. And that’s the way it should be, because it is critical to train young doctors to be diligent and complete in their evaluations.

In today’s medical world, doctors vary in their opinion as to when a patient needs a DRE. For instance, some still maintain that a pelvic examination is incomplete without a DRE in order to access the deeper structures of the female pelvis. The same goes with prostate cancer screening – DRE is always mentioned in conjunction with the PSA blood test. We are now advised to have a lengthy and detailed discussion of the relative merits of prostate cancer screening with men.  But if we’re realistic, we know that most men will choose to dodge the finger if given the choice! The number of additional cancers found because of an abnormal DRE in men with low PSA levels is estimated to be limited. 

Clearly there are times and circumstances when DRE is critical to an accurate diagnosis. Rectal bleeding or pain, for instance, or a change in bowel habits suggesting a rectal or colon cancer would necessitate an examination of the rectum. Also, an unexplained anemia can be a sign of bleeding in the intestinal tract, so checking the stool for traces of blood by DRE is quite important.

The question really is whether routine DRE for the purposes of screening is helpful or important. On the one hand, DRE is easy(for the doctor anyway), low risk,  and inexpensive to perform. While there may be a random surprise diagnosis made by routine DRE, those would be few and far between, especially if the systems review is honestly and completely negative. So if the patient has a trusting relationship with the physician and honestly reports no unusual symptoms, then DRE is very unlikely to be helpful. Furthermore, how many men and women demure from regular check ups for fear of DRE?  Humorous parodies of patients enduring DREs are widespread and influential. We’ve all been subjected to the juvenile quips from those whom we are approaching with index finger extended. I can’t prove it, but I suspect unspoken fear of DRE is the basis for declining routine physicals for a significant number of adults.

Given that the most common killer of Americans is cardiovascular disease, we would do much better to selectively perform DRE only on those patients who have a positive systems review, especially if both colon cancer and prostate cancer screening by colonoscopy and PSA is up to date. Wish I would have known this when I was 20!


  1. So Dr. Frederick, I was in your office earlier today getting my first physical in many many years (since little league baseball I think). I'm male and just turned 50, so my insurance lets me get them for free. But I was dreading the prostate exam... You came in, checked me over, we had a nice chat about all kinds of stuff, but no DRE. As I was getting ready to leave I noticed the URL for your blog on the wall and jotted it down. When I got back to my office, I checked it out and what should be the latest post but your explanation about why you don't use the DRE... All I can say is I have the finest Physician in the country!

    I have recently been reading about why men don't go to the Dr. as much as women and the #1 reason is the DRE. I don't know what it is, but men are terrified of it. I think Dr. Frederick is exactly right, we need to publicize that it is not needed unless there are other symptoms.

  2. Hi,

    I have a quick question about your blog, would you mind emailing me when you get a chance?