Rectal exam for appendicitis

This method has been widely used in our country before and now, but in pediatrics. I had my appendix removed at the age of 28, probably the complaints and the results of palpation were so informative that no other confirmation was required.

Question for the more medically astute - was the rectal exam for appendicitis universal, or male only?

Even intuitively it seems logical that an internal pelvic exam would give good access to that region of the abdomen. What’s more, I have certified mainstream television dramedy proof!

Anyone remember Doogie Howser M.D., with the brilliant Neil Patrick Harris as a teenage medical prodigy with his medical degree? In one of the earlier episodes, he was on duty in the ER when his girlfriend was brought in for acute abdominal pain. The attending was busy but insisted that a pelvic exam must be done to verify appendicitis.

She begged him not to do it, but in the end, medical ethics won the day and the virgin doctor buried his fingers inside his virgin girlfriend. For her own good.

As a contemporary of young Neil and having a strong medical fetish, I never gave much thought to whether this was valid medical practice or not. I was too busy imagining myself being “forced” to perform the same on a few girlfriends of my own!

I suppose I’m ready for the truth…Did Doogie do the right thing here? Or should he have violated her back passage instead?

-g

Reference: https://www.imdb.com/title/tt0817152/

Again, this is all kinda superseded now by CT, if available. However, if not, a pelvic exam is vital, not so much to confirm appendicitis as to rule out a gyn cause of the pain such as ovarian cyst or torsion or some manifestation of pelvic inflammatory disease.

When I was 8 years old, I had to go to hospital with suspected appendicitis. After the doctor palpated my abdomen and did an ultrasound, I also had a rectal examination. He put two fingers in the back and pressed on my stomach with the other hand. I felt a lot of discomfort during that exam.

Interesting. I was always more nervous about the possibility of a pelvic exam, which I'd heard was one way they diagnosed appendicitis. Luckily I never had to find out.

This is really interesting this discussion about various types of imaging replacing physical examining. It turns up in quite a few discussions on Zity. I have a friend (in his sixties like me) who teaches medicine at a UK university. He has extra classes early in the morning for his clinical students, that's to say the ones shortly to take their finals and qualify. The classes are to cover what he describes as 'old fashioned skills of examination and diagnosis'. He does the extra classes because he says the students' training should include these skills but doesn't put the same priority on them now. He says his students appreciate the extra classes. But he's pretty firm as a teacher and I'm not sure he let's them choose whether they come to the classes.

He tells me good physical and mental exam and diagnostic skills are essential even in these days of such high quality imaging. He says a physical exam can assess far more quickly whether a patient may have a problem. And this can get them much quicker to an ultra sound or a MRI scan for confirmation and/or to a specialist team to deal with the problem.

I'm not a doctor so I just quote his point of view out of interest.

Personally, though, I do feel younger doctors I encounter definitely impress me with their professionalism and competence.

@Cefn It’s no different than older artists rejecting the new computer related medium as not true art, or before that rejecting photography as an art medium. Those who proposed the earth was round vs flat were ridiculed - or worse! Art, science, technology and medicine continue to evolve and change….for the good!

But it’s still good to appreciate the past.

Don’t believe rectal exams are used much for appendicitis diagnosis any more unless other tests are inconclusive. Even then, questionable. Modern tools are much more conclusive. Wonder how many appendices were wrongly removed because of this.

As @Dr_Philip said, this has been discussed before.

Before my appendectomy I had a rectal and gynecological examination because they were not completely sure that it was the appendix. At my appendix surgery I was 17.

The handbook for the norwegian ER, still say that a rectal is to be done. A rectal is a part of every abdominal exam, and is to be done before every surgery. It's the rule, but if it's done, i don't think so.

The lady that I am with had her first rectal exam, years ago. When she was in the hospital emergency, they feared she had an appendicitis, so the doctor came in he had her spread her legs and he inserted his finger. She did not have an appendicitis, she had a uterine fibroid and needed surgery instead.

This would have been 2001. A young guy I know, high school senior at the time, got a rectal exam as part of his diagnosis for appendicitis in the emergency room. His first rectal exam. I'm sure it was bad at the time but he laughed about it later.

Happened to me as a kid! Story similar to the first post, I suppose it was standard practice in France in that era!

Question for anyone reading this who is a medical profession, or who knows the answer... When you look at illustrations of the digestive system (male and female). the anus/rectum is nowhere near the cecum end of the upper intestine where the appendix is attached. I don't understand how literally a rectal exam could help diagnose a ruptured appendix. Also, if the patient is in so much pain due to the appendicitis, do they really notice any discomfort when a rectal exam is performed?

