Exploring the Willingness and Understanding of Digital Rectal Examinations in Assessing Anorectal Conditions Among Saudi Patients in the Western Region of Saudi Arabia

Background: A digital rectal examination (DRE) is a crucial diagnostic examination used to identify various medical conditions by inserting a finger into the patient's rectum to check for abnormalities. Although clinically significant, DRE can be challenging, especially for first-time patients. Reasons for refusal often include misunderstandings about the examination, fear of the way the test is done, and feelings of embarrassment. This study seeks to explore the views, opinions, and perceptions of individuals in the Western region of Saudi Arabia towards DRE. The objective is to guide interventions and improve healthcare practices related to anorectal conditions in this population. Method: In this cross-sectional study, we used a validated questionnaire, which was translated from English into Arabic, before distributing it to the target population. The target population included adults older than 18 years residing in the Western region of Saudi Arabia. Although our initial sample size was determined to be 385, we successfully recruited a larger sample of 1,147 participants. Data were statistically analyzed using IBM SPSS Statistics software for Windows, version 22 (IBM Corp., Armonk, NY). Results: A total of 1,087 eligible participants completed the study questionnaire. Among them, 480 participants (44.2%) demonstrated a good overall awareness and understanding of DRE, while the majority, 607 (55.8%), had poor awareness. University-educated participants exhibited better awareness, with 363 (47.7%) showing good overall awareness compared to 103 (35.2%) of those with only secondary education, a statistically significant difference. Furthermore, 269 (46.7%) of students had a good awareness of DRE compared to 55 (34.8%) of unemployed participants. Notably, 218 (58.4%) of individuals working or studying in the medical field had a good awareness of DRE, compared to 207 (37.2%) in non-medical fields. Conclusion: The majority of individuals showed limited knowledge regarding DRE. The findings suggest increasing public understanding and raising awareness of and importance of DRE for improving healthcare outcomes.


Introduction
Digital rectal examination (DRE) is an invaluable diagnostic tool capable of uncovering crucial findings that can lead to the early detection and treatment of severe medical conditions, ultimately improving patient outcomes [1].Its scope encompasses various medical areas, covering the management of conditions like rectal cancer, hemorrhoids, and fistulas, as well as the identification of bleeding such as melaena or hematochezia, assessment of fecal incontinence or constipation, evaluation of prostate cancer, and examination of pelvic floor prolapse or pelvic inflammatory disease.Moreover, DRE serves as a reliable method for evaluating anal tone in specific spinal, orthopedic, or neurological conditions, playing an essential role in the comprehensive assessment during secondary surveys for multi-trauma cases [2][3][4].During a DRE, a healthcare professional inserts a finger into the rectum to assess any abnormalities or irregularities in the lower abdomen and pelvis.Typically, men are examined in a lateral position with knees bent upward towards the chest, although they may also be assessed while standing or partially bending forward at the waist.Women undergo an examination with their feet apart, raised in stirrups, or lying on their back with knees bent [5].
A DRE is a classical part of the examination in patients presenting with gastrointestinal bleeding.A retrospective cross-sectional study was conducted on 1,237 patients who presented to the emergency department with gastrointestinal bleeding.It showed that rectal examination has significantly decreased admission numbers, medical therapy, and endoscopy for patients with acute GI bleeding [6].Despite its clinical significance, DRE poses substantial challenges, particularly for individuals undergoing the examination for the first time [7].A study shows that refusal rates for DRE were higher among individuals without urological complaints (57%) and those anticipating pain or discomfort (18%), with attendees citing personal benefit (82%) and contribution to science (49%) as primary motives.Refusers tended to be older, less educated, with poorer general health, less knowledge about prostate cancer, and a less positive attitude towards screening compared to attendees [8].Another study mentions other factors for refusing DRE, including misconceptions regarding prostate cancer screening, anticipation of severe discomfort, fear of potential cancer detection during the examination, and the perception of DRE as a source of shame [9].
Given the extensive global lack of research on this specific aim, a notable gap exists in the literature, particularly concerning the population of the Western region of Saudi Arabia.None have specifically addressed this topic within the population's unique cultural and societal context.Therefore, our study aims to bridge this critical gap.By investigating the attitudes, beliefs, and perceptions of the population towards DRE, we aspire to unearth invaluable insights that can inform targeted interventions and enhance healthcare practices for the assessment of anorectal conditions in this specific demographic.Through our research, we endeavor to contribute to advancing medical knowledge and optimizing healthcare delivery for the benefit of individuals in Makkah and beyond.

Study design
The current study is a cross-sectional descriptive online study.Data were collected by distributing an online questionnaire to the general population in the Western region of Saudi Arabia.The study secured ethical approval from the Biomedical Ethics Committee at the College of Medicine, Umm Al-Qura University (UQU), Makkah, Saudi Arabia (approval number: HAPO-02-K-012-2024-05-2153).

Study population
The study included the general population who lives in the Western region of Saudi Arabia, specifically adults over 18 years of age from both genders.The exclusion criteria consisted of individuals who were temporarily visiting the Western region of Saudi Arabia.

