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Digital rectal examination in the evaluation of rectovaginal septal defects

Rachaneni S, Atan IK, Shek KL, Dietz HP

Int Urogynecol J, 2017 Sep;28(9):1401-1405.
PMID: 28213798 DOI: 10.1007/s00192-017-3285-8

INTRODUCTION AND HYPOTHESIS: The objective was to evaluate the diagnostic potential of digital rectal examination in the identification of a true rectocele.
METHODS: This is a retrospective observational study utilising 187 archived data sets of women presenting with lower urinary tract symptoms and/or pelvic organ prolapse between August 2012 and November 2013. Evaluation included a standardised interview, ICS-POPQ, rectal examination and 4D translabial ultrasound. The main outcome measure was the diagnosis of rectocele by digital rectal palpation on Valsalva manoeuvre. This diagnosis correlated with the sonographic diagnosis of rectocele to determine agreement between digital examination and ultrasound findings.
RESULTS: Complete data sets were available for 180 participants. On imaging, the mean position of the rectal ampulla was 11.07 (-36.3 to 44.3) mm below the symphysis pubis; 42.8% (77) had a rectocele of a depth of ≥10 mm. On palpation, a rectocele was detected in 60 women (33%). Agreement between palpation and imaging was observed in 77%; the kappa was 0.52 (CI 0.39-0.65). On receiver operator characteristic analysis, the area under the curve was 0.854 for the relationship between rectocele pocket depth and the detection of rectocele on palpation.
CONCLUSION: Moderate agreement was found between digital rectal examination for rectocele and translabial ultrasound findings of a "true rectocele". Digital rectal examination may be used to identify these defects in clinical practice. Extending the clinical examination of prolapse to include rectal examination to palpate defects in the rectovaginal septum may reduce the need for defecatory proctograms for the assessment of obstructive defecation and may help triage patients in the management of posterior compartment prolapse.

Matched MeSH terms: Digital Rectal Examination/methods*
Common proctological conditions

Monro JK

Journal of the Malaya Branch of the British Medical Association, 1940;3:396-9.

Matched MeSH terms: Digital Rectal Examination
Can Anal Sphincter Defects Be Identified by Palpation?

Shek KL, Atan IK, Dietz HP

Female Pelvic Med Reconstr Surg, 2016 Nov-Dec;22(6):472-475.
PMID: 27682743

OBJECTIVES: The aim of this study was to correlate clinical findings of anal sphincter defects and function with a sonographic diagnosis of significant sphincter defects.

METHODS: This is an observational cross-sectional study on women seen 6 to 10 weeks after primary repair of obstetric anal sphincter injuries (OASIs). All patients underwent a standardized interview including the St Mark incontinence score, a digital rectal examination, and 3-/4-dimensional transperineal ultrasound imaging.

RESULTS: Two hundred forty-five patients were seen after primary repair of OASIs. Mean age was 29 (17-43) years. They were assessed at a median of 58 (15-278) days postpartum. One hundred fifty-seven (64%) delivered normal vaginally, 72 (29%) delivered by vacuum, and 16 (7%) delivered by forceps. A comparison of external anal sphincter (EAS) and internal anal sphincter ultrasound volume data and palpation was possible in 220 and 212 cases, respectively. Sphincter defects at rest and on contraction were both detected clinically in 17 patients. Significant abnormalities of the EAS were diagnosed on tomographic ultrasound imaging in 99 cases (45%), and significant abnormalities of the internal anal sphincter were diagnosed in 113 cases (53%). Agreement between digital and sonographic findings of sphincter defect was poor (k = 0.03-0.08). Women with significant EAS defects on ultrasound were found to have a lower resistance to digital insertion (P = 0.018) and maximum anal squeeze (P = 0.009) on a 6-point scale. The difference was however small.

CONCLUSIONS: Digital rectal examination does not seem to be sufficiently sensitive to diagnose residual sphincter defects after primary repair of OASIs. Imaging is required for the evaluation of sphincter anatomy after repair.

Matched MeSH terms: Digital Rectal Examination/standards*
Fulltext Ethnicity is an independent determinant of age-specific PSA level: findings from a multiethnic Asian setting

Lim J, Bhoo-Pathy N, Sothilingam S, Malek R, Sundram M, Hisham Bahadzor B, et al.

PLoS One, 2014;9(8):e104917.
PMID: 25111507 DOI: 10.1371/journal.pone.0104917

OBJECTIVES: To study the baseline PSA profile and determine the factors influencing the PSA levels within a multiethnic Asian setting.
MATERIALS AND METHODS: We conducted a cross-sectional study of 1054 men with no clinical evidence of prostate cancer, prostate surgery or 5α-reductase inhibitor treatment of known prostate conditions. The serum PSA concentration of each subject was assayed. Potential factors associated with PSA level including age, ethnicity, height, weight, family history of prostate cancer, lower urinary tract voiding symptoms (LUTS), prostate volume and digital rectal examination (DRE) were evaluated using univariable and multivariable analysis.
RESULTS: There were 38 men (3.6%) found to have a PSA level above 4 ng/ml and 1016 (96.4%) with a healthy PSA (≤4 ng/ml). The median PSA level of Malay, Chinese and Indian men was 1.00 ng/ml, 1.16 ng/ml and 0.83 ng/ml, respectively. Indians had a relatively lower median PSA level and prostate volume than Malays and Chinese, who shared a comparable median PSA value across all 10-years age groups. The PSA density was fairly similar amongst all ethnicities. Further analysis showed that ethnicity, weight and prostate volume were independent factors associated with age specific PSA level in the multivariable analysis (p<0.05).
CONCLUSION: These findings support the concept that the baseline PSA level varies between different ethnicities across all age groups. In addition to age and prostate volume, ethnicity may also need to be taken into account when investigating serum PSA concentrations in the multiethnic Asian population.

Matched MeSH terms: Digital Rectal Examination
Clinicopathological Features and Prognostic Value of Incidental Prostatic Adenocarcinoma in Radical Cystoprostatectomy Specimens: A Systematic Review and Meta-Analysis of 13,140 Patients

Fahmy O, Khairul-Asri MG, Schubert T, Renninger M, Stenzl A, Gakis G

J Urol, 2017 02;197(2):385-390.
PMID: 27569436 DOI: 10.1016/j.juro.2016.08.088

PURPOSE: There is controversy in the literature about the oncologic significance of incidental prostate cancer detected at radical cystoprostatectomy for bladder cancer.
MATERIALS AND METHODS: An online search was done for studies reporting incidental prostate cancer in cystoprostatectomy specimens. After following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines we identified a total of 34 reports containing 13,140 patients who underwent radical cystoprostatectomy for bladder cancer with no previous history of prostate cancer. A cumulative analysis was performed on the available data regarding prevalence, clinicopathological features and oncologic outcomes. RevMan, version 5.3 was used for data meta-analysis.
RESULTS: Of the 13,140 patients incidental prostate cancer was detected in 3,335 (24.4%). Incidental prostate cancer was significantly associated with greater age (Z = 3.81, p = 0.0001, d = 0.27, 95% CI -0.14-0.68), lymphovascular invasion of bladder cancer (Z = 2.07, p = 0.04, r = 0.14, 95% CI 0.09-0.18) and lower 5-year overall survival (Z = 2.2, p = 0.03). Among patients with clinically significant and insignificant prostate cancer those with clinically significant prostate cancer significantly more frequently showed a positive finding on digital rectal examination (Z = 3.12, p = 0.002, r = 0.10, 95% CI 0-0.19) and lower 5-year overall survival (Z = 2.49, p = 0.01) whereas no effect of age was observed (p = 0.15). Of 1,320 patients monitored for biochemical recurrence prostate specific antigen recurrence, defined as prostate specific antigen greater than 0.02 ng/ml, developed in 25 (1.9%) at between 3 and 102 months.
CONCLUSIONS: This meta-analysis suggests that incidental prostate cancer detected during histopathological examination of radical cystoprostatectomy specimens might be linked with adverse characteristics and outcomes in patients with invasive bladder cancer.

Matched MeSH terms: Digital Rectal Examination