Digital Rectal Examination in Newborns
Digital rectal examination can be performed in newborns when clinically indicated, but should be done with extreme caution using the smallest finger (typically the fifth finger) and only when the diagnostic benefit outweighs the risks, as routine use is discouraged due to potential complications including rectal perforation. 1
Clinical Context and Safety Concerns
The digital rectal examination in neonates carries significant risk and should not be performed routinely. Three cases of rectal perforations in neonates caused by rectal thermometer use have been documented, emphasizing the fragility of neonatal rectal tissue and the difficulty of diagnosing such complications even at laparotomy. 1 This underscores that any rectal instrumentation or examination in this age group requires exceptional care.
When DRE May Be Indicated in Newborns
Digital rectal examination in the neonatal period has specific, limited indications:
Anorectal malformations or suspected anatomical abnormalities where assessment of anal patency, sphincter tone, and anatomical structure is essential 2, 3
Evaluation of constipation or suspected Hirschsprung disease where assessment of rectal tone and presence of stool is diagnostically valuable 3
Suspected spinal cord abnormalities where anal sphincter tone assessment provides neurological information, though sensitivity for detecting spinal cord injury is limited at 34% 4
Gastrointestinal bleeding or abdominal mass where rectal examination may provide diagnostic information 3
Technical Considerations
When performing DRE in a newborn:
Use the fifth finger (little finger) as it is the smallest digit and least likely to cause trauma 5
Ensure adequate lubrication and gentle technique to minimize risk of perforation 2
Obtain appropriate consent from parents and explain the necessity of the examination 3
Assess for normal findings including appropriate sphincter tone at rest and with squeeze, no masses, and normal anal reflex 6
Important Caveats
The examination should be avoided when:
- There is no clear diagnostic indication that would change management 3
- Alternative diagnostic methods (such as imaging) can provide the necessary information without the risks of DRE 1
- The examination is being considered purely for "completeness" rather than specific clinical suspicion 4
Physicians often avoid this examination due to discomfort, lack of training, concern about causing harm to vulnerable patients, and belief that other testing can provide equivalent information. 3 However, when clinically indicated, the examination should be performed with appropriate technique rather than deferred.
Clinical Utility Limitations
The DRE has significant limitations in pediatric patients, with poor sensitivity for many conditions including 100% false-negative rates for bowel injuries, rectal injuries, pelvic fractures, and urethral disruptions in trauma settings. 4 This reinforces that the examination should only be performed when it can provide unique diagnostic information not obtainable through other means.
In obstetric settings, digital rectal examination is recommended after all vaginal deliveries to improve detection of obstetric anal sphincter injuries, demonstrating its value in specific clinical contexts. 5 This principle of targeted use based on specific diagnostic need applies equally to neonatal examination.