Age and Ageing 1998; 27: 353-356

Rectal examinations in elderly subjects:attitudes of patients and doctorsROSEMARY MORGAN, BRANWELL SPENCER1, DEBRA KING1

Department of Geriatric Medicine, Stepping Hill Hospital, Stockport SK2 7JE, UK'Department of Medicine for the Elderly, Arrowe Park Hosprtal, Wirral, Merseyside L49 5PE, UK

Address correspondence to: R. Morgan. Fax: (+44) 151 604 7192

AbstractObjective: to determine the attitudes of older patients and hospital doctors to rectal examinations.Design: a structured interview and audit of case notes.Setting: departments of medicine for the elderly in two NHS hospitals.Subjects: 178 mentally alert patients and 76 hospital doctors in general and geriatric medicine.Results: some patients would feel embarrassed (13%), offended (2%), reluctant (11%) or neutral (73%) if asked toundergo a rectal examination (PR). Most (76%) thought a PR examination was important and 92% would givepermission if a doctor asked. Of 200 case notes audited, only 38 patients had a PR documented.Of the hospitaldoctors interviewed 3 said they would routinely do a PR examination. Some doctors lacked confidence in detectinga rectal mass (33%) or abnormal prostate (41%). Thirty (39%) of doctors thought elderly patients were offended byPR examinations and 65% that there was not sufficient training in this procedure.Conclusion: most older patients do not find PR examinations disagreeable and regard it as an importantexamination. Despite this, few doctors routinely perform this procedure and some feel unable to detectabnormalities. The importance of PR examinations and adequate training needs to be addressed.

Keywords: elderly subjects, rectal examination

IntroductionMedical students and junior doctors are taught thatdigital examination of the rectum (PR) should be part ofany general physical examination. This simple proce-dure may be omitted for a number of reasons, includingobjection by the patients—who may find the proce-dure disagreeable —and extra trouble for the doctor,who may also find it unpleasant [1]. Rectal examinationis especially important in the older patient in whompathology is more common [2].

The attitudes of older people to this procedurehave not previously been established. Patients' anddoctors' attitudes may influence whether the proce-dure is performed as part of the routine physicalexamination.

One hundred and seventy-eight elderly alert inpa-tients (abbreviated mental test score [3] ^8/10; medianage 82 years, 116 females) were interviewed by adoctor on their views on PR examinations using asupervised questionnaire. All patients had recoveredfrom the acute phase of their illness and all welcomeddiscussion. The case note audit was independent of thepatient questionnaire.

Seventy-six hospital doctors working in general andgeriatric medicine at five hospitals in the North West ofEngland were interviewed at random by telephone ontheir views on rectal examinations, using a standardquestionnaire. All doctors contacted participated in thestudy.

Results

Subjects and methods

The study was approved by two district ethicscommittees. Two hundred case notes of patients(median age 82 years, 121 females) admitted to acutegeriatric wards in two NHS trust hospitals were auditedusing a standardi2ed proforma.

Case notes

Of the 200 case notes audited, only 38 patients (20female) had a PR examination documented. Consis-tency of stool was not documented in 21 patients. Ofthe 18 male patients, eight had no description of theprostate gland. Most of the PR examinations (27/38)

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Table I. Frequency that various grades of doctorperformed rectal examinations (PR) when examiningpatients on admission

Grade of doctor

House officerSenior house officerSenior registrar/registrar

No. of examinations

Total

32161

7

With PRs

13196

X =18.36, P< 0.0001

had positive results, including rectal mass (two)impacted faeces (14), abnormal prostate (five), rectalprolapse (two), blood (three) and third-degree haemor-rhoids (one). In all of these cases, the findings in rectalexamination influenced (use of enemas or laxatives,sigmoidoscopy or referral to the urologist or generalsurgeon). Information from the nursing staff revealedthat 10 patients were faecally incontinent but only twoof these had a PR examination, whilst in 34 patientswith urinary incontinence only four had a PRexamination. Registrars were most likely to perform aPR if they had clerked the patient initially (Table 1; x2 =18.4, P < 0.0001).

Sixty-one patients were taking laxatives: fybogel(three), senna (23), codanthromer (14) and lactulose(21). Only 22 patients who were prescribed laxativeshad a PR documented in the case notes.

Patient questionnaire

Thirty (17%) of the patients questioned had had a PRexamination and six could not recall a doctor askingpermission to do this examination. Only one thirdrecalled a doctor explaining the reason for the need forthis examination.

None of the patients had refused permission for arectal examination. Most (76%), thought that theexamination was important, 20% were not sure andonly 4% did not think it was important. Fourteen patientswho were not sure if the examination was importantthought it could be under certain circumstances.

Although 23 (13%) would feel embarrassed, 19(11%) reluctant, three (2%) offended, four (2%) upset,the majority 129 (73%) would feel neutral if a doctorasked to examine the back passage. Most patients(92%) said that they would give permission for a rectalexamination if a doctor asked. Only seven would refuseand seven were not sure what response they wouldgive. Some patients who felt reluctant or embarrassedwould give permission if a doctor requested it.

The majority of patients (84%) had no preferencewhether a PR examination was carried out by a femaleor a male doctor. More female patients expressed apreference for a female doctor than male patients for a

male doctor to perform a rectal examination (23/116versus 3/62, x

2 = 5.67, P < 0.02).

Doctors' attitudes to PR examinations

The hospital doctors who were interviewed included48 males and 28 females (Figure 1). Most (53) were UKgraduates. Only three said they would routinely do a PRexamination in every patient they examined (oneconsultant and two house officers).

Some doctors (33%) did not feel confident in theirability to detect a rectal mass whilst some (41%) did notfeel confident in their ability to detect an abnormalprostate gland. Two-thirds believed they had insuffi-cient training in rectal examinations. Most (79%) feltcomfortable in performing PR examinations, however,30 (39%) thought that elderly patients were offendedby a PR examination.

The equipment for PR examinations, disposablegloves, lubricating jelly and gau2e were readily availableon all the acute geriatric wards in this study.

Discussion

Digital examination of the rectum is an importantpart of a physical examination but especially so in theolder patient, in whom pathology is more common.Inspection alone my reveal rectal prolapse, prolapsedinternal haemorrhoids, pruritus ani, perianal haemato-mas, external orifices of a fistula in ano or a sentinel tagof a fissure, ulcers and peri-anal abscesses andcarcinoma of the anus [4]. Many patients over the age

Constipation

Diarrhoea

Confusion

Weight Loss

Urinary Problems

Abdo Pai

Gl Bleed

1 I ' ' " I ' " ' I " TT T " " I ' ' " I ' r T T l "10 20 30 40 50 60 70 80

% Doctors

Figure I. Clinical conditions for which junior doctorswould request permission from an elderly patient toperform a rectal examination.

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Rectal examinations in older people

of 50 years admitted to general medical and surgicalwards do not have rectal examinations performed [5]

Older patients are predisposed to constipationbecause of physical inactivity [6], a reduced fluidconsumption and a reduction in consumption of foodand fibre. Up to 50% of people aged 60 years or moreliving at home use laxatives [7], which can causedehydration, hypokalaemia and myenteric plexusdamage [8] and may therefore aggravate constipation.The older patient is also more likely to be onmedication which contributes to constipation (e.g.sedatives, opiates and diuretics). Complications ofconstipation include idiopathic megacolon [9] andfaecal incontinence.

Faecal incontinence and the indignity it causes anolder person can always be avoided if managedcorrectly. In one study [10] of long-stay geriatricwards, there was a 45% incidence of faecal incon-tinence. In a more recent study [11] 26% of older peopleon geriatric wards were doubly incontinent. In our study5% (10) of the patients were faecally incontinent butonly two had undergone a PR examination.

Faecal incontinence may arise from underlyingdisease of the colon or rectum or anal sphincter,neurogenic change and faecal impaction [12]. Faecalimpaction may cause urinary incontinence due toretention with overflow or with loss of bladdercapacity. In this study only four of the 34 patientswith urinary incontinence had undergone a PRexamination. Faecal impaction may also cause anacute confusional- state and abdominal pain [13]-Only three of 21 patients with acute confusion had aPR examination whilst six of 13 patients withabdominal pain had had a PR examination.

