I
Rectal Examination Revisited
Richard A. Donaldson
606
Digital Rectal Examination (DRE)
Digital rectal examination (DRE) is undoubtedly a very important part of the examination and assessment of most casualties, but one must be aware of its limitations.
Recently, a soldier with a gunshot wound (GSW) was admitted to a Field Hospital. He had a small entry wound over the left femoral triangle and a large open exit wound in the upper part of the right buttock, with a fist-sized cavity in the gluteal muscles. There was no evidence of any neurovascular damage to the left leg. Digital rectal examination by an experienced A&E consultant revealed no abnormality, especially no “blood on glove.” Catheterization was straightforward, with clean urine obtained.
Ultrasound scan (USS) revealed a slight increase in intraperitoneal-free fluid.
Laparotomy revealed a small amount of intraperitoneal bleeding with all intraperitoneal structures intact. The blood in the peritoneal cavity was assumed to be the result of transudation from a large pelvic hematoma. On exploration of the exit wound, a strong smell of feces was noted. The wound was extended to allow exploration of the rectum and a two-centimeter laceration of the rectum was found. The rectum was repaired and a de- functioning colostomy was carried out.
One would normally expect to find at least a trace of blood macroscop- ically in cases of rectal injury, although a tear in the rectum could not be palpated. In this case, it seemed so unlikely that a projectile could have tra- versed the extraperitoneal pelvis without damage to at least one important structure in that area such as the urethra or rectum.
Lesson Learned
In cases of pelvic injury with a high index of suspicion of rectal damage and where DRE is normal, it would be worthwhile to carry out a Fecal Occult Blood Test, followed by proctoscopy if positive.
“High Riding” Prostate
It is taught, and it is a misconception, that the prostate can be felt “riding high” on DRE in cases of pelvic fracture with associated transection of the supra-membranous urethra and dislocation of the prostate gland.
It is not a common injury, and in 30 years of urological practice, I have seen but four or five cases in the presenting stage.
In such cases, the dislocated prostate becomes absorbed into a “boggy”
pelvic mass consisting mainly of bladder and hematoma and cannot be felt as a separate entity. What one feels on DRE is a space where the prostate should normally be located, and possibly the symphis pubis.
I. Rectal Examination Revisited 607
Section 5
And Finally
