Is the Physician Expertise in Digital Rectal Examination of Value in Detecting Anal Tone in Comparison to Anorectal Manometry?

Abstract

BACKGROUND: Digital rectal examination (DRE) is part of the physical examination, is also essential for the colorectal surgeon evaluation. A good DRE offers precious information related to the patient’s complaints, which will help in decision making. It is simple, quick and minimally invasive. In many centers around the world, the DRE is still the only method to evaluate the anal sphincter prior to patient’s management. On the other hand, anorectal manometry (ARM) is the main method for objective functional evaluation of anal sphincter pressures. The discrepancy of DRE depending on the examiner to determine sphincter tonus in comparison to ARM motivated this study. OBJECTIVE: To compare the DRE performed by proficient and non-experienced examiners to sphincter pressure parameters obtained at ARM, depending on examiners expertise. METHODS: Thirty-six consecutive patients with complaints of fecal incontinence or chronic constipation, from the anorectal physiology clinic of the University of São Paulo School of Medicine, were prospectively included. Each patient underwent ARM and DRE performed by two senior colorectal surgeons and one junior colorectal surgeon prior to the ARM. Patient’s history was blinded for the examiner’s knowledge, also the impressions of each examiner were blinded from the others. For the DRE rest and squeeze pressures were classified by an objective scale (DRE scoring system) that was compared to the parameters of the ARM for the analysis. The results obtained at the ARM were compared to the DRE performed by the seniors and the junior colorectal surgeons. STATISTICAL ANALYSIS: Descriptive analysis was performed for all parameters. For the rest and squeeze pressures the Gamma index was used for the comparison between the DRE and ARM, which varied from 0 to 1. The closer to 1 the better was the agreement. RESULTS: The mean age was 48 years old and 55.5% of patients were female. The agreement of rest anal pressures between the ARM and the DRE performed by the senior proficient examiners was 0.7 (CI 95%; 0.32-1.0), while for the junior non-experienced examiner was 0.52 (CI 95%; 0.09-0.96). The agreement of squeeze pressures was 0.96 (CI 95%; 0.87-1.0) for the seniors and 0.52 (CI 95%; 0.16-0.89) for the junior examiner. CONCLUSION: More experienced colorectal surgeons used to DRE had a more significant agreement with the ARM, thereafter would have more appropriate therapeutic management to patients with sphincter functional problems. ARM, therefore, persists as an important exam to objectively evaluate the sphincter complex, justifying its utility in the clinical practice.

To what extent are anorectal function tests comparable? A study comparing digital rectal examination, anal electromyography, 3-dimensional high-resolution anal manometry, and transperineal ultrasound

“…The correlation between the surgeons' DRE, pelvic floor physical therapists' DRE, and the 3D-HRAM in our study was moderate and somewhat better for squeeze tone/pressures than resting tone/pressures. Several studies compared DRE with ARM and showed an overall good agreement of pressures, however similar to our study, slightly better for squeeze pressures, but results are not consistent [9,15,[34][35][36][37][38][39]. For example, the study by Beatrice et al showed that DRE correlates well, but not perfectly, with the ARM for resting pressures, (r = 0.71 (p < 0.001) [9].…”

“…In contrast, Soh et al described a poor agreement between DRE and ARM for resting pressures with a k coefficient of 0.01 and a moderate agreement for squeeze pressure with a k coefficient of 0.42 [ 35 ]. Pinto et al showed a moderate to strong agreement for resting pressure with a Gamma index of 0.7 and a strong correlation of the squeeze pressures with a Gamma of 0.96 [ 37 ]. All studies—including ours—report that the examinations were performed by experienced examiners but the results vary considerably.…”

Tonus anal : déterminant physiologique, évaluation clinique et paraclinique, caractéristique pathologique

“…Ce score est critiquable, non pas tant dans sa dimension « tonique » que dans celui testant la force musculaire, car les scores « supra-normaux » sont difficilement envisageables. D'une manière générale l'examen du tonus et de la motricité anale sont plutôt en accord avec les données manométriques [8,9,10], ce qui n'est pas confirmé par toutes les études [11,12,13,14] notamment en termes de sensibilité et en particulier chez les médecins juniors [13].…”

Design of a printed electrochemical strip towards miRNA-21 detection in urine samples: optimization of the experimental procedures for real sample application

“…Additionally, DREs are subjective tests and the degree of precision depends on the examiner's experience [ 8 ]. In a meta-analysis, DRE has shown a sensitivity and a positive predictive value (PPV) of 17.8% for PCa [ 6 ].…”