[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.
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...
