Digital Rectal Examination
Simulation
The simulator offers 12 different scenarios that test your ability to prepare for and perform a digital rectal examination of either a male or female.
Video
The video guides you through a step-by-step demonstration on how to set up and perform digital rectal examination of a male or female.
Anatomy
The anatomy provides a detailed cross section of both male and female pelvic structures, including a 360-degree rotating coronal image to illustrate the key structures of the examination.
Text
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Step 1: Preparation
1.1. Set-up
Have the required equipment close at hand.
1.2. Patient preparation
Ask the patient to lie on the examination couch in the left lateral decubitus position with their buttocks at the edge of the bed and their hips and knees flexed at 90 degrees.
The traditional position of standing bent over with elbows on knees is now less commonly used (see reference).
1.3. Operator preparation
Don the examination gloves.
Use courtesy and sensitivity during the procedure.
Step 2: Inspect the anal and perianal region
Lift the glutei muscles to clearly expose the anus and perianal region (see reference).
Inspect the skin and anal folds for any anal and perianal pathology.
Step 3: Perform the digital rectal examination
Generously apply lubrication onto the gloved index finger.
Insert the gloved index finger into the anal canal and then into the rectum. If the patient does not tolerate the insertion of your finger into the anal canal, abandon the procedure and offer the patient an examination under anesthetic.
Sweep your finger 180 degrees around the mucosa in each direction (see reference).
Take note of any anal canal or rectal pathology by palpating for any masses, areas of tenderness, or fecal material (see reference).
Step 4: Palpate the prostate in men, or perform a rectovaginal exam in women
In men
Palpate the prostate through the posterior rectal wall.
Palpate the two lobes and the central cleft. Take note of the consistency, the presence of any nodules or masses, tenderness, size and symmetry.
In women
Palpate the rectovaginal septum between the rectum and the vagina.
Take note of any laxity, masses (such as enteroceles) or loss of integrity (see reference). In some women, you may be able to palpate the cervix.
Step 5: Assess the anal tone
Anal tone is assessed by examination of the internal and external sphincter function (see reference).
Assess the anal tone in a resting state to demonstrate the internal sphincter function (see reference).
Ask the patient to bear down or squeeze and assess the external sphincter function (see reference).
NOTE
Traditionally in trauma patients, digital rectal examination has been used to evaluate spinal nerve damage by assessing the rectal tone. There may be evidence that other clinical findings may be of more value than the digital rectal examination (see reference). However, it should not be excluded from the trauma assessment.
Step 6: Assess the fecal material
Remove the finger from the rectum.
Observe the gloved finger for any fecal material taking note of any mucoid discharge or blood. Blood may be tarry black (malena) or bright red suggesting upper and lower gastrointestinal bleeding respectively.
NOTE
- Test for fecal occult blood if there is no blood on the glove but the patient has signs and symptoms suggestive of gastrointestinal bleeding.
Step 7: Additional steps
Consider performing an anoscopy, proctoscopy, or sigmoidoscopy if indicated.
Step 8: Make the patient comfortable
Wipe off the lubrication jelly and any mucous or blood from the anus.
Offer the patient tissue paper and allow them to get dressed.
Reference
Reviews
1. Pfenninger JL, Zainea GG. Common anorectal conditions: Part 1. Symptoms and complaints. American Family Physician. 2001 Jun 15;63(12):2391-8. PMID: 11430454.
2. Whitehead WE, Wald A, Diamant NE, et al. Functional disorders of the anus and rectum. Gut. 1999 Sep;45 Suppl 2:II55-9. PMID: 10457046.
3. Pfenninger JL, Zainea GG. Common anorectal conditions: Part 2. Lesions. American Family Physician. 2001 Jul 1;64(1):77-88. PMID: 11456437.
Prospective Studies
4. Esposito TJ, Ingraham A, Luchette FA, et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. Journal of Trauma. 2005 Dec;59(6):1314-9. PMID: 16394903.
5. Hennigan TW, Franks PJ, Hocken DB, et al. Rectal examination in general practice. BMJ. 1990 Sep 8;301(6750):478-80. PMID: 2207403.
Textbooks
6. Gutman RE, Cundiff GW. Anorectal dysfunction. In: Berek JS, ed. Berek & Novak's Gynecology. 14th ED. Philadelphia, PA: Lippincott Williams & Wilkins. 2007; Chapter 25: 935-988
7. Goroll AH, Mulley AG. Approach to the patient with anorectal complaints. Primary Care Medicine. 5th ed. Philadelphia, PA:Lippincott Williams & Wilkins, 2006;Chapter 66: 489-496
