A recent review (S Rajindrajith et al. JPGN 2021; 72: 794-801. Functional Fecal Incontinence in Children: Epidemiology, Pathophysiology, Evaluation, and Management) provides a quick review of fecal incontinence in children but one part left me unsettled.
Under the section titled, “Clinical Evaluation,” the authors state the following:
“Digital examination of the rectum is not needed as general history and examination reveal the diagnosis in most cases; however, in case of diagnostic uncertainty, digital examination should be performed and can provide information about the integrity of the spincter complex…the presence of a large fecal mass helps to differentiate between constipation-associated FI [fecal incontinence] and FNRFI [functional nonretentive fecal incontinence].”
Of course, there are many situations in which a rectal exam should be deferred. But I think it is a big mistake to state in a leading pediatric GI journal that the default position is that a rectal exam is unnecessary. Here’s why:
- A rectal exam is the best way to determine if a patient needs a ‘cleanout’ prior to a routine management plan.
- A rectal exam can help avoid unnecessary hospitalizations. I have been made aware of patients in the inpatient setting who have been subjected to cleanouts when they did not need this. Unnecessary cleanouts for outpatients also happen. This can occur in children with irritable bowel syndrome who are having regular bowel movements and are told by practitioners that they are backed up due to flimsy evidence (like a normal abdominal xray).
- A rectal exam does not add any additional costs to the evaluation. Later in this same review the authors describe many potential expensive investigations including colonic transit studies, anorectal or colonic manometry, and MRI of lower spine. Is it really a good idea to order any of these tests without completing a rectal exam first?
- The article also reviews potential treatments beyond fiber and pharmacology including psychological interventions, transanal irrigation, botulinum toxin injection, antegrade continence enemas, bowel resection and neuromodulation. In my view, none of these should be undertaken prior to a rectal exam.
The review does state that guidelines recommend against using plain abdominal X-ray for evaluation for defecation disorders, noting that “the sensitivity and specificity are not sufficient to provide the required diagnostic accuracy.”
My take: I fundamentally disagree with the premise that a rectal exam is NOT part of the routine evaluation of children with defecation disorders.
Related blog posts:
- What’s Wrong with Ordering an AXR for Constipation in the ER …
- Improving ER Performance for Suspected Constipation | gutsandgrowth
- Soap Suds Enemas & ED Management of Impactions | gutsandgrowth
- Prucalopride -Not Better Than Placebo for Children with Constipation | gutsandgrowth
- Don’t Let the Chief of Staff Review This Constipation Study | gutsandgrowth
- Refractory Constipation -Terrific Update | gutsandgrowth
- Diagnosis and Misdiagnosis of Constipation
- Key to Reducing Unnecessary AXRs: Individualized Metrics | gutsandgrowth
- Diagnostic tests hardly ever help patients poop | gutsandgrowth
- Updated Pediatric Expert Constipation Guidelines | gutsandgrowth
Picture below from “Robert Is Here” Fruitstand (Homestead, FL)
Pradhan S, Jagadisan B. Yield and Examiner Dependence of Digital Rectal Examination in Detecting Impaction in Pediatric Functional Constipation. J Pediatr Gastroenterol Nutr. 2018 Nov;67(5):570-575. doi: 10.1097/MPG.0000000000001969. PMID: 29601443.
hallo mrs mr barathjag, rectal examination odf a unsedated child???
Rektal digital examination ist he best way to leave a child-patient. He/She will never came back and avoid to meet you on the street.
Since the introduction of ultrasound in the clinical practice of every pediatrican, who examine the abdomen – this is 20 Years ago – rectal digital examination gives
– no additional information, other then pain and bleeding,
– avoid no hospitalization, other than the patient run and run and comes never back,
– is a form of child misuse.
If you see and feel (palpation oft he tommy) hard Stool impaction, the Child needs an iv sedation and desimpaction. This is a normal outpatient procedure in my pediatric gastroenterologic practice. i do this since 2008 in my own praxis every day.
It´s the same in the veterinary practice. Nobody performs a rectal examination of my dog – be aware oft he dogs reaction. I dont fix him, Hugo is a dobermann.
Hey, we dont live in the 18th centuary.
sincerely yours, thomas from Hamburg, germany, pediatric gastroenetrologist.
In U.S., most pediatric offices do not have ultrasounds readily available and their use for constipation is not generally recommended either. So, this is impractical and costly. A rectal exam is not a form of child abuse; pediatric practitioners routinely recommend blood tests and immunizations -because they hurt, is this child abuse as well? Most exams are much less painful than passing a bowel movement, particularly in children with chronic constipation. Assuring that the diagnosis is correct is important for effective treatment. In addition, no child is examined without their parent’s permission.
I have to rearrange my replay
1. if a child suffer from long standing constipation, he/she need to see a specialized paediatrician or Ped gastroenterologist, outpatient, with time, family – friendly, not a hospital-emergency-room. The most pediatric offer no modern technique (echokardiography, lung function and so on) – this is clear and a world-wide problem for children (if you have gallstones and visit your practitioner, you expect to get a ultrasound – or not?).
2. a specialized pediatric person (for ped gastroent) should be able to perform an ultrasound (or not?). this needs 5 minutes, is cheaper than a 15 minute speech about the risk of anything … and gives the diagnosis.
3. the most reason for stool impaction is an elevated Tonus of the anal sphincter. For Treatment (disimpaction) you must relax the anal sphincter or the risk of rupture is very high. The only save way is sedation. Otherwise it needs only time and you will see complications.
4. believe in me, rectal examination is – today, in my view – more than obsolete. If you see this with the eyes of justice or psychologist, it may be an untolerable behaviour (watch the crisis of the catholic church – isn’t it?).