1. Gender Related Examinations

1.3. Digital Rectal Examination

 

Digital Rectal Examination

STANDARD SETTINGS
  • Wash hands
  • Introduce yourself
  • Explain about examination
  • Offere a chaperone and record if this is refused
    • A chaperone may be provided to help protect and enhances the patient's comfort, safety, privacy, and dignity during sensitive examinations and procedures
  • Seek permission to proceed with the examination
  • Ask if the patient is comfortable or has any pain before proceeding
  • Wear an apron and pair of sterile gloves before proceeding
  • Always approach the patient from the right side

Exposure

  • Ask the patient to remove their underwear
  • Provide the patient with privacy to remove clothing
  • Seek permission before re-entering the room
  • Offer a sheet to allow exposure only when needed

Position

  • Ask the patient to lie down in the left lateral position
  • And bend their knees towards the chest

Equipment required

  • Examination code
  • Pillow
  • Non-sterile gloves
  • Apron
  • Lubricant
  • A box of tissue paper
Steps of the digital rectal examination
  1. Inspection
  2. Palpation
Indications
  • Assessment of the prostate
  • Rectal bleeding
  • Constipation
  • Change of bowel habit
  • Urinary or faecal incontinence

Details of the steps involved

INSPECTION

Gently part the buttocks and inspect the perianal region for the following

  • Skin excoriations
  • Skin tags
  • External haemorrhoids
  • Anal fissure
  • Pilonidal sinus
  • External bleeding
  • Anal fistula
  • Genital warts

Ask the patient to cough and inspect for the following

  • Rectal prolapse
  • Internal haemorrhoids

Skin excoriations

    • Skin excoriations are secondary to anal pruritis
    • Can be caused by
      • Haemorrhoids
      • Faecal incontinence
      • Constipation

Skin tags

    • Excess growth of skin around the anus that are usually benign
    • In some cases, can be associated with inflammatory bowel disease

Haemorrhoids (piles)

    • Haemorrhoids are swollen and inflammed veins around the anus or in the lower rectum.
    • External haemorrhodis
      • These are located below the dentate line (it divides the upper two third and lower one thrid of the rectum) and innervated by somatic nerves 
    • Internal haemorrhoids
      • These are located above the dentate line (it divides the upper two third and lower one thrid of the rectum) and innervated by visceral nerves
        • On inspection, they appear to be bluish, bulging vessels covered by mucosa
        • Usually become visible when the patient coughs

Anal fissure

    • An anal fissure is a tear in the mucosa of the anal canal typically located in the midline posteriorly
    • They are very painful and often makes sometime examination impossible
    • They develop mostly secondary to constipation

Pilonidal sinus

    • A pilonidal sinus is a small hole or tunnel in the skin at the top of the buttocks, where they divide.
    • Usually they do not cause symptoms and should only be treated if get infected

External bleeding

    • May be caused by the following
      • Haemorrhoids
      • Anal cancer
      • Brisk gastrointestinal bleeding

Anal fistula

    • A chronic abnormal communication between the internal canal and perianal skin and it may discharge pus
    • Causes of anal fistula include
      • Perianal crohn's disease
      • Chronic anal abscess
      • Diverticulitis

Genital warts

    • Small lumps that develop around the anus, also known as anogenital warts
    • They are usually caused by the infection of human papilloma virus (HPV)

Rectal prolapse

    • Rectal prolapse is the protrusion of either the rectal mucosa or the entire wall of the rectum
      • On examination, a mass with cocentric rings of mucosa protudes through the anus
      • It will become more visible when patient coughs

PALPATION

  • Lubricate the index finger of your right hand
  • Warn the patient you are going to insert your finger
  • Insert your complete finger slowly in to the anal canal

Palpation of prostate

    • Palpate the prostate gland anteriorly in males
    • And assess the following
      • Size 
      • Symmetry
      • Texture

      • Normal prostate

        • In healthy individual, prostate size is approximately equal to the walnut size
        • It should be smooth and symmetrical and has consistency similar to the tip of the nose

        Abnormal findings

        • Pain on palpation of the prostate is suggestive of prostatic infection
        • Hard prostate on palpation is suggestive of prostatic cancer
        • Enlarged prostate on palpation is suggestive of benign prostatic hyperplasia (BPH)
Palpation of the anal canal
  • Rotate your finger 360 degree to assess the anal canal completely
  • Assess for the following
    • Rectal lumps (e.g. polyp, tumor, internal haemorrhoid)
      • Note the location (e.g. 11 o'clock) and size of the lump
      • Also, note the texture of the lump (e.g. smooth, irregular)
    • Hard stool
      • Sugestive of constipation
    • Tenderness
      • Note the location of tenderness
Assessment of anal canal
  • Ask the patient to squeeze around your finger and assess the tone of the anal canal
  • If there is reduced anal tone, it can be due to 
    • Disease of nervous system
      • Central nervous system (e.g. multiple sclerosis)
      • Spinal cord (e.g. cauda equina syndrome)
    • Inflammatory bowel disease
    • Previous rectal surgery

Final Steps

  • Withdraw your finger and inspect for the following
    • Dark sticky blood
      • Due to upper GI bleeding
      • Also known as melaena
    • Fresh blood
      • Due to lower GI bleeding
      • Suggestive of rectal malignancy, or fissure
    • Excess mucous
      • Can be associated with ulcerative colitis
  • Clean the patient using tissue papers
  • Cover the patient with the sheet
  • Explain that the examination is over
  • Provide the patient with the privacy so they can get dressed
  • Thanks the patient
  • Dispose off apron and gloves into a clinical waste bin
  • Wash hands
  • Document the procedure including the details of chaperone
Tags: