Awareness and Acceptance of Digital Rectal Examination for the Clinical Evaluation of Anorectal Conditions Among the Saudi Population: A Cross-Sectional Study

Introduction: Digital rectal examination (DRE) is an important diagnostic tool used by physicians to resolve several confusing clinical situations. The history and physical examination cannot be complete without performing a DRE. Any patient that presents with abdominal complaints (e.g., diarrhea, constipation, nausea, vomiting, abdominal or rectal pain, bleeding) needs a DRE which is important for detecting warning signs of serious conditions that require further investigation and evaluation such as malignancies. Therefore, our aim was to assess and measure the awareness of the Saudi population regarding the importance and acceptance to perform DRE. Methods: This cross-sectional study was conducted in Riyadh, the capital city of Saudi Arabia, using an online survey between September 2022 and March 2023; the targeted participants were adults between the ages of 18 to 75. Results: The study indicated that the general community awareness of DRE is low, with only 59.1% of participants having heard of DRE and 14.6% having undergone the procedure previously. The majority of individuals (60.9%) were willing to undergo DRE if a healthcare provider suggested it. Participants' knowledge of DRE's ability to detect various anorectal diseases varied. While the majority of individuals believed DRE could detect hemorrhoids, just 40.4% believed DRE could help detect colorectal cancer. Chronic constipation or diarrhea, feces-induced stretching, and prolonged sitting were the most oft-cited causes of hemorrhoids. Anemia was the most often reported consequence of hemorrhoids, followed by hypertension and diabetes. Conclusion: The significance of DRE as a screening tool for the early detection and prevention of anorectal problems, as well as the need for adequate care and treatment of hemorrhoids to prevent complications, are highlighted by these findings. Healthcare practitioners should actively recommend and provide information about DRE and other screening technologies, as well as address their patients' concerns and misconceptions.


Introduction
Digital rectal examination (DRE) comprises simultaneous visual inspection of the perianal skin, manual palpation of the rectum, and assessment of the perineal neuromuscular function [1] and constitutes an important diagnostic tool that is clinically used by physicians for differential diagnosis [2]. History-taking and physical examination cannot be completed without a DRE as any patient who presents with abdominal complaints such as diarrhea, constipation, nausea, vomiting, abdominal or rectal pain, or rectal bleeding, needs a rectal examination; this is important for detecting findings indicative of serious conditions such as malignancies that require further investigation and evaluation [3]. The age at which DRE is required and the frequency of DRE remains debatable. The American Cancer Society recommends that DRE and stool examination with occult blood testing should be performed annually for all individuals aged 40 or more to screen for both prostate and colorectal cancer [4].
An inspection of the buttocks of the patients can provide clues to many disorders including hemorrhoids, skin tags, fissures, and fistulous tracts in patients with inflammatory bowel disease, rectal prolapse, polyps, tumors, and ulcers caused by herpes simplex or syphilis [5]. The perianal skin may be affected by dermatological conditions including psoriasis and vitiligo, or infections such as syphilitic dermatitis and candidiasis. The assessment of neuromuscular function using DRE is unavoidable in conditions such as the cauda equina syndrome or multiple sclerosis wherein loss of neuromuscular function can cause fecal incontinence, which may constitute one of the first symptoms of serious systemic diseases, including neuropathies and spinal cord-compressing masses [6][7][8].
There are contraindications to performing a DRE which are as follows: immunocompromised patients (the risk of introducing infection can be potentially life-threatening), the absence of anus, imperforate anus, prolapsed thrombosed internal hemorrhoids, stricture, severe anal pain, and/or an unwilling patient. Therefore, the importance and relevance of DRE should not be underestimated as DRE can prove lifesaving through early detection of serious diseases. This study was conducted to assess and measure the awareness and acceptance of the Saudi population regarding the importance of DRE.

Materials And Methods
This cross-sectional study involved a survey conducted between September 2022 and March 2023 in Riyadh, the capital of Saudi Arabia. The study population comprised Adult Saudi residents of Riyadh aged between 18 to 75 years who consented to participate in this research. The study was approved by the Institutional Review Board of Al-Imam Mohammad Ibn Saud Islamic University (approval no: HAPO-01-R-001).
Data were acquired using a bilingual (Arabic and English) self-administered Google form online questionnaire that comprised 23 questions pertaining to demographic variables, awareness and acceptance of DRE, and knowledge of hemorrhoids (Appendices). The demographic component of the questionnaire included questions on age, sex, nationality, level of education, employment status, field of employment (medical or non-medical), and history of anorectal disorders. The DRE awareness and acceptance section of the questionnaire portion asked participants if they had heard of DRE and had ever undergone a DRE. Participants were asked if they would consent to a DRE and why they would or would not. The section on hemorrhoids contained questions on its definition, etiology, consequences, and prevention.
Prior to the initiation of the main investigation, a pilot study with 20 participants was undertaken to test the validity and reliability of the questionnaire and revealed a Cronbach's alpha coefficient of 0.707, which is acceptable. The results of the pilot study helped refine the wording and format of the questionnaire to ensure clarity and readability. Before answering the questionnaire, all participants provided informed consent, and the data collected were utilized only for research purposes while ensuring anonymity. The anticipated response rate was between 300 and 600. Individuals aged 18 to 75 years who agreed to participate in the study were included, whereas those who declined or were outside the stipulated age range were excluded.
The acquired data were analyzed using SPSS version 25 (IBM Corp., Armonk, NY). Descriptive statistics were utilized to describe the demographic features of the participants, and a chi-square test was utilized to investigate the relationship between demographic characteristics and knowledge and acceptance of DRE.

