JustinPA Posted August 23, 2016 Share Posted August 23, 2016 When assessing for rectal tone with the digital rectal exam, are you simply assessing the amount of resistance when your finger enters or are you having the patient attempt to squeeze your finger? I was taught the first way, however I've read in some references that you are supposed to have the patient attempt to squeeze for assessment of tone. I feel like it's highly subjective and as far as I know I've never felt anyone with decreased tone on exam. Is it something you'll just know if you come across it? I came across this study which suggests even among experienced doctors it wasn't all that accurate, it also mentioned the squeeze test. http://www.ncbi.nlm.nih.gov/pubmed/25811266 If you are doing the squeeze test how are you instructing the patient to do it? Thanks. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 23, 2016 Share Posted August 23, 2016 Yes and yes. It's like everything else. You have to know normal to appreciate abnormal (lots of DREs). Also stick a snapped, sharp point cotton swab stick or 18 ga. needle around the anus and check for saddle anesthesia. Link to comment Share on other sites More sharing options...
Soulfari Posted August 23, 2016 Share Posted August 23, 2016 I don't practice EM but on my Neurosurgery rotation the attending used to crack jokes at documentation of "decreased/diminished rectal tone" - he would say, "It's either there or it ain't, and unless you have one finger in yourself and one finger in the patient theres no way you can document that it's 'deceased [from baseline]'" He was more in favor of the pinpoint sensation test mentioned above^^^ Link to comment Share on other sites More sharing options...
sk732 Posted August 23, 2016 Share Posted August 23, 2016 I had one that had unequal tone between the two sphincters...one of his complaints was fecal incontinence (go figure). Do enough rectal's and you'll notice a difference in "It's either there or it ain't". SK Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 23, 2016 Share Posted August 23, 2016 In a Level 1 trauma center - it was a finger in every orifice on trauma. We inserted a gloved lubed finger in the rectum of back fracture patients and ==== First - the "What the hell...." response meant they felt it and Second - we asked them to squeeze Then, we did cremasteric reflex on the inner thigh to see if the scrotal sac contracted and raised up. This is L1 and L2. Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 23, 2016 Share Posted August 23, 2016 Seems to me that within the last couple of years there was a case report of an assault charge for such an exam without obtaining pt. consent (pt. didn't want exam and expressed same multiple times). Trauma pt., and they won as I recall. Take away point, always tell pt. and get ok. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 23, 2016 Share Posted August 23, 2016 Seems to me that within the last couple of years there was a case report of an assault charge for such an exam without obtaining pt. consent (pt. didn't want exam and expressed same multiple times). Trauma pt., and they won as I recall. Take away point, always tell pt. and get ok. Yeah, informed is good. Drunk and rollover car crash with multisystem trauma - the trauma guys weren't awesome about "informed" anything on initial eval in the trauma room. Sometimes we found the drug stash in that particular orifice - little plastic baggy of unknown substance worth a lot of money. Hopefully not ruptured and soaking in...... The Neurosurgery residents would tell the patient "I am a neurosurgeon here to check out your spine injury. I have to make sure your spinal cord works. I have to see if you can squeeze your rectal muscles" - this usually happened AS the finger was approaching and going in. If you aren't in a Level I moving at light speed with multiple patients from multiple traumas - there is no excuse for not informing patients about needed exams. Not sure how I would respond if a patient refused..... "If you refuse this exam you could be paralyzed, incontinent, get decubitus ulcers and spend your life in a wheelchair with no function below the waist, etc." Haven't ever encountered that. Link to comment Share on other sites More sharing options...
SERENITY NOW Posted August 23, 2016 Share Posted August 23, 2016 At our level 1 trauma center we rectalize nearly everyone with legit trauma. Most of us do ask the patient to bear down "like you're trying to have a bowel movement" for the squeeze test. We just use the sharp edge of the lube gel for perianal sensation. Its true that you have to do a lot of DREs to get comfortable with them, but just practice on a few 90 year olds to get a sense of what decreased rectal tone feels like... you're finger will slide in with minimal to no resistance. Link to comment Share on other sites More sharing options...
Moderator ventana Posted August 23, 2016 Moderator Share Posted August 23, 2016 correct me if I am wrong (and I might be) but bowel and bladder incontinence from spinal injury is an upper motor neuron and this results in increased tone? and therefore overflow incontinence... course if you fracture at the level of the lower motor neuron then it might be flaccid..... hence more or less tone But am I correct in the above?? Link to comment Share on other sites More sharing options...
