Reader Q: Take A Laxative Before A Rectal?

Bob Asks:

Hi doc! I have an appointment with a urologist in a few days for an enlarged prostate.

I know the doc will probably need to do a digital rectal exam. Should I take a laxative or something else similar to what you’d take before a colonoscopy in order to make sure the rectal cavity is empty?

This is rather embarrassing and I don’t want to make this any more unpleasant for myself or the doctor than it has to be.

Also, if you think I should use a laxative, which one should I use, and how long before the appointment should I use it?

The Ignominous Future of Every Human With A Prostate
The Ignominious Future of Every Human With A Prostate

Bob –

It’s good for me to get questions like this because I often forget how much anxiety a physical exam can cause.  I only recently learned that many women shave their legs, and often wax their pubic areas, in preparation for their pelvic exams.

One woman, just as I was about to insert the speculum, said something along the lines of, “See doc?  No hair!  Isn’t that nice?”

The truth is that performing physical exams – the scientific evaluation of the of the human body – is the job of every doctor.  By the time we’re fully-trained, we’ve done thousands of them.  This makes non-medical things like smell, hair, feces, dirt, grime, growths, etc, decidedly uninteresting.

There really is a disconnect between the medical and non-medical parts of a physical exam.  This is part of the bigger question about how a male Ob/Gyn, for example, can see breasts and vaginas all day and then go home and be sexually attracted to his wife.  To most Ob/Gyns in that situation, it’s a strange question.  They’re two totally different worlds.

Plus, after you’ve done so many physical exams, you’ve seen some pretty crazy things.  Most ER’s have a “butt box”, for example.  This is a place where all the things people have inserted – in a state of sexual arousal, or out of just plain curiosity – into their rectums.  I had a patient once who came in with a full-size can of deodorant in his rectum.  “Fell on it in the shower, dude.  Can you get it out?”

So, it takes a lot for a PE to be memorable for a doctor.

That said, yes, a laxative might reduce the fecal matter in your rectum prior to the exam.  Over-the-counter laxatives won’t clean you out like the stuff they give you before a colonoscopy, but honestly dude, you don’t need that.  I’d do the laxative – any over the counter brand is fine – about 6 hours before your appointment, and make sure you’re near a bathroom!

It Could Be Worse..
It Could Be Worse..

Remember that a rectal exam takes all of 8 seconds.  The doc then quickly pulls the glove off and tosses it in the trash can.  Even if covered in something icky, you barely see it and rarely smell it.  I’d just recommend a good shower prior to your appointment.

If you’re really worried about this issue, you could do an enema.  There are over the counter versions you can do yourself, or you can have them done by a pro…which probably would not be helpful in your case!  An enema the day before your appointment will remove most of any material in your rectum.  So, you might feel less anxious prior to the appointment.

But again…all we ask is a good shower.

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Missed Diagnosis

So, I finally did it. I correctly diagnosed a previously-missed diagnosis. I’ve found that most of the time when a doc talks about catching something all the other super-smart docs missed, they have some sort of ax to grind. Most commonly – and not to start a war about the merits of chiropractic – I’ve heard it from chiropractors. I even heard one talk about how he correctly diagnosed herpes zoster after the patient had seen two other specialists.

Sometimes, like with the chiro guy, I don’t believe the stories. Mostly, though, I don’t believe in myself enough to think that I could catch something these other incredibly smart docs miss. I remember my med school class. Those people were SHARP. I watched them evaluate and diagnose patients every day. It never seemed like they missed a THING while I was always bumbling around trying to untangle myself from the IV tubing. Now, in residency, I’m a little less in touch with my colleagues, but they all seem so infallibly competent as well. I trust most of them implicitly. This is doubly true of the docs who are working and practicing in the community. These are full-fledged doctors. How could I ever do it better than them?

But I did. It wasn’t because I was smarter or better. The diagnosis was simple. If anything, I picked up what others missed just by listening to the story. Maybe everyone else was rushed when they saw this patient. They all got into highly competitive residencies and ostensibly know more medicine than me. But somehow, four doctors mis-diagnosed this patient. I knew his problem within 10 minutes.

The patient is a middle-aged male who came in saying he had an appointment with a specialist (a urologist) because he’s been having severe pelvic pain for the past 2 weeks. Come to think of it, it’s actually been much longer than that, but the past 2 weeks it’s been really bad. He was seen by two doctors in an urgent care clinic, who first gave him antibiotics and told him he had an infected prostate (in spite of a perfectly normal UA), and then gave him pain meds and told him to go to the ER if things got worse. Then he went to our vaunted ER, and was also told he had prostatitis and maybe prostate cancer and that he needed to see a specialist.

Sitting my office, he says he “hates doctors” (greaat, nice to meet you too) and hasn’t seen one since he was 12. He’s one of those tougher-than wood kinda guys that has worked in construction since the trade was invented. And I notice that he’s near tears. It’s the cancer bit, I figure. Works every time. I don’t know why docs throw that out there when they have no evidence. So now this guy is sitting on the exam table, visibly shaking, taking deep breaths and scared to death. I’m thinking that it would be easier to make a slab of drywall cry than to make a guy like this emotional, so I know he’s about a low at he gets.

