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
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