Thursday, February 07, 2008

That'd Be Up The Butt, Bob

[If you don't get the reference, I ain't explaining.]

I have some memories of the first time I did a rectal exam as a student. I even seem to recall that we were made to do it to each other, before inserting ourselves into the affairs of patients. Embarrassing, to be sure, there was also a sense of gratitude and bemusement that people would agree to such a thing, while surely knowing it was of no benefit to them. They allowed students, overtly unsure and explicitly unskilled, to prod them for the sake of furthering education.

Much maligned, and stereotyped as a physician's perverted pleasure; the (obvious word here) of comedians' jokes, rectal exam is in fact an important intervention. Especially, I'd propose, for surgeons. Like a Swiss Army Knife, it's an all-purpose tool. Many things in one. E probicus, unum. (Not that anyone would put a Swiss...) For most doctors, it's a matter of poking around for a little stool to test for blood, and, half the time, to make a pass over the prostate. For a surgeon, it's diagnostic, therapeutic, and a means of making plans.

It's impossible for me to be unaware of the inequities inherent in the fact of one person having his finger up the hindmost of another. Of the things we do, on an awake patient at least, it's arguably the strangest, and I've always wondered how it seems to the recipient. Like some sort of ritual? A rite of passage? (Passageway?) Something akin to what witch doctors do; a sacred privilege given only to them? An assumption that there's some special divining going on, the mysteries of which are learned in secret? In any case, it behooves one fully to explain exactly the reasons for such a transgression. So here are some:

  • In evaluating a patient with bowel obstruction, it's useful to determine if there's air in the rectal vault.
  • By revealing localized pain on the right, it can help in the diagnosis of appendicitis.
  • With a pelvic abscess from any source, it can determine the feasibility of trans-rectal drainage. (Yes, it's possible to do it without a radiologist, and there's still a place for it.) In fact, under some unusual circumstances, such an abscess, followed for "ripening," can be drained digitally and yuckally, right there in the bed.
  • Rectal exam can stimulate the bowels to move, in a post-op patient (hopefully not in an instantaneous fashion.)
  • Among the most important: it predicts successful resection of rectal cancer with the ability to re-connect the colon without colostomy. (If I can feel the tumor on rectal exam, I won't be able to resect with a margin safe for anastomosis.)
  • The exam helps to judge how extensive a rectal tumor is; how large, and how fixed in position. The need for pre-op radiation is determined, in part, this way.
  • When that very low stapled anastomosis becomes too tight (which they sometimes do), it can be permanently fixed with a single digital dilatation.
  • Some anal fistulae track up into areas that can be felt and mapped out by a rectal exam.
  • In addition to routine evaluation of the prostate, there are some circumstances wherein prostate massage is therapy.
I'm sure I'm missing some.

Despite the fact that my own doc liked to do the exams from behind, with me standing up and leaning onto the exam table, I always felt (perhaps from that very experience*) that the most gentle and least humiliating way to do a rectal exam is with the patient curled up on his/her side, and covered except for the target orifice.

I've been told that some clinicians of the older school (but within my lifetime) insisted on doing rectal exams ungloved, for maximum sensitivity. Hopefully, someone was jerking my chain. For me: properly fitting glove, plenty of lube, and thoughtfully trimmed nails.

*And from thinking of the apocryphal story of the military doc (it would have to be military) who had some patients bend over and would then put his left hand on their left shoulder, his right index finger in the anus, and then have a hidden corpsman sneak out and put his right hand on the victim's right shoulder...


Anonymous said...

About 50% of the gynecologists I have seen think it's an important part of a pelvic exam. They say it helps them press against the organs better. I question how the other 50% can get the job done. In my experience the ones who go rectal are more in a hurry to be done, probably for obvious reasons, so I question the practice even further.


shadowfax said...

I love the title/picture. Hysterical!

Anonymous said...

OMG...that title reference had me just about busting a gut! (I was very young when that show originally aired, but I still remember it.) Fortunately I've never had the need for such an exam, but all I could think of while reading this post was that funny little blurb I first discovered after typing in "surgery" or "surgeon" into a YouTube search engine, called "The Colorectal Surgeon Song".

In any case, thanks for the laughs!

Anonymous said...

Dr. Schwab,
I just wanted to make a quick little point to say that we've been told the following as well when determining the source of pain in my kids (usually when they're younger):
'By revealing localized pain on the right, it can help in the diagnosis of appendicitis.' But two of my kids have their appendixes on the left side, so its thrown us and doctors off because its outside of the norm. Not everyone's built the same!:) We're much more comfortable with doctors who don't make a big deal about the difference, and once everyone catches their bearings we feel on the lower left side.

Dr. Rob said...

For those of us with very long fingers, it is a fine way to check the gall bladder, liver, and tonsils.

It can also be quite hilarious to put itching powder on the gloves.

Anonymous said...

I like to have the patient lie down just in case they get light headed...

Then there was the patient who wanted to be re-examined monthly, to catch any lumps at the earliest possible moment.

