An 80-year-old female presents with fecal incontinence. What physical exam technique would be the most helpful in evaluating this complaint?
The correct answer and explanation is:
Correct Answer: Digital rectal examination
A digital rectal examination (DRE) is the most helpful physical exam technique when evaluating an elderly patient, such as an 80-year-old female, with fecal incontinence. This method provides direct information about the integrity and function of the anorectal area, which is essential in identifying the underlying cause of the incontinence.
Fecal incontinence is the inability to control bowel movements, leading to involuntary stool leakage. This condition becomes more common with age due to weakening of the pelvic floor muscles, damage to the anal sphincter, neurological impairment, or changes in rectal compliance and sensation. The digital rectal examination allows the clinician to assess several important features: anal tone, sphincter strength, presence of rectal masses or impaction, and the ability to voluntarily contract the anal sphincter.
The process involves the examiner inserting a lubricated gloved finger into the rectum. Anal resting tone is evaluated by the tightness around the finger when the patient is relaxed. The patient is then asked to squeeze the finger to test voluntary contraction strength, which helps determine external anal sphincter function. The examination may also detect abnormalities such as rectal prolapse, masses, hemorrhoids, or fecal impaction, all of which could contribute to or worsen fecal incontinence.
Although other diagnostic tools like anorectal manometry, endoanal ultrasound, and MRI defecography provide more detailed imaging and functional data, these are often reserved for complex cases or when surgery is being considered. In most clinical settings, especially during an initial evaluation, a digital rectal exam remains the most accessible and informative tool.
In summary, for an elderly patient presenting with fecal incontinence, performing a digital rectal examination is a critical and effective step in the physical assessment process. It guides diagnosis, management, and the need for further investigation.