Study procedure
The targeted population in this study consists of adults over 18 years of age from the general population residing in the Western region of Saudi Arabia.According to the Saudi census of 2022, this population numbers 8,021,463 individuals [10].We aimed to develop a questionnaire that is simple, concise, and easy for the population to understand.The questionnaire was adapted from a previously conducted study published in 2023 that assessed knowledge and willingness regarding DRE for assessing anorectal conditions in the Riyadh population [11].An online Arabic questionnaire was created using Google Forms (Google Inc., Mountain View, CA).The respondents received electronic links along with information about the survey objectives, the target population, and a request to participate voluntarily.After obtaining approval from the UQU Institutional Research Board, the questionnaire was distributed electronically through data collectors to all eligible populations who met the inclusion criteria.

Data collection and management
The data were collected using a convenience sampling technique from the targeted population, with data quality ensured through supervision by data collectors.The collected data were directly transferred to a statistical database.This process was facilitated using an Arabic-language questionnaire, which included the following sections: consent form, sociodemographic data, and study questionnaire.To safeguard the confidentiality of participants' information, a system of codes, numbers, and pseudonyms was established.Access to the data was restricted solely to the researchers involved in the study.

Sample size determination
The Raosoft sample size calculator (Raosoft Inc., Seattle, WA) was used to determine the minimum sample size required for this study [12].The population size of the Western region of Saudi Arabia is approximately 8,021,463.With a 95% confidence interval (CI), an anticipated frequency of 50%, and a design effect of one, the sample size was calculated to be 385 participants.To account for potential data loss, the total sample size was increased to 400 participants.We aimed to balance the sample size with 200 female and 200 male participants.

Statistical analysis plan
After data extraction, it was revised, coded, and analyzed using IBM SPSS Statistics software for Windows, version 22 (IBM Corp., Armonk, NY).All statistical analyses were conducted using two-tailed tests, with a p-value of less than 0.05 considered statistically significant.Regarding awareness and perception of DRE, the overall score was obtained by summing all discrete item scores.Participants with an overall score of less than 60% of the maximum score were considered to have poor awareness levels, while those with a score of 60% or more were considered to have good awareness levels.Descriptive analysis based on frequency and percentage distribution was performed for all variables, including bio-demographic data, university affiliation, and medical and family history.Participants' knowledge and perceptions regarding DRE were tabulated, and their overall knowledge level was graphed.Cross-tabulation graphs were used to assess factors associated with participants' knowledge level about DRE, which was tested using Pearson's chisquare test and the exact probability test for small frequency distributions.

Results
Out of 1,147 responses, a total of 1,087 participants who completed the study questionnaire were included.Participants ranged in age from 18 to 65 years, with a mean age of 23.8 ± 11.6 years.Of the respondents, 716 (65.9%) were female, 965 (88.8%) were Saudi nationals, and 761 (70%) had a university level of education.Exactly 634 (58.3%) were students, and 295 (27.1%) were employed.Regarding the study or work field, 373 (40.2%) were in the medical field.A total of 121 (11.1%) had anal and rectal diseases, and 36 (3.3%) had a relative with a rectal disease (Table 1

TABLE 3: Perception and awareness of the study participants regarding hemorrhoids
Regarding awareness and understanding of DRE, 480 (44.2%) of the study participants had good overall awareness and understanding, while the majority (607, 55.8%) had poor awareness (Figure 1).

FIGURE 1: Participants' overall awareness and understanding of digital rectal examination
Factors associated with participants' awareness and perception of DRE showed that 363 (47.7%) of university-educated participants had good overall awareness compared to 103 (35.2%) of those with only a secondary education, which was statistically significant (P = 0.001).Additionally, 296 (46.7%) of students had good awareness compared to 55 (34.8%) of unemployed participants (P = 0.001).Good awareness was found among 218 (58.4%) of medical field workers/students compared to 207 (37.2%) of the non-medical field group (P = 0.001) (Table 4).

