The Trauma Professional's Blog
Don’t Ignore The Naughty Bits

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

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Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis - Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum - Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina - external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum - Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus - Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft - Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position. 

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

Related posts:


Don’t Ignore The Naughty Bits

A major part of any patient encounter is the physical exam. This is particularly true in the trauma patient, because it allows trauma professionals to identify potential life and limb threatening injuries quickly and deal with them. Unfortunately, we tend to mentally block out certain parts of the body, typically the genitalia and perineum, and may not do a complete exam of the area. I call these areas the naughty bits. For those of you who don’t get the reference, here’s the origin of this phrase:

Specifically, the naughty bits are the penis, vagina, perineum, anus and natal cleft (aka the butt crack or arse crack). These areas are more likely to remain covered when the patient arrives, and are less likely to be examined thoroughly.

In penetrating trauma, a detailed exam of these areas is extremely important in every patient to avoid hidden injuries and to determine if nearby internal structures (rectum, urethra) might have been injured.

Here are some tips for each of the areas:

  • Penis - Always look for any blood at the meatus (or a little blood in the underwear) as a possible sign of urethral injury. This is frequently associated with pelvic fractures.
  • Scrotum - Blood staining here is usually from blood dissecting away from pelvic fractures. Patients with this finding are more likely to need angiographic embolization of pelvic bleeding.
  • Vagina - external exam should always be done. Internal and/or speculum exam should be done in pregnant patients, and those with external bleeding or pelvic fractures
  • Perineum - Also associated with pelvic fracture and significant bleeding. Skin tears in this area are usually lacerations indicating an open pelvic fracture. Alert your orthopaedic surgeons early, and do a good, clean rectal exam (carefully wipe away all external blood). Rectal injuries are common with this finding, and a formal proctoscopic will probably be required.
  • Anus - Skin tears virtually guarantee that a deeper rectal injury will be found. Proctoscopic exam in the OR is mandatory.
  • Natal cleft - Usually not a lot going on in this area, except in penetrating injury. This is the only area of the naughty bits that can be safely examined in the lateral position. 

Bottom line: The naughty bits are important because the occasional missed injury in this area can be catastrophic! Do your job and force yourself to overcome any reluctance to examine them.

Related posts:


More On The “Passing” Of The Rectal Exam

I’ve gotten quite a few comments on my recent post on the “passing” of the rectal exam. One theme has come up that I want to clarify: proper position. Both yours and the patient’s, to be specific.

Precordial Thump commented:

"I have concerns about performing the rectal exam with the patient supine in frog leg position if a pelvic fracture is present. Any further comment?"

This was in regards to my opinion about the proper postion, noted at the very end of my post. Unfortunately, it was a bit too simplistic. As noted, the exam should be performed while the patient is supine, and not on their side, in order to reduce unexpected movement on their part.

The legs have to be moved apart somewhat, because it’s very important to examine the perirectal area before placing a finger. On occasion, blood from elsewhere (IV stick gone wild, bloody clothing) has contaminated the area. If the examiner just blindly inserts a finger and it comes back bloody due to contamination, they have just created a need for some additional, unnecessary diagnostic tests. If the area is bloody before the exam, take a moment to wipe it clean.

There are two ways to get the needed exposure. One thigh can be gently abducted enough to see the perineum. However, most ED carts are not very wide, so the amount of movement allowed is usually small. I usually find it necessary to slightly flex the hip and externally rotate it (half frog-leg), but only enough for exposure. Hopefully you would have detected any significant pelvic fractures with your physical exam before this point, and can plan the rectal exam accordingly.

My final comment deals with examiner position, which nobody ever talks about. One common error I see is that the wrong hand/wrong side problem. People do their best exam with their dominant hand. But if they’re on the wrong side of the patient, they turn at all kinds of angles to try to do it. I call it the “reverse english” exam (billiard reference). The ideal way is to stand next to the patient, looking toward their head, with your dominant hand next to them. Reach across and move their thigh with your nondominant hand, and examine with the dominant. So if you’re right handed, stand on their right side and use your right hand to do the exam.

Related post:


The Passing Of The Rectal Exam In Trauma

It has long been standard operating procedure to perform a digital rectal exam in all major trauma patients. The belief has always been that valuable information about blood in the GI tract, the status of the urethra, and the neuro exam (rectal tone) could be gleaned from the exam.

Unfortunately, the exam also serves to antagonize or even further traumatize some patients, especially those who may be intoxicated to some degree. On a number of occasions I have seen calm patients become so agitated by the rectal that they required intubation for control.

So is it really necessary? A study in 2001 conducted over a 6 month period (1) showed that the rectal exam influenced management in only 1.2% of cases. The authors felt that there was some utility in 3 special cases:

  • Spinal cord injury – looking for sacral sparing
  • Pelvic fracture – looking for bone shards protruding into the rectum
  • Penetrating abdominal trauma – looking for gross blood

A more recent 2005 study (2) was also critical of the rectal exam and found that using “other clinical indicators” (physical exam and other diagnostic study information) was at least equivalent, changing management only 4% of the time. They concurred with the first two indications above as well.

The Bottom Line: For most major trauma patients, the rectal exam is not worth the patient aggravation it causes. I still recommend it for the 3 special cases listed above, however, as there are no equivalent exams for these potentially serious patient problems. And remember, DON’T do it while the patient is in the logroll position. No patient likes a rectal exam, so they’ll do their best to defeat your attempt at spine precautions if you have them on their side. Supine, frog-leg only.

References:
1. Porter, Urcic. Am Surg. 2001 May;67(5):438-41.
2. Esposito et al. J Trauma. 2005 Dec;59(6):1314-9.