Results
In total, there were 406 respondents to the survey, but only 384 of them were suitable for this study; the other 22 responses were excluded because they were not from Saudi Arabia.
The demographic characteristics of the participants are shown in Table 1. The majority of participants (64.8%) were female, with an age range of 18 to 65 years. The largest proportion of participants were in the 18 to 25 years age group (46.4%). The majority of participants were university-educated (80.2%) and either unemployed (60.4%) or students (36.2%); 66.9% of participants were from non-medical sectors and 28.4% of individuals indicated a personal or familial history of anorectal disorders.   5% of interviewees felt that the DRE is excessively intrusive and should not be used by physicians. When asked whether customs or traditions pose a societal barrier in postponing or not going to the doctor for a DRE, 64.0% of participants responded "yes" whereas only 12.0% said "no" and 27.6% responded "maybe." With regard to the use of folk medicine to treat anorectal diseases, 68.8% of participants said they would not avail of such therapy whereas 9.1% reported that they would and 22.1% responded "maybe." Only 39.8% of participants said that they would consent to be examined in screening clinics for anorectal diseases that employ DRE; whereas, 35.2% said they would not and 25.0% responded "maybe." When asked if they would see a doctor promptly if they or a family member were diagnosed with anorectal diseases, 76.2% of participants responded "yes", only 4.8% responded "no", and 19.0% responded "maybe."  As shown in Figure 1, the most common factors that stopped patients from undergoing a test were a reluctance to expose themselves (67.3%) and a fear of the procedure (50.3%). As reported by 49.0% of participants, disgust at the thought of the procedure was a significant issue. Fear about the result and absence of symptoms were less common, as reported by 17.0% and 24.5% of the participants, respectively; 4.1% of patients said that none of the aforementioned reasons prohibited them from undergoing a DREbased screening.  The participants were allowed to choose more than one choice as a definition of hemorrhoids ( Figure 2 (19), painful urination (6.3%) (24), and urinary incontinence (6.3%) (24) were additional symptoms that participants associated with hemorrhoids (5.7%) (22).