GetMeOuttaThisMess Posted August 23, 2016 Share Posted August 23, 2016 You can have either. Retention or loss of B/B function. Link to comment Share on other sites More sharing options...
moestown1016 Posted August 24, 2016 Share Posted August 24, 2016 One girl tried to trick a coworker into thinking she had no rectal tone on exam. She came in asking for an MRI for her chronic back pain or something. She tried to do the exam and asked the girl to squeeze. She said "I can't!". My coworker just paused for a few seconds while her finger was still in there without saying anything and she squeezed. Case closed. It's like "don't think about elephants!". She couldn't not do it. The one time I had a true cauda equina I kept telling him to squeeze and he kept saying "I can't" until he almost shouted at me that he couldn't. He also came in with a cane because he suddenly needed it to walk. Idk. I've only had one that I know of. Remembering that helps me document better. Why are you suddenly having problems with ambulation? I'm no expert obviously just what I've observed. Now I'm off to read more about it... Sent from my iPhone using Tapatalk Link to comment Share on other sites More sharing options...
sk732 Posted August 24, 2016 Share Posted August 24, 2016 I"d seen one in my previous life...then out of the blue we had two come trundling through our doors in here in the space of 6 monhs...and went trundling out almost as soon as they came in. SK Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 24, 2016 Share Posted August 24, 2016 I have seen Brown Sequard once with a chunk of bone retropulsed into the spinal cord from a fall and landing on feet, back, buttock. Have seen cauda equina 1-2 times with severe swelling around the spine with fracture requiring emergent decompression in the OR. I believe the other expired because the number of bullets and number of organs hit rendered injuries unfixable. "injuries inconsistent with life" was the attending's determination in the OR. You can take out the spleen, pack the liver and resect some, take out some kidney, try to stent a ureter and keep putting blood in but it continues to leak from the swiss cheesed aorta and other arteries and things go downhill from there. I ran the bowel and couldn't find more than about a 4-5 cm stretch without a perf from a shotgun pellet and it was starting to turn blue on the table. Too many holes to patch and too much blood much less the spinal injury, swelling and nerve compression. It wasn't his day........................ Don't forget bilateral calcaneal fractures from jumping or falling off roofs and the 50% chance of an L1/L2 burst from impact. The guy was wailing in pain and the dipthong ER doc gave him a whopping dose of morphine to quiet him before we could do the neuro exam. He had a 50% compression of L1 and was so stoned we couldn't do a thorough neuro exam. Gave the guy narcan and WOW - that really woke up his pain fibers. Thankfully his sphincter worked and my doc didn't kill the whiney ER dude. His calcanei were, however dust and at a very young age he had a horrendous injury and ending up having to rehab in a nursing home for 3-4 months. I think I recall a skateboard and a roof being involved.................... Link to comment Share on other sites More sharing options...
DolphinsPA2 Posted August 25, 2016 Share Posted August 25, 2016 You can have either. Retention or loss of B/B function. You typically have retention first that leads to overflow incontinene Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 25, 2016 Share Posted August 25, 2016 The guy was wailing in pain and the dipthong ER doc gave him a whopping dose of morphine to quiet him before we could do the neuro exam. He had a 50% compression of L1 and was so stoned we couldn't do a thorough neuro exam. Gave the guy narcan and WOW - that really woke up his pain fibers. Thankfully his sphincter worked and my doc didn't kill the whiney ER dude. His calcanei were, however dust and at a very young age he had a horrendous injury and ending up having to rehab in a nursing home for 3-4 months. I think I recall a skateboard and a roof being involved.................... Traumatic pain needs pain control, usually fentanyl. Lots of evidence that appropriate analgesia doesn't interfere with examination. Maybe he was over-sedated, but we've all given someone an appropriate dose of narcotics only to find the pt was unusually susceptible to them and get overly-sedated. I don't worry about this in significant trauma, cause if they get too drowsy then they get plastic. Would you want your son sitting in my ED with dusted calcanei and a new L1 compression fx for 30 minutes or an hour while waiting for a consultant? I wouldn't. Re decreased rectal tone - this is supposedly a late finding in CES. Link to comment Share on other sites More sharing options...
Reality Check 2 Posted August 25, 2016 Share Posted August 25, 2016 Traumatic pain needs pain control, usually fentanyl. Lots of evidence that appropriate analgesia doesn't interfere with examination. Maybe he was over-sedated, but we've all given someone an appropriate dose of narcotics only to find the pt was unusually susceptible to them and get overly-sedated. I don't worry about this in significant trauma, cause if they get too drowsy then they get plastic. Would you want your son sitting in my ED with dusted calcanei and a new L1 compression fx for 30 minutes or an hour while waiting for a consultant? I wouldn't. Re decreased rectal tone - this is supposedly a late finding in CES. This guy was SO narc'ed that he fell asleep between words and was drooling. I think a bit too much narcotic perhaps..... I am not opposed to pain mgmt but this doc snowed the patient to keep him quiet for the doc's benefit - nothing to do with patient safety. We couldn't even get him to say his name or tell us what happened much less do a thorough reliable exam. What if the patient needs to sign a surgical consent with heavy narcs on board? Always a concern. So, I get your point. My patient was over medicated for all the wrong reasons. Link to comment Share on other sites More sharing options...
Boatswain2PA Posted August 25, 2016 Share Posted August 25, 2016 Gotchya. Link to comment Share on other sites More sharing options...
ohiovolffemtp Posted August 29, 2016 Share Posted August 29, 2016 I had a patient with conversion disorder that actually had no rectal tone. Her emergent MRI did show cord compression but the on-call spinal surgeon said not enough to actually cause the unilateral leg flaccidity she showed. She wasn't faking. Her flaccid leg stayed flaccid even when she lifted the non-affected leg. Link to comment Share on other sites More sharing options...
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