Discussion
The study included 1,087 participants with a mean age of 23.8 years.Most of the participants were female Saudi nationals with a university level of education.Among them, only 373 (40.2%) were from the medical field.Awareness regarding DRE was moderate, with 510 (46.9%) having heard of it and 71 (6.5%) having undergone the examination.Reasons for refusal of the examination, if advised, included embarrassment, disgust, fear of the examination, and absence of symptoms.Some participants felt that the examination should not be performed by doctors and cultural and traditional barriers were cited as hindrances to seeking medical help.Additionally, misconceptions about hemorrhoids were identified, particularly regarding their causes and definitions.The results highlighted education level, student status, and medical occupation as significant predictors of awareness of DRE.
When asked about their awareness and experience with DRE, less than half of the participants reported having heard of DRE, and only 71 (6.5%) had undergone the examination.This aligns with related studies on the prevalence of acute gastrointestinal bleeding among patients presenting to the emergency department [6], suggesting low awareness and limited knowledge about this screening and diagnostic tool among the general population.
The respondents demonstrated a poor understanding of the types of diseases that can be diagnosed by DRE.
Although more than half believed that hemorrhoids could be identified through DRE, fewer were aware of its application in detecting colorectal cancer, anal fissures, and prostate cancer.This underscores the significant need to raise public awareness about DRE and its numerous benefits.
Notably, 171 (15.7%) of respondents agreed that DRE was a painful and invasive examination that should not be performed by doctors.Furthermore, more than half believed that cultural and social taboos prevent individuals from seeking DRE.These perceptions highlight the necessity for substantial efforts in knowledge enhancement and promotion to address misconceptions and improve acceptance of DRE.
Regarding hemorrhoids, the most recognized symptom was anal injuries, reported by 649 (59.7%) of participants, followed by dilated anal blood vessels, recognized by 535 (49.2%), and swelling in the area around the anus, reported by 404 (37.2%).Itching was the least recognized symptom, identified by only 101 (9.3%).The higher number of participants recognizing symptoms such as anal injuries and dilated blood vessels indicates a moderate level of health literacy on the basic symptoms of hemorrhoids.However, the low number of participants who reported itching as a symptom highlights the need for enhanced health literacy regarding other symptoms of hemorrhoids.
A study in Saudi Arabia indicates that there is limited awareness of hemorrhoid symptoms [13].Awareness of hemorrhoid symptoms is essential, as it is an indication for performing DRE and facilitates acceptance and understanding from patients [14].
Many factors may affect the level of awareness and perception of DRE, including ethnicity and age.Both are important to investigate, as a study conducted in the United States shows that ethnicity and age significantly influence factors such as income and education, which, in turn, affect DRE acceptance.However, the study did not report a direct effect of age and ethnicity on DRE screening rates [15].Ethnicity is a paradoxical factor that may show significance in some studies and not in others.For instance, one review found that Hispanic individuals are more likely to undergo DRE, while another study found no differences based on ethnicity [16], which aligns with our findings that nationality has no significant effect.Additionally, it is reported that people over 50 years old are more likely to undergo DRE [17], yet in our study, there is no significant effect of age on the level of awareness.Psychologically, fear has been shown to reduce acceptance and affect the perception of screening methods like DRE [15].This is supported by another study indicating that fear of the examination is negatively associated with DRE acceptance.Regardless of the patient's education level, it is important to educate them about the examination and its importance.
Educating patients can reduce their fear and anxiety [16].Sufficient education is essential to overcome this barrier and increase the acceptance level of medical examinations, as education and health are crucial to the overall well-being of individuals and communities [17].
In the current study, overall awareness and perception are significantly affected by educational level, employment, and the field of study or work.Interestingly, participants in high school show that 190 (64.8%) of them have poor knowledge, followed by participants with an educational level below secondary, with 19 (57.6%) having poor awareness levels.Additionally, a study indicates that having previous experience with anorectal diseases significantly improves one's perception and awareness of DRE [11].However, our findings show no difference in awareness between individuals who have suffered from anorectal diseases and those who have not.
Regarding gender variation, our study found no significant differences in awareness and perception of DRE between males and females.Both genders exhibited high percentages of poor awareness, with 204 (55.0%) of males and 403 (56.3%) of females having low levels of awareness.It is also reported that both genders experience high levels of anxiety and fear before undergoing DRE [16].
Finally, to the best of our knowledge, this is the first study covering a large population in Saudi Arabia, and it adds to the literature, especially since there are not enough studies investigating the research topic.We collected a large amount from the Western region of Saudi Arabia; still, it is a limitation as the results cannot be generalized; further study is required to cover several populations for generalizability.A notable limitation is the unequal sex distribution, with more women responding to the survey than men.Another limitation is that the method of collection was an online survey; advanced collection methods in future studies will make the results more accurate.Also, we recommend some modifications to the questionnaire to investigate if the physician's gender affects the feeling of fear by patients or not.Some modification is also recommended to assess if the feeling of embarrassment is affected by the gender of the patient.Lastly, as we discussed earlier, our findings suggest a poor level of awareness among the targeted population; therefore, we recommend that future researchers start to think about providing solutions for this issue and improving the level of awareness.

Conclusions
This study was conducted to explore the willingness and understanding of DRE in assessing anorectal conditions among Saudis in the Western region of Saudi Arabia.According to our findings, most people demonstrated poor awareness of DRE.This indicates a low level of awareness regarding the benefits and appropriate timing for performing DRE.Consequently, the Saudi Ministry of Health should focus on increasing public understanding of DRE and raising awareness about the dangers of neglecting this important examination, as well as the advantages it offers.

Have you ever suffered from anal and rectal diseases?
).

TABLE 1 : Biodemographic characteristics of study participants from the Western region of Saudi Arabia (n = 1,087)
member had anal and rectal diseases, they would resort to traditional medicine.Additionally, 261 (24%) said they would agree to be examined if there was a screening clinic for anorectal diseases for prevention purposes using DRE (Table2).

If you or someone in your family was afflicted with anal and rectal diseases, would you resort to traditional medicine?
2024 Basamih et al.Cureus 16(8): e67702.DOI 10.7759/cureus.677025 of 12

TABLE 4 : Factors associated with participants' awareness and perception of digital rectal examination from the Western region of Saudi Arabia
P: Pearson's X 2 test; *P < 0.05 (significant); ^: Exact probability test