Colorectal cancer is the second most commoncancer in the UK, with between 25 000 and 28 000new cases each year [2, 14]. The incidence begins torise appreciably after the age of 40, when it rises ineach decade by a factor of 2 until it reaches a peakbetween the ages of 75 and 85 [15]. Since mostpatients will present in the sixth and seventh decades,colorectal cancer represents an important problem inold age [16, 17]. About 55% of colorectal carcinomasinvolve the rectum and 35-50% can be diagnosed bydigital examination [18]. In our study of the 38 PRexaminations performed, two revealed a rectal massand these were referred to the surgeon. Althoughsymptoms may have led to a PR being performed,potentially resectable carcinomas may be missedbecause of failure to do PR examinations in olderpatients.

Prostate cancer is the third most common cancer inmen in England and Wales accounting for 11.5% of allmale cancers [19]. The average age at diagnosis inEngland and Wales is 73 years and most are beyondsurgical cure at presentation. In North America, whereroutine health checks including regular rectal exam-inations have been commonplace, the average age at

diagnosis is 66 years with up to half of cancers beingconfined to the prostate and therefore potentiallycurable by radical prostatectomy. Combining prostate-specific antigen measurements with rectal examina-tions increases the positive predictive value from 32 to49% [20]. Of the five abnormal prostate glandsdocumented in the medical notes in our study, threehad advanced prostatic carcinoma and were treatedwith endocrine therapy. There was a failure to mentionthe prostate gland in eight of the 18 PR examinationsdone on male patients.

Few junior doctors routinely do PR examinations onelderly patients. House officers are more likely toperform a PR examination than senior house officers.This might suggest that they leave medical school withthe knowledge that PR examinations are important,but as they advance they are less enthusiastic aboutperforming this simple procedure. Another explana-tion may be that die examination is delegated to themost junior member of the team. It is of concern that49 (65%) doctors interviewed did not feel they hadsufficient training in PR examinations and several didnot feel confident in detecting a rectal mass 25 (33%)orabnormal prostate gland 31 (4l%).There may be manyreasons for failure to perform a PR examination. Juniordoctors with increasing pressure on their time maydefer a PR examination on admission, intending to do itat a later date but unfortunately never finding the timeto do it or simply forgetting. If senior doctors overlookthe fact that their elderly patient has not had a PRexamination then their trainees may take this as tacitagreement that such an examination is not expected.Another factor may be lack of confidence by doctors intheir ability to detect an abnormality on PR examina-tion: many may feel that there is no point to subjectingtheir patient to such an examination since they may notbe able to detect an abnormality even if one were to bepresent. Some doctors may not do PR examinationsbecause they find it an unpleasant procedure. Therewas no lack of the basic equipment needed for doing arectal examination on any of the acute geriatric wardsin this study.

On some geriatric wards, nurses routinely performPR examinations to check for faecal impaction.However, nurses are not trained to detect rectal orprostatic masses, so the responsibility for an initialrectal examination should remain with the doctor.

The finding that 30 (40%) of junior doctors believethat elderly patients are offended by rectal examina-tions is interesting, as we found that only a few (2%)patients feel this way. Are doctors projecting their ownfeelings about this examination onto their elderlypatients? Younger doctors may regard the thought ofa PR examination on themselves as something that isoffensive and an invasion of privacy. Some olderpatients are pre-occupated by their bowels, havinglived through an era where regular and frequent bowelactions were thought to be important for a healthy life.

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Hence they may be less reluctant than people of otherages to undergo this examination. Perhaps olderpatients may accept a PR examination as a conse-quence of greater awareness of an increased risk ofcolorectal disease.

Although there is no evidence that rectal examina-tions have any value as a screening procedure in theadult population as a whole, in the elderly patient (in•whom pathology is not only more common but whomay have an atypical clinical presentation) rectalexaminations are important. Early detection of anabnormality might avoid unnecessary investigationsand a more appropriate management.

hi conclusion, hospital doctors are not performing PRexaminations as often as they should. The importance ofthis simple examination needs to be reinforced inundergraduate and postgraduate education.

Key points• Few hospital doctors routinely perform rectal

examinations on older patients.• Two-thirds of hospital doctors felt inadequately

trained in this procedure.• Some doctors lack confidence in detecting abnor-

malities on rectal examination.• Over one-third of doctors thought elderly patients

were offended by rectal examinations.• Most older patients would give permission for a

rectal examination.• Most older patients do not find rectal examina-

tions disagreeable and regard it as an importantexamination.

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Received 13 April 1997

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