Was rectal exam necessary?

[CoconutJellyBean]

My 10 yr old DD has suffered with constipation since she was about 4. She has had movicol on and off all this time. She can have phases of not needing it. A few months ago she had started to be constipated again and had got to about 11 days without having a poo even after 3 sachets every day. So I called the docs to get her a repeat prescription and he asked me to bring her in. We have had several docs over the years just when you are happy with one they seem to leave and you get a new one with no choice in the matter. My daughter had not seen this doc before and I knew she would hate going to see the doc about her problem anyway. I told him this and asked him on the phone what he would be likely to need to do and he told me he would just need to look at her tummy. I told her this and she was happy to go. When we did go he asked all the question you would expect about her diet etc. then started to chat with her about friends and school obviously to make her feel at ease. He then got her to get on the bed and felt her tummy, but then he asked her to turn on her side and pull down her skirt and pants and I asked why he needed to do that and he said to check if there are any anal fissures. She went along with this and I did not stop it but feel I should have interjected and said no that's not necessary, I feel I have let her down because I know that she is still really bothered by it, and dislikes the doctor because of it, she even said today when we were near the doctors surgery, that she hates that doctor because he stuck his finger up her bum (her words) I feel that he was sneaky about the way he did it and I feel terrible that I let it happen. I have been trying to find out whether this is the proper procedure and can't find any conclusive guidelines as some guidance seems to say it is and others say it should be avoided in children because it can be upsetting for them. He also suggested that she should see a paediatrician because it has gone on for so long, but she is so upset when I tell her about the appointments that I end up cancelling and not taking her. I am now in the position where the doctor has stopped the repeat prescription until I take her back. I have been trying to change to a female doc but there are none available. I have tried so many things with her diet over the years and have recently discovered Flaxseed which really seems to help so I am sticking with that for now. But I just can't help feeling I let her down and should gave handled the whole thing differently. Hoping there is a doctor on here who knows if this was right or wrong. Thanks

Well, you need to get a referral to a decent paed and clinic. This stuff isn't gp territory. She needs to go to see someone who can help her get over this, as it's likely she has impaction as well.

That said, Ds has had rectal exams. It's fairly standard procedure with long term childhood constipation etc.

Avoiding doctors because they carry put medical procedures isn't something you want to be encouraging, to be honest. No one likes having a rectal exam, but it's fairly normal.

Presumably you've had her on a toileting timetable and whatnot, alongside the meds? Ds had to try a few different things before finding out what helped him, but he's seen a number of different Paeds/ had ultrasound tests/ bloods to test for coeliac etc.

If you are looking for someone to tell you that it was abuse and not necessary, I don't think you are going to be in luck. The fact that you are even asking this questions suggests to me that your dd is not getting enough help for this completely ordinary problem and that you seem to be trying to hide and ignore it. She needs to know that this is quite normal and that she needs a referral to help get over the problem.

And don't cancel her appointments. That is worse than a rectal exam - she's been referred to a specialist to help her. You are not helping at all - she needs to be reassured that these appointments are in her best interests, not have her fear validated by her mother. If she does have impact ion, you are doing her no favours at all by delaying treatment, and possibly causing long term damage to her bowel.

Yes, Ds has had issues with constipation and impaction for years. No, having to give him suppositories is not fun. Yes he hates the appointments and he hates suppositories.

Yes, I am his mother, and I work with the doctors to find a solution. I sympathise that he doesn't like it, but I don't refuse treatment on the grounds that he might not like it. Parents do sometimes have to do things that their kids don't like.

I'm actually appalled that you have been cancelling her referrals. If it was any other illness, would you let her refuse to see a specialist?

You HAVE let her down. But not by failing to stop a rectal exam. You have let her down by stopping her seeing specialists because of a silly squeamishness about bowels and bottoms.

Ask the doc for a referral and follow through this time.

She does need a referral to a paed or a gastro.

I don't think it is abuse but it is also not necessary. My kids have chronic longterm constipation and bowel disease and their gastro doesn't do them unless they are under GA for other testing. She says the limited amount of info they give is not worth the indignity and distress caused. And a fissure? If she has one, the treatment is stool softeners--she needs those anyway so why do an exam? I would refuse on her behalf personally.

I think it was perfectly valid for a GP to check for fissures and other abnormalities, he should just have explained he was going to do it. And I think she DOES need a referral.

I think it's perfectly reasonable for the GP to want her to be referred, do you not think its about time they tried to find a reason for the ongoing constipation rather than just sporadically treating it? Why would you cancel the appointment?

I've seen plenty of children have a rectal examination, including babies (I'm a children's nurse). It's not painful but it's a good way of feeling for fissures or abnormalities. He should have told you he was doing this though. Please get her referred and stop cancelling.

Thanks for your opinions. I am booked to see a different doc, and hopefully can get her sorted out. I think it was more the way it was done and the not being advised it would be done that makes me dubious. I really only want to sort this for her with minimum trauma.

I think you need to realise that you might be making things worse for her, sorry. Cancelling appointments because she's upset will just make her think there's something to be scared of. This is all pretty standard medical procedure and I really think its very important that you need to treat it as such.

Ask for a re referral to the paed and do not cancel.

That said, he shouldn't have said on the phone it would just be to feel her tummy if it wasn't. I do think you're making too big a deal of it I'm afraid.

I hope you take this post in the way it's intended.

Minimum trauma?

She has been suffering with this for SIX YEARS.

Reality check. That is over half of her life.

And you are upset over one single rectal exam?

Really?

Stop overblowing a normal clinical procedure and help your child get over her own fear of this stuff. It's going to be bloody hard work to sort it out if you keep building up her fear.

Seriously what abnormalities is a GP going to pick up on rectal exam? We've always needed anal manometry or biopsy for that. If only it was that easy to diagnose outlet problems and tight pelvic floors!

OP you do need to see a specialist and get her help but it's perfectly reasonable to refuse a rectal exam from a GP. Just because it's routinely done apparently doesn't mean you have to allow it. Especially when you stop and think about what info is gained by it. Essentially nothing at all. There's enough indignity and trauma which is unavoidable in bowel conditions--a finger up a kid's jacksy is avoidable.

Thing is OP, a rectal exam isn't a big deal. The GP didn't give you and your DD any "warning" that he was going to perform one because he, understandably, didn't think you or DD were going to be so upset or traumatised by it.

My DD is 2.5 and has had several rectal exams to check for fissures and anal abnormalities (she has suffered from constipation all her life).

So, in conclusion: I think you're overreacting. Your DD wasn't assaulted or treated inappropriately. And for the love of god please allow your daughter's constipation to be investigated. If this carries on being badly managed through her teens and into adulthood it will blight her life. I speak from bitter experience.

Incidentally, at 10 of course she was mortified at having a finger up her bum, but as her mum you should have reassured her ("I know it wasn't nice darling, but please don't worry because doctors see a lot of bottoms and he was just doing his job") instead of validating her worry and embarrassment by being so squeamish yourself.

Maybe he didn't mention the procedure because he knows people get irrational fears over that particular procedure and they cancel their appointments. I'm with others on here, I don't think you should be making a big deal of it and tell her it's normal for this type of procedure is normal when you have constipation.

I think it is important to be matter of fact about such procedures, so they don't become an alarming prospect. But naturally a child (as many adults do) will find the prospect fo the exam unpleasant. I think its important to acknowledge that's a total valid response, but to explain the reasons and how it will help towards making her feel better in the long run.

I would go for the 'its not much fun but its over fairly quickly' approach.

I do agree that the GP should have been more communicative and should have told you that he was going to do a rectal exam. I think in future ask specifically if this will be part of the appointment so you can prepare your DD, and discuss with her what she might prefer to be wearing etc (for instance I always feel more comfortable for such things if I'm in a skirt rather than trousers - illogical I know) or you could make sure the GP gives her something to cover herself with, so she doesn't feel so exposed and vulnerable.

