Digital rectal exams in children who present with constipation
Date First Published:
June 5, 2007
Last Updated:
June 8, 2010
Report by:
Nesba Naheed, Medical Student (Manchester Royal Infirmary)
Search checked by:
Rachel Jenner, Manchester Royal Infirmary
Three-Part Question:
In a [child presenting with constipation] is a [digital rectal examination] recommended to [confirm the diagnosis]?
Clinical Scenario:
A five year boy is presented to the Emergency department by his mother. His mother complains that he has constipation. After examining the boy's abdomen you wonder whether in order to confirm the diagnosis you should perform a digital rectal exam (DRE).
Search Strategy:
Medline using the OVID interface 1950 to January Week 2 2010: (constipation.mp OR exp Constipation/ exp Feces/ or exp feces impaction/ or stool$.mp OR faec$.mp) AND ([rect$ adj exam].mp OR digital rectal examination.mp OR exp Digital Rectal Examination/). Limit to human and English and all child 0–18 years
Search Details:
Embase 1980-present via the NLH interface: (constipation.ti.ab OR exp Constipation/ exp Feces/ or exp feces impaction/ or stool$. ti.ab OR faec$. ti.ab) AND ([rect$ adj exam]. ti.ab OR digital rectal examination. ti.ab OR exp Digital Rectal Examination/). Limit to human and English and (newborn infant or infant or preschool child or child or adolescent).
The Cochrane Library January 2010: MeSH descriptor Digital Rectal Examination explode all trees.
The Cochrane Library January 2010: MeSH descriptor Digital Rectal Examination explode all trees.
Outcome:
46 papers were found, of which 4 articles were useful.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Digital rectal examination and the primary care physicians: a lost art? Safder S. Rewalt M. Elitsur Y 2006 USA | 96 children aged between 0 and 16 presenting to a specialist clinic with constipation, encopresis or rectal bleeding. DRE performed in only 14 (15%) of the patients before referral. Compared to 96% by the specialist. | Survey | Result of the DRE | The DRE performed by the specialist resulted in diagnoses of faecal impaction, hard stools and anal fissure | The paper is focussed on the effect of DRE on referral rates. It wasn't clear in the study whether the diagnoses could have been arrived at without a DRE |
| Use of the rectal examination on children with acute abdominal pain. Scholer SJ, et al, 1998 USA | 1140 consecutive children aged between 2 and 12 years presenting with abdominal pain that had lasted for 3 days or more. 56 children (4.9%) had a DRE. Of whom 6 had constipation | Survey | Clinical contribution of the DRE | In 12 children (21% of patients who had the DRE) the DRE contributed clinically | The study was not specific to the usefulness of DRE in constipation. The study was aimed more towards the usefulness of DRE in abdominal pain as a whole. The term clinically contributing was not specific, the study did not determine whether the management of the child changed because of the findings on DRE |
| Frequency of digital rectal examination in children with chronic constipation. Gold DM, et al, 1999 USA | 128 children aged between 1 month and 13 years old referred to a specialist gastroenterology clinic. 98 (77%) children had not had a DRE prior to referral |
Survey | Effect if any DRE had on treatment | Of the 128 patients, 66 (52%) had been on stimulant laxative therapy prior to referral, of these patients 47 (71%) had not had a DRE | The paper is focussed on the effect of DRE on referral rates. The paper did not report whether management would have been altered by DRE |
| Accuracy of clinical variables in the identification of radiographically proven constipation in children. Beckmann KR, Hennes H, Sty JR, et al. 2001, USA | 251 children aged 2–12 years with abdominal pain requiring abdominal radiography | Diagnostic cohort | Clinical utility of DRE at predicting radiographic constipation | Sensitivity 68.6% Specificity 57.4% |
Author Commentary:
There is no direct evidence to answer the question posed—none of the papers found look at the particular group of children identified. Two papers that focus on children referred to specialist clinics suggest that the use of DRE in clinical practice would decrease the referral rate; the implication is that the management of the referred children would have been improved if a DRE had been performed prior to referral—though neither paper fully explained how management would have been altered. One paper looks at children with protracted abdominal pain from any cause—and the DRE rate is minimal. Finally, another paper concentrated on children referred for abdominal x-ray who have radiographic constipation and shows that DRE is the best predictor of a loaded colon. This, again, says nothing about the value of DRE in routine examination of this group of children and, considering the distress that DRE can cause, could be used to argue for abdominal x-rays for diagnosis. Overall, there is nothing to suggest that DRE should be undertaken in every single patient who presents with possible constipation.
Bottom Line:
TThere is no direct evidence to answer the question posed—none of the papers found look at the particular group of children identified. Two papers that focus on children referred to specialist clinics suggest that the use of DRE in clinical practice would decrease the referral rate; the implication is that the management of the referred children would have been improved if a DRE had been performed prior to referral—though neither paper fully explained how management would have been altered. One paper looks at children with protracted abdominal pain from any cause—and the DRE rate is minimal. Finally, another paper concentrated on children referred for abdominal x-ray who have radiographic constipation and shows that DRE is the best predictor of a loaded colon. This, again, says nothing about the value of DRE in routine examination of this group of children and, considering the distress that DRE can cause, could be used to argue for abdominal x-rays for diagnosis. Overall, there is nothing to suggest that DRE should be undertaken in every single patient who presents with possible constipation.
References:
- Safder S. Rewalt M. Elitsur Y. Digital rectal examination and the primary care physicians: a lost art?
- Scholer SJ, et al,. Use of the rectal examination on children with acute abdominal pain.
- Gold DM, et al,. Frequency of digital rectal examination in children with chronic constipation.
- Beckmann KR, Hennes H, Sty JR, et al.. Accuracy of clinical variables in the identification of radiographically proven constipation in children.