Year 2 MBChB

Clinical Skills Session

Rectal examination

Reviewed & Ratified by:

Miss R Hamm – Urinary and Renal System Lead

Dr Paul Collins – Consultant Gastroenterologist

Mr Ben Horsburgh – SpR Urologist

August 2018

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Learning objectives. To revise rectal examination including an understanding of the common abnormalities and examination of

appropriate lymph nodes

Theory and background.

The rectum is the distal (end) portion of the large intestine. The rectum is about 12 cm long and begins at the

rectosigmoid junction. The rectum’s lumen increases near its termination, forming the rectal ampulla where

faeces is stored prior to defecation and terminates at the anus.

Photographer: Armin Kübelbeck, CC-BY-SA, Wikimedia Commons

Indications for a rectal examination – also known as PR (per rectum) or DRE (digital rectal examination)

There are many indications for performing a rectal examination. The examination may be performed as part of a

GI examination or in isolation for any of the following reasons:

Rectal bleeding

Rectal Pain / itching

Abdominal Pain / pelvic pain (as part of an abdominal examination)

Passing blood / mucus in the faeces

Presence of lumps or other palpable abnormalities

Neurological symptoms / incontinence

Urological symptoms in the male patient (hesitancy, frequency, urgency, poor stream, retention)

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Equipment required to perform the examination

Procedure tray

Hard surface wipes

Pair of gloves

Apron

Tissues

Lubricating gel

Clinical waste bin

Faecal occult blood test kit if indicated

Culture swab if indicated

Patient safety.

On first meeting a patient introduce yourself, confirm that you have the correct patient with the name and date

of birth, if available please check this with the name band and written documentation and the NHS/ hospital

number/ first line of address.

Check the patient’s allergy status, being aware of the equipment you will be using in your examination. Ensure

the procedure is explained to the patient in terms that they understand, gain informed consent and ensure that

you are supervised, with a chaperone available as appropriate. Don personal protective equipment as required,

especially if you are likely to come into contact with bodily fluids.

Be aware of hand hygiene and preventing the spread of disease, WHO

(2018) http://www.who.int/infection-prevention/tools/hand-hygiene/en/

This procedure will require a warm, well lit & private environment with the presence of a chaperone. Someone

who is