Digital rectal examination: a skill neglected?

We are quietly abandoning the digital rectal examination (DRE), and the patients may be the ones who suffer. Once considered an essential skill in bedside medicine, DRE is declining in routine use across modern clinical settings. When did we begin to view this examination as optional rather than essential? Following the changes in prostate cancer screening recommendations, national survey data showed a steep decline in DRE rates [1]. The evidence is also clear in the recently published data from a large academic health center, where DREs were documented in only 8.5% of outpatient encounters, and even lower in primary care [2]. Surveys of physicians and trainees similarly reveal that DRE performance has declined in frequency across training environments [3]. Clinicians are increasingly relying on imaging and biomarkers, leading to slow erosion of foundational bedside skills, raising concerns about missed diagnoses and shifting clinical norms. Despite the decreasing use, DRE continues to offer essential diagnostic information spanning across multiple clinical contexts, including prostate cancer screening, acute gastrointestinal bleeding, fecal incontinence, anorectal disorders, and suspected rectal malignancies; information that is not easily replicated by technology. Though not recommended as a standalone screening tool for prostate cancer, DRE retains selective relevance for risk stratification and biopsy decision-making in men with abnormal prostate-specific antigen (PSA) [4]. Similarly, for acute gastrointestinal (GI) bleeding, early DRE has been shown to reduce admissions, endoscopies, and empiric therapies by improving clinical risk stratification [5]. When performed by expert physicians, DRE assessments of sphincter tone and pelvic floor coordination correlate well with high-resolution manometry and can approximate the value of formal anorectal physiology testing [6]. Indian national consensus guidelines for chronic constipation endorse DRE as an effective tool and recommend it for frontline screening of Fecal Evacuation Disorders (FED) [7]. Collectively, these data reaffirm that DRE is still a valuable, inexpensive, and information-rich component of bedside evaluation.