I think its incredibly important that people don't get hung up on intimate examinations, as we need to be proactive in our health and embarrassment shouldn't ever stop you getting the help you need.
But I think it's also important to ask people if they want this examination, and to explain why it is helpful, and what is being checked for. Your DD wasn't consulted about something that happened to her body, she needs to be allowed to feel she has a choice, and you can help her make the correct choices by talking about it between appointments.

I suspect it wasn't so much the finger up the bottom that upset your DD, as suddenly finding herself exposed and in a situation she wasn't epecting and had no control over. That must have been a bit frightening for her as she didn't know eactly what he was going to do. He should have explained, and that is an inadequacies on his part and poor communication skills.

I think its also important for future life not to feel cancellation is a way to deal with unpleasant examinations. I always get through these things by thinking about what I'll do afterward (usually a large latte and a cake )

Doesn't a clinician have to get informed consent before doing any procedure? Preferably from the patient but in the case of young children it might have to be the parent. At 10 she is probably old enough to have the procedure explained and give or decline consent herself. Then it would be the parent's job to support her by clarifying and rationalising the procedure to help the child understand. In this case your are unsure if the examination was necessary. You should have been able to ask that question because it should have been discussed prior to asking for the removal of clothes.

Of course this is entirely separate to the issue of seeing the paediatrian and cancelling appointments which you have to just get over. As a parent we have to act in the best interests of our child and sometimes that means giving consent for painful or upsetting medical procedures where they are in the child's best interest. Privately we are allowed to find it tough and be upset but it is our duty.

So no, you are not wrong to be upset that informed consent was not sought for the rectal exam. It absolutely should have been, but you are wrong to avoid further medical treatment that she obviously needs.

Thanks once again to everyone for responding to my post. The reason I posted was to gauge other mums opinions and as I know some of you are in the medical profession also, you are a valuable source of information. I would like to point out that I am absolutely not squeamish or embarrassed about intimate examinations. I have never been that way, and I did reassure my daughter afterwards that this is something that sometimes we just have to get on with and accept and that indeed I have had my own bum looked at by a doctor on more than one occasion. We talk about things very openly in our house and the squeamishness some refer to is not an issue. Some of you have understood that it was the manner in which the GP went about doing it. And the lack of necessity for doing it which concerns me. Consent was not requested. And the fact that I had specifically asked the GP on the phone prior to taking her in and had not been told that I should expect her to be examined this way compounds my concern. And I know that you will be thinking why did you not refuse? I wish I had believe me. I questioned and he gave an explanation why he was doing it, but he did not explain the procedure or ask for consent prior to requesting the removal of clothing and going ahead. I actually feel I was duped into letting him continue. I have researched the guidelines and it is advised to avoid this kind of examination in children unless it is really necessary. I am convinced it was not. Guidelines also state that consent should be obtained. How can you consent to something that hasn't been explained? I wanted a repeat prescription to ease her condition. I am totally in agreement that she should see a specialist, but I feel that it should have been left to the specialist / paediatrician to decide what examinations were necessary and that the GP should have issued the prescription and made the referral and nothing else. I have requested referrals from previous doctors because I was worried about her taking the laxatives long term, and I have been told to just continue giving Movicol as there is no harm in taking it long term. I also want to clarify that I have cancelled one referral only due to the seriously distressed reaction of my daughter. I am not in the habit of avoiding medical treatment for my children. I did try to explain to her that it would help her in the long term and that there could be something causing the condition and if we can find out what it is then we can help her get better and all of the things you would expect to try to reassure her, but she was so upset at the prospect that I decided to cancel and continue with Movicol when required and look for alternative natural remedies. With a view to getting another referral if it didn't work out. And that is why I have been back to the doctors today, I booked an appointment with a female doctor. My daughter felt much more comfortable with her, she spoke to her very sympathetically and issued a prescription, nothing else. I am waiting to hear from her when she has spoken to the previous doctor. So we are getting somewhere again. I have to say there are some very presumptuous and self righteous personalities on this forum, as well as some who are very understanding and insightful. I appreciate your responses.

I have read through this and I think you are not helping your DD as well as you could.

I would have thought the rectal exam was necessary. Her constipation is obviously quite serious if the Movicol isn't working and she has been unable to go for 11 days. I imagine the doctor was checking for fissures in order to try and work out if the pain of a fissure was causing your daughter to hold on subconsciously.

