Per Rectal Examination in Pediatric Patients: Indications and Considerations
Per rectal examination should only be performed in pediatric patients when there are specific clinical indications, and should not be done routinely as part of a general physical examination.
Appropriate Indications for Per Rectal Examination
Per rectal examination in pediatric patients is indicated in select clinical scenarios:
- Suspected constipation: When history suggests constipation and confirmation of fecal impaction is needed 1, 2
- Persistent vaginal discharge in sexually active females 1
- Lower abdominal pain with suspected pelvic or rectal pathology 1, 3
- Gastrointestinal bleeding or suspected rectal pathology 3
- Suspected rectal prolapse requiring assessment 1
- Neurological symptoms affecting bowel function 3
Contraindications and Limitations
- Routine trauma assessment: Evidence shows poor sensitivity for detecting injuries in pediatric trauma patients 4, 5
- Asymptomatic patients: Not indicated as part of routine physical examination 1
- When alternative diagnostic methods are available: Transabdominal ultrasound can reliably assess rectal filling state with good agreement with digital rectal examination (kappa 0.62) 6
Approach to Performing Per Rectal Examination
When indicated, the examination should be conducted with sensitivity:
- Obtain appropriate consent: Explain the procedure to both the child and parents/guardians
- Ensure comfort and privacy: The examination should only be done when the child and family are comfortable with the procedure 1
- Consider patient preference: Be sensitive to gender preference for the examiner 1
- Document findings thoroughly: Particularly presence of formed feces, sphincter tone, or other abnormalities 1
Alternative Diagnostic Methods
- Transabdominal ultrasound: A non-invasive alternative to assess rectal filling state in children with suspected constipation 6
- Imaging studies: For specific indications such as suspected inflammatory bowel disease, CT or MRI may be more appropriate 1
- Laboratory tests: For suspected infections or inflammatory conditions
Common Pitfalls to Avoid
- Performing unnecessary examinations: Studies show that 85% of primary care physicians don't perform DRE before specialist referral for constipation, yet many referrals could be avoided with proper assessment 7
- Inadequate explanation: Failure to explain the procedure appropriately can cause unnecessary anxiety
- Ignoring constipation-enuresis connection: Constipation can contribute to urinary symptoms including UTIs and daytime wetting 2
- Overlooking psychological impact: Consider past trauma or abuse that might affect the patient's comfort with the examination 1
Conclusion
Per rectal examination in pediatric patients should be performed selectively based on specific clinical indications rather than as a routine practice. When indicated, it should be conducted with appropriate sensitivity to the child's comfort and dignity, with clear explanation and consent. Alternative non-invasive methods should be considered when available and appropriate.