Abstract
Dear Editor:
Changes in people's usual bowel habits present clinically as constipation or diarrhea. Successful palliation of such problems is optimized by understanding the most likely pathophysiology underlying the symptom. However such problems are highly subjective. An assessment must therefore always begin with the person's self-description of their problems, supplemented with physical examination. Specialist gastroenterology and palliative care guidelines recommend that this includes a digital rectal examination (DRE).1–3
The reasons for this recommendation include the fact that few data prove a relationship between constipation symptoms and the anatomical site of pathology. 4 In real terms, there is a risk of failing to identify people whose symptoms could be due to apparently contradictory mechanisms. For example, people who present complaining of diarrhea often in fact have overflow diarrhea. 5 Furthermore, people who have impaired anorectal sensation may not be able to reliably describe their physical sensations. 6
A DRE is a quick, easy, and safe examination that correlates with other objective measures of the neuromuscular structures of defecation. 7 It is possible at the bedside to assess the strength of the sphincteric and supportive pelvic muscles and exclude a neuropathy. Fecal impaction may be reliably diagnosed 5 and local disorders such as hemorrhoids excluded. Given the evidence that supports the DRE as a useful diagnostic tool, the limited capacity of palliative care patients to tolerate more invasive assessments, and the incidence of disturbed bowel function in palliative care, it would be expected this is routine when making a palliative assessment of bowel disturbances.
To explore this, with the approval of the institution's research office, the inpatient files of 166 admissions to tertiary referral palliative care inpatient unit were reviewed. The main aim was to ascertain how commonly rectal examinations were undertaken as part of the admission process. Of this cohort, 116 (68%) had laxatives prescribed on admission, only 52 (31%) had “constipation” listed as a problem. “Fecal incontinence” was reported in 14 (8%), and three (2%) were described as having “diarrhea.” However, only six people (4%) had a rectal examination recorded in the notes, with only three of these undertaken in patients identified as being “constipated.” None of the people described as being “incontinent” or having “diarrhea” had a DRE documented as part of their admission. When performed, documentation of the rectal examinations was scanty, with no records describing inspection of the perineum, anocutaneous sensation, or assessment of pelvic or abdominal muscle strength. Three described the rectal contents, with only one diagnosis of impaction made. Three descriptions commented on the anal sphincter tone which was described as “lax” in two cases and “normal” in the other.
This scarcity with which DRE was undertaken study implies that many palliative care practitioners may not recognize the potential usefulness of the DRE to diagnosis and classify the disease-related constipation of palliative care. Further study and dissemination of information regarding the use of the DRE as part of the comprehensive assessment of constipation, diarrhea and fecal incontinence in this population is warranted.