I think it was totally correct to refer on (to someone who will be able to help solve it) and actually think the doctor you saw more recently was "pandering to you" by not making a referral. If you are stopping and starting the Movicol and she has periods of being so constipated it is IMO not professionally sensible to just keep issuing the repeat prescriptions as other options should be considered (hence the referral).

It looks like you realise you made a mistake by cancelling the first specialist appointment which is good. Unfortunately our children will all have to go through things they don't like and that make them unhappy. Our role as parents is to do our best to support them through those things which will help them face up to them in the future. Especially in this case where the appointment was actually for her long-term health benefit.

I don't think any of us on here can know if the examination was necessary. Even if we were experienced GPs we wouldn't know without seeing the patient and knowing her history. I also think it is unfair to expect a gp to outline all possible treatment/examination options over the phone. Patients need to be seen to build the full picture. However, it is almost an irrelevance because the point is that any medical procedure needs to be undertaken with informed consent and if the patient/patient's proxy is in any doubt that it was necessary or feels as the op does then it is clear it has not been.

Op, I am glad you have seen another gp. Do go and see the specialist because it could cause your dd problems longer term not to get this sorted out. It won't hurt to go and you can evaluate and discuss examinations/treatment options with the specialist being fully prepared to do so. You can always ask "what would happen if we didn't do that? What would happen if we waited for a month/a year?". You can also ask "is this strictly necessary?" to any procedure.

Good luck :)

You state ' the doctor said he needed to check for anal fissures' so he did tell you what he was doing.
You have returned to see a female gp - I presume its the same practice so she wouldn't have needed to check as the previous chap has checked and he would have written it on her notes.
I hope that they are issuing the prescriptions only until she gets referred to a paed or specialist ... poor love she needs to have this sorted.
A friends daughter had the same thing however at 4 her mum had had enough and she was referred / seen and a small operation has sorted it . I hope it is the same or less for your daughter.

You are totally in denial, op. But there's no changing your mind.

No one is wondering why you didn't stop the exam. We are wondering why you are taking exception to the exam, and why you are stopping your dd getting specialist help.

Six years is a long time. Your dd will soon be in secondary school. She needs a referral to a specialist, not just repeat prescriptions.

I think your attitude is contributing to dd's serious distress, and she has picked up on your concerns about exams and the like. Her distress is entirely normal and medical professionals will ensure they look after her as they go along the process. You pandering to her every whim and stopping professional help because she is upset is horrific. You are condoning her fear and making it impossible for her to get the help she needs. And you are making the problem worse by letting it continue. If she has impaction, it needs to be dealt with before her bowel is permanently damaged.

Would you withhold other medical treatment because she was upset?

I assume you don't think this issue is important, so it's easier for you to avoid dealing with it like a parent, in the best interests of your dd.

I'm going to leave the thread. You have persuaded yourself that what you are doing is in the best interests of your child, and it is not. Hopefully one day you wake up and get her some help. In the meantime, I hope she continues to manage the pain and discomfort of her condition without causing you too much trouble.

OP, you are totally blind to the real issues here.

Stop this dramatic "I feel duped" nonsense. Why are you so fixated on this. The GP did nothing wrong.

Incodentally, yes Movicol is safe to use long term. And since your DD's constipation is severe, you should be giving it to her daily.

Also, I really feel that your reaction to this isn't normal, reading guidelines to see whether a rectal examination is required, etc. You were in the room with your DD remember, so the GP wasn't doing this for kicks.

It really sounds like you are projecting.

You are being silly and looking for an issue which iisn't there
She didn't need a repeat prescription - its been going on too long and needs sorting.

My ds has chronic constipation and also has needed rectal exams. He was on 6 moviol a day and still struggling.

He sees a pead cons and she switched him to 10ml senna a day. You can but it OTC if you really feel that you don't want to take her back.

But please consider whether you really believe a gp would carry out such a personal examination on a child unless it was deemed necessary. And I wonder If your DD is picking up on your reaction to the exam?