Pelvic and Digital Rectal Examinations to Evaluate Lower Urinary Tract Symptoms

Importance: A thorough examination of the patient is a crucial component of providing high-quality care and is regarded as best practice in the assessment of female patients presenting with lower urinary tract symptoms (LUTS). Nevertheless, anecdotal reports suggest that pelvic examinations are infrequently performed in the outpatient setting, raising important questions regarding adherence to established standards of care. Objective: To explore the practices and attitudes of urologists toward pelvic examination for patients with LUTS. Design, Setting, and Participants: In this qualitative, mixed-methods study, a structured 9-question survey about digital rectal and pelvic examination practices was distributed between November 19, 2023, and May 19, 2024, to urologists and urology trainees via the Urological Society of Australia and New Zealand newsletter across Australia and New Zealand. The end of the survey invited clinicians to participate in a semistructured interview to further discuss their responses. Main Outcomes and Measures: The primary outcomes were urologist-reported responses to the survey assessing the numbers and percentages of male and female clinicians who routinely performed pelvic and digital rectal examinations for patients with LUTS at their initial appointment and qualitative semistructured interview responses to identify themes associated with clinician attitudes toward pelvic examinations. Results: Of 553 consultant urologists and 100 urology trainees sent the survey, 74 participants responded, a response rate of 11.8%. A total of 74 clinicians (46 [62.2%] male), comprising 63 urologists and 11 urology trainees, completed the survey. While 89.1% (95% CI, 80.1%-98.1%) of male clinicians and 92.9% (95% CI, 83.3%-100.0%) of female clinicians consistently performed digital rectal examinations for male patients presenting with LUTS, only 8.7% (95% CI, 5.5%-16.8%) of male clinicians routinely conducted pelvic examinations for female patients compared with 85.7% (95% CI, 72.8%-92.9%) of female clinicians (P < .001). In total, 10 semistructured interviews were conducted. Two major themes were identified: fear, including medicolegal reprimand, clinician and patient discomfort or reluctance, and failure to recognize pathology; and barriers to pelvic examinations, including perceived poor utility, limited access to chaperones, and concerns for patient discomfort. Conclusions and Relevance: Findings of this study suggested that male clinicians were less likely than female clinicians to perform pelvic examination for female patients who presented with LUTS. Barriers to pelvic examination need to be addressed to enable female patients to receive optimal care. Focused training may help prevent unnecessary operative procedures and improve patient outcomes.