None of his symptoms sound like prostatitis. Or a UTI, which is pretty rare in males anyway. The pain argues against cancer. Few people this upset are mere drug-seekers, and he isn’t asking for drugs anyway (although seekers use this tack frequently too). “Let me see this famed abdomen,” I say. I already have an idea that he simply has hernias. Sure enough, one quick check and it’s abundantly clear he has bilateral, indirect inguinal hernias. A med student coulda made that diagnosis. I think HE thought it was hernias. But both he and I figured we must be wrong because all these brilliant, well-trained docs said it was something else.

“Nobody’s actually done that exam thing on me,” He said as I took off my glove. “They always just jammed a finger up my butt. Don’t you need to do that too? I HATE the finger thing.”

“I hate that test too” I said (just read my blog about it, I think sardonically) “But I’d do it if I thought you needed it…and you don’t. You have hernias and if you go see that urologist, whatever doc referred you there is going to be pretty embarrassed. Cancel the appointment. Today. You don’t have cancer, either. It’s a simple surgical problem; you’ll be out of the hospital the same day.”

He couldn’t believe it. “REALLY?” He says. We look at each other in perfect understanding. I’m not offended by his suspicion. I’m this punk family medicine resident, not even out of training yet. I ride a skateboard to work, my hair’s never combed and I’m rarely on time. I went to school in Israel as a ploy to make global traveling look legitimate. Who am I to contradict wiser heads than mine?

“Man, I’m telling you. I’m dead-on. It’s hernias.” It felt good, strong, to say that. Even if it was only hernias.

Yesterday, I saw the guy again. Surgery is done. He’s all wide-eyed and looking at me like I’m brilliant. Says he told everyone in the ER (went back there while waiting for surgery because the pain got so bad, and got the surgery emergently that night) that I was the only doc in town who got the diagnosis right. I’m sure the ER doc loved hearing THAT. In truth, I made an elementary diagnosis partly because other stuff had been ruled out and partly because I had the time and wherewithal to really listen to the guy’s story. I think that’s why there’s more than one doc on this planet, and why there’s such a thing as second opinions. None of us gets it right every time, which is why I hate medical litigation. We’re all just human. I don’t even want to THINK about how many times my colleagues have picked up the fragmented pieces of my near-misses and forged them into a good outcome for my patients. But, for once, it was gratifying to be the guy who picked up the pieces. To make things right. This patient thinks I’m a hero. I figure it was just my turn…and it sure was fun.

The Rectal Is Dead…Long Live The Rectal

My R-1 presented a case this morning, describing a 58 year old woman with left lower abdominal pain. Tradition holds that, in these situations, you get the patient’s name, ask a few other inconsequential questions, and then immediately jam your finger into their rectum.

O.K., that’s hyperbole. But from the perspective of an intern, sometimes that’s exactly how it seems.

“We have a 58 year old lady with left lower quadrant pain wh-”

“Did you do a rectal?”

So, the rectal exam looms over the entire patient encounter, tapping impatiently on the back of your skull until you finally relent and just get it over with. Not to be crass (although I’m post-call and feeling a little punchy), but doing a rectal – especially the first few – is a little like I remember the first kisses of my high school girlfriends (all 2 of them). At some point, The Kiss becomes the elephant in the room. I know I’m about to drop her off at her house, and I know we’re at that point where I have to kiss her or walk away, and so I procrastinate and ask all kinds of stupid questions to delay the inevitable.

rectal.jpgBut unlike a kiss (which is more like a rectal exam than you might think…so don’t think about it), I have never wanted to do a rectal exam. As medical students and interns, however, the exam is not only expected…it’s DEMANDED. One sure way to get torn up by an attending is to skip the rectal exam. Here’s a few of the things you’re supposed to be able to learn from the simple “digital sweep”:

– if there’s feces in the “rectal vault” and whether it’s hard (suggesting constipation) or soft
-if there’s blood (have to smear your finger on a test-card after the rectal exam, which isn’t pretty looking or smelling.
-if there’s external hemorrhoids
-if there’s rectal sphincter tone (if not, worry about major neurological trauma or stroke)
-if there’s polyps
-theoretically you can identify a fissure which can be a major source of bleeding
-you can check the prostate on males and feel for nodules (has almost no statistical correlation to prostate cancer, but we do it anyway in this country)

So, that’s a lot of stuff you can figure out with a simple rectal exam. Today, my intern failed to do the exam. He failed to “remember” it the other day as well. The ire of our attending was impressive as a result, but still, I think my intern will “forget” to do the exam on his next patient as well. Here’s some reasons why:

-the exam is an outmoded test that isn’t necessary – only old-school docs still do it
-it often stinks
-it makes everyone uncomfortable – doc and patient
-I can’t think of many places I’d less like to be
-modern imaging and a good history give you just as much information
-it really, really stinks

sunfinger.jpgThere was a time when every patient who came to the ER got a rectal by a hapless med student or intern. It was like they just wandered around the unit with an extended finger, a box of gloves and some KY, looking into every exam room. These days, even many ER docs don’t do the exam. Same for the admitting internists. The truth is that many physical exam techniques are becoming extinct, much to the dismay of the Old Guard who believe that you can diagnose everything from a triple-A to a spinal abscess with a good stethoscope and a tongue depressor. Back in the day, the physical exam was just about all a doctor had to diagnose serious disease. These days, we have all kinds of nifty tools that, yes, cost bajillions of dollars but spare us the ignominy of coating our fingers with someone else’s feces. Frankly, to most of us, it’s worth it.