Sid Schwab said...

rob: I liked you better when you were miserable.

Anonymous said...

I'm surprised they made you do rectal exams on each other. They thought about it at our med school but thankfully decided against it.

Anonymous said...

I was hesitant before my first one, but it really wasn't so bad. The P.A. made it painless and I felt like I was being dealt with professionally. I was laying on my side at the time and it was over fairly quickly and my prostate was fine (which was all I really cared about.)

And I had forgotten all about that show. I think I was too young at the time to get the joke.

Anonymous said...

Yuckally-is that one of those highly technical medical terms that only doctors know?

Anonymous said...

I'm working with one of the most respected urologists of my country (he's also "mostly retired"). For diagnosis of prostate cancer he insists on doing rectal exams in general anesthesia, arguing that a totally relaxed patient is paramount to a good and thorough exam.

What do you think?

BTW: If he had known the abbreviation for digital rectal exams, rapper Dr. DRE would probably have chosen another name...;)

Anonymous said...

I might have been alive when that episode aired but far too young to have known what was going on; however, this essential piece of television history eventually became known to me in college with much hilarity. :)

Regarding uses for the oldskool phlangeal scanner, one that might have been left out was testing for sphincter tone/bulbocavernosus reflex. But that's just yet another smoke-and-mirrors ploy in the great doctorectal conspiracy.

The idea of medstudents performing this on each other gives me shudders--I thought it was bad enough we stuck each other with needles and deep palpated LLQ to elicit involuntary flatulence (under the guise of checking for sigmoid masses, diverticulitis or the like).

Lastly, only you could use the word "ripening" in this context (are you waiting for that satisfying timpanic timbre as if checking a melon?) and get away with it. ;)

Bongi said...

we had a saying, if you don't put your finger in it, you will put your foot in it.

this i saw as a registrar when we'd get a referral for haemorrhoids which the gp had treated without success for a year or so. pr typically revealed a massive fixed rectal cancer.

Sid Schwab said...

sterileeye: not being a urologist I can't say with authority. But I've never heard such a thing, and think it's way over the top. Or is it "under the bottom?"

rico: sphincter tone: I should have mentioned that.

bongi: that's a great and true saying. i'd have used it, if i'd heard it!

Assrot said...

Well doc, I never much liked these exams and have been through several. I had what I think they called "recurring prostratitis" when I was a teenager up into my late twenties. Then poof, like magic, it went away.

I remember when I was young what one of my old hillbilly cousins told me and I quote "Any doctor that sticks his finger in your ass is a homo and you should stay away from him."

I always got the slightly embarassing bend over the table exams and my cousins words always rang in my ears during every exam.

I really didn't give a darn whether the doc was a "homo" or not as long as he was a competent doctor and he only stuck his finger up there. (I always made sure it was a finger when I was younger.)

These days (my late 50s) I still don't care much for the physical discomfort of these exams but I only get them once every year during a complete physical.

As for the feeling embarassed, I could care less anymore but once in awhile I do crack up laughing during the exam when my cousins previous comment comes to mind.

Of course I have to tell the doc so he doesn't think I'm some nut job that has a ticklish behind. We usually both get a laugh out of my cousin the ignoramus and his comment to a young boy so many years ago.

My cousin is still the same dumbass, bigot he has always been and he refuses all rectal exams, colonoscopies, etc. He's a few years older than me. I pray the idiot doesn't die of colon or prostrate cancer due to his ignorance.

Thanks for giving me something to chuckle about today. I hope none of your exams bring about instantaneous bowel movements.



Sid Schwab said...

Joe: not wishing to make any implications about you in particular, but the pattern you describe can be seen in relation to sexual activity; ie, congestive prostatitis may occur in the absence of, uh, clearing of the pipes, and become less of a problem when the, uh, activity becomes more regular. In fact, the massage situation to which I referred in the post was something I did in Vietnam, when guys had brought an abrupt end to sexual activity. I recommended what might be called self-service, as part of the prevention.

Anonymous said...

Long ago one of my senior partners, a gyn, did a rotation at the cancer center in NY. Just before a radical hysterectomy, he was told to examine the patient rectally. He went to get a glove and was told that they didnt use them in long cases because the sweat built up in the gloves that were sure to leak because they were not disposable.So they did surgery and exams bare handed. That must have been in the 40's.

Anonymous said...

An old dictum of trauma surgery is, "A finger in every orifice," but I've recently become much more selective about doing rectals on trauma patients with no suspicion of pelvic or perineal injury. I just can't see the benefit in the vast majority of the people we see.

Plus, my intern's glove broke recently while doing a rectal and he came out with a stinky finger!

SeaSpray said...

My main gynecologist is the only doc who ever did rectals on me and he always gave me a real thorough exam...never rushed. His other 2 partners never did and I didn't ask why. I hate them. I'd rather have 100 paps then have one rectal because as far as I am concerned it's a one way street back there! :)

Rob that's hysterical!


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