Discussion
This study examined the participants' knowledge, attitudes, and perceptions of DRE and anorectal diseases such as hemorrhoids. According to our findings, only 59.1% of participants in the current study had heard of the DRE, and 14.6% had already received it, which aligns with results from earlier studies. Only 78% of males would participate in a test that included both a DRE and a prostate-specific antigen, demonstrating a lack of understanding or interest in DRE [9]. Similar findings were made by Lee et al., who found that 24% of people reported having annual DREs and 33% had never had one, indicating a need for increased DRE awareness and use [10]. However, most participants (60.9%) claimed they would consent to DRE if a medical professional recommended it. These data suggest that healthcare professionals should increase public awareness regarding DRE.
Furthermore, DRE prevalence was 41.6% in men who used the publicly funded healthcare system and 63.3% in those who used services associated with private health insurance [11]. These data imply that access to healthcare services may influence DRE adoption. By increasing knowledge, education, and access to healthcare services, DRE utilization can be increased, resulting in earlier detection and prevention of anorectal disorders. Healthcare providers should play an active role in suggesting and disseminating information on DRE, particularly among groups with lower rates of knowledge and utilization. Additionally, efforts should be made to expand access to healthcare services, particularly among underprivileged communities, such that all individuals can undergo DRE and receive appropriate therapy.
With 60.4% of participants answering "yes" to this question, the survey also demonstrated that customs and traditions might hinder societal postponement or avoidance of DRE-related treatment. This result is comparable to the findings of previous studies which indicated that traditions could be seen as significant hurdles to DRE [12,13]. In addition, reluctance to expose themselves (67.3%) and dread of the process were the most prevalent factors stopping patients from undergoing screening (50.3%). In an earlier study, the authors established that patients' rejection of DRE during prostate cancer screening is primarily due to the absence of lower urinary tract symptoms, misconceptions about prostate cancer screening, and embarrassment, particularly when screening for the first time. The most common reasons given for not getting screened were the fear of learning something was wrong (48.1%), not knowing what would be done during the screening (54.3%), believing that prostate cancer is not a severe condition (55.8%), and thinking that rectal examination is embarrassing (56.6%), according to a previous study done in Oman [14]. These data show that, in order to educate patients about the value of DRE and early detection of anorectal illnesses, healthcare professionals must overcome social and cultural barriers.
When asked about their perceptions of symptoms and conditions requiring DRE, participants generally stated that they would accept the examination in the case of pain (63.3%). Participants frequently mentioned bleeding (56%) and lumps (55%) as symptoms that would lead them to accept DRE, and this is similar to what was reported in several studies, showing that the presence or absence of symptoms would affect a patient's decision to undergo DRE [15,16]. The abovementioned results imply that patients may link DRE with the existence of symptoms; therefore, healthcare professionals should emphasize the relevance of DRE as a screening tool for early identification and prevention of anorectal diseases.
The study additionally demonstrated that participants' understanding of DRE's utility for detecting diverse pathological scenarios varied. Only 40.4% of people thought DRE could help detect colorectal cancer, compared to 64.8% who believed it could help diagnose hemorrhoids. DRE is an effective method for detecting and preventing anorectal diseases, including colorectal cancer [17,18] which is the second most common disease and the second major cause of cancer-related mortality worldwide [19,20]. People with an average risk of colorectal cancer should begin screening at age 45, according to the American Cancer Society. Besides colorectal cancer, DRE can be utilized to detect anorectal conditions such as hemorrhoids [21]. Hemorrhoids are a frequent ailment marked by enlarged and irritated veins in the anus and rectum [22,23]. DRE can assist in identifying the presence of hemorrhoids, guide therapy, and help prevent problems. These results emphasize the significance of patient education on the DRE's potential to detect various anorectal disorders.
Hemorrhoids are frequently attributed to chronic constipation, diarrhea, feces-induced stretching, and prolonged sitting [24]. Hemorrhoids are brought on by inflamed and swollen veins in the anal and rectal regions which can lead to discomfort, bleeding, and other symptoms [25]. Chronic diarrhea or constipation can induce strain with bowel movements, increasing the pressure in the anal and rectal areas and causing hemorrhoids. Similar to that of holding or stretching out the tract by the feces during extended defecation, hemorrhoids can develop due to straining and increased pressure. Furthermore, prolonged sitting on a hard surface may lead to increased pressure in the anal and rectal regions that could lead to the formation of hemorrhoids due to prolapse of the veins due to increased anorectal pressure.
The most frequent side effect of hemorrhoids was anemia (67.4%), followed by hypertension (38.6%), and diabetes mellitus (14.4%). Another study reported that the most common side effect of hemorrhoids was anemia, which is consistent with other earlier studies [26,27]. Bleeding from hemorrhoids can result in blood loss and anemia which is characterized by an insufficiency of red blood cells and can cause fatigue and other symptoms [28]. This study identified hypertension and diabetes as potential consequences of hemorrhoids. Several factors, including weight, stress, and inactivity, can contribute to hypertension [29]. Hemorrhoids can cause discomfort and agony, resulting in stress and reduced physical activity, possibly contributing to hypertension. Insufficient insulin synthesis or inefficient insulin usage are the hallmarks of diabetes mellitus which is a metabolic disorder [30]. As constipation and other factors might increase pressure in the anal and rectal regions, hemorrhoids may be more common in patients with diabetes due to constipation. These findings imply that patients may have misconceptions regarding the origins and complications of hemorrhoids; therefore, healthcare practitioners should provide appropriate information and patient education regarding these disorders.
Patients may have some understanding of hemorrhoid prevention. Nevertheless, healthcare providers should emphasize the importance of adopting a healthy lifestyle which includes regular exercise, proper water, and a fiber-rich diet. The most oft-suggested preventative methods for hemorrhoids were consuming fiber-rich foods (77.8%), excessive fluid consumption (72.8%), and defecating when necessary (53.3%). As additional preventive measures, smoking cessation and avoidance of extended sitting or standing should be emphasized.
Finally, this study explored the relationship between participants' attitudes, their awareness of DRE, and their demographic characteristics. Participants who had previously experienced anorectal problems were more likely to have heard of DRE and to agree to DRE if recommended by a physician. The likelihood that a person would accept DRE if offered by a doctor was significantly influenced by their sex and work status, with male and employed individuals being more inclined to accept DRE. These findings imply that healthcare professionals should consider patient demographics such as sex and work position when recommending DRE and educating patients about anorectal problems.
The were some limitations to the study; there was trouble in the process of data collection and the time was prolonged due to the refusal of some people to participate in the questionnaire due to its title. Therefore, we assigned data collectors. Our recommendations for further research include expanding the study sample for a more precise representation, shifting to a paper-distributed questionnaire to reduce bias, and involving participants from more regions of Saudi.

Conclusions
In conclusion, the current study emphasizes the necessity for patient education and knowledge of the significance of DRE as a screening tool for early detection and prevention of anorectal diseases. The results of the study provided valuable insights into the level of awareness and acceptance of DRE among adults in Riyadh, Saudi Arabia, and could assist healthcare professionals in developing strategies to promote the importance of DRE screening and increase the general population's acceptance of this clinical examination. Healthcare providers should address cultural and societal barriers and provide correct information about the causes, symptoms, consequences, and prevention of anorectal disorders. In addition, healthcare practitioners should consider patient demographics when prescribing DRE and educate patients to help promote acceptance and utilization of this essential screening technique.