EP719 - Anorectal Physical Examination by Primary Care Physicians: Practices and Challenges

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Purpose/Background: The digital rectal examination (DRE) is a fundamental component of the physical examination for assessing anorectal conditions. However, recent studies show a concerning decline in DRE utilization among primary care physicians (PCPs). This is particularly important, given the rise of young-onset colorectal cancer. The aim of our study was to investigate anorectal examination practices among PCPs at an academic health system, focusing on DRE utilization, factors influencing its lack of performance, and referrals patterns for continued clinical investigation of symptoms.

Methods/Interventions: An IRB-approved, cross-sectional, online survey was administered to PCPs at a single institution over one month via secure email and responses were collected in REDCap. The survey included questions about demographics, confidence in knowledge of anorectal disorders, comfort level and frequency of DREs performance, factors influencing change in practices, and referrals to specialists and APPs. Question types included multiple choice and 4-point Likert scale design.

Results/Outcomes: A total of 46 (37%) PCPs out of 124 surveyed responded. Most respondents were females (61%), 35% were 51-60 years old, and 72% had over 17 years of practice experience. Among this experienced group of PCPs, 39% felt confident or very confident in their knowledge of anorectal disorders, 30% were very comfortable in their DRE, and only 11% were very comfortable diagnosing anorectal disease (Figure). In the work up of a patient with symptomatic anorectal complaints, 63% PCPs performed a DRE 75 – 100% of the time. The majority (70%) of PCPs reported factors that have changed the frequency of DREs, including changes to virtual visits (53%) and increased ease of specialty referral (32%). Some barriers to performing DREs were the time required to do the examination (67%) and the lack of necessary facilities (e.g., lighting, examination table, anoscope, lubricant) as reported by 54% of participants.

Regarding diagnostic workup categorized by patient age group, 67% PCPs considered that, for patients younger than age 45, the most important diagnostic tools were DRE and anoscopies, while 26% considered colonoscopy the most important. For patients between age 45 – 74 years, 57% of PCPs considered colonoscopy the most important examination compared to 35% for DRE and anoscopies. For patients over age 75 years, 70% of PCPs considered DRE and anoscopies the most important diagnostic tools. When presented with patients with suspected anorectal disorders, the majority (65%) of PCPs tend to refer patients to specialists between 50 – 75% of the time and 17% refer 100% of the time. Finally, when asked about their comfort level in referring patients with suspected anorectal disorders to colorectal advanced practice providers (APPs), 85% reported feeling at least somewhat comfortable.

Conclusion/Discussion: This study identifies the need for continued education around the importance of anorectal physical examination and diagnoses and may suggest a change in current practice to meet the needs of patients with anorectal complaints. Increasing the use of highly trained colorectal APPs, working in independent clinics specializing in anorectal disorders, may be one method to narrow the gap in frequency of DRE and type of workup which may lead to earlier detection of colorectal cancer.