@turnheadandcough I found this answer :

In the physical examination for evaluation of appendicitis, digital rectal examination (DRE) has been considered necessary, it has been described that when the appendix hangs into the pelvis, abdominal findings may be absent; right-sided rectal tenderness is said to help in this situation.

https://www.elsevier.es/en-revista-medicina-universitaria-304-articulo-how-do-we-approach-an-S1665579616300540

Thank you @Woyzeck

This is occasionally done, but it is very, very uncommon as a diagnostic criteria nowadays. Indeed, the standard of care is abdominal exam to evaluate tenderness and rebound pain, abdominal ultrasound and confirmatory CT scan. A doctor who substituted a rectal and did not perform imaging would be considered to be committing malpractice, and if you are doing the imaging you would not need a rectal under any circumstances.

Retired FP Physician here. Folks need to remember that patients don't show up complaining of appedicitis or kidney stone, etc. (Well with the Internet now I suppose they do) but with a list of symptoms that the doctor should be doing everything he/she can to investigate the "Differential diagnoses" or list of possible causes of said symptoms. A thorough history and physical should be the first (low cost) items, and should be used to decide the next diagnostic steps in the process. A rectal exam should be a requirement in that process, but because the (expensive) CT Scan is now so easy to order, it frequently gets skipped to save time and energy. @Brooklynne I would argue that skipping the rectal exam is as much malpractice as skipping the CT Scan, and increases the cost of health care these days.

Lol, I think we’ll have to agree to disagree on this one @DocH2O…. I think it certainly WAS part of the standard of care (and perhaps was when you were in practice), but definitely now it is not (speaking as an attorney who regularly handles medical malpractice cases, and is married to a practising surgeon who works in the hospital setting). Definitely not in lieu of CT and ultrasound, which are far more accurate. And certainly if it were possible to substitute a rectal exam and get similarly reliable results, they would… hospitals are generally designed (sadly) to be cost effective wherever possible. Of course, if the patient shows up in a regular doctors office and not a hospital, perhaps a rectal is still performed. But I have reviewed literally dozens, maybe hundreds, of medical records involving appendicitis, and I have only ever seen a rectal exam performed or recommended in hospital twice- neither time as a direct criteria for diagnosis of appendicitis. Nor has that ever come up as a standard with any of the expert witnesses (physicians in practice) who we have had testify. At least not in modern medicine.

There would be no problem with a doctor who performed a rectal AND the imaging, but nobody would perform just the rectal, and very few would do a rectal when the imaging makes it unnecessary - which, in appendicitis specifically, is always.

Of course, I can speak only to what is common practice and standard of care in the countries where I have handled cases (mostly UK, and a few US).

Largely, it’s a pipe dream if you’re turning up with symptoms of appendicitis and expecting a rectal exam. You MIGHT get one if they think you are constipated or have a different type of intestinal complaint. But even then, it’s a rarity in the hospital setting these days.

@Brooklynne

I'm sure you're right about how appendicitis is diagnosed today. But I can tell you that I had two rectal exams--one in '86 and one in '00--when they suspected that I had appendicitis. The first was at my pediatrician's, the second was in the ER. It did used to be SOP.

@Brookelynne We are coming at this from totally opposite ends. I see a patient with certain symptoms, probably including abdominal pain, asking "What's causing this?" My contention is that with those symptoms, it would be malpractice to skip a rectal exam. With a history and physical that include appendicitis in the differential, I agree that imaging, usually a CT Scan is indicated. You, on the other hand are reviewing cases of diagnosed appendicitis, possibly missed, and saying that absense of a CT is malpractice, and I would agree in most cases. There are, however things in the H&P that might lead to other diagnoses or better imaging options.

That would have been nice. Although I was in a lot of pain when I made it to the hospital with appendicitis. I was 23 yrs old. And since I through up the contrast agent they skipped the CT and took me straight to the OR. Oh those lovely pain killers they gave me…

I had hoped to wake up with a catheter after surgery to remain in bed. But nothing.

When I was doing my surgical rotation in medical school the chief of surgery said the presumptive diagnosis of appendicitis is made with right lower quadrant pain and tenderness. We've sure moved beyond that!

@pollux That’s what was first done on me and then confirmed by digital rectal exam. All this done twice because the hospital wanted independent confirmation.

If I had one whenI was small with suspected appendicitis, I don't remember it.

When I was about 13 or 14, (1975 or 6) I was having belly pain pretty bad. My sister had just had her appendix removed a couple months before, so, erring on the side of caution, my folks took me to the ER. They got me into a room and had me remove my outer clothing and lay down in my underwear and a gown. The doctor came in and talked to my parents (not me). He removed the gown and palpated my belly, then told my parents he would have to do a rectal exam. (I had never had one) They got me rolled over onto my left side, pulled my underwear down, and bent my leg. He gloved up, lubed me up then went in. IT HURT! He spent what seemed like an eternity feeling around in there. The end result was that I only had very severe constipation, so he prescribed some suppositories, which my father had to teach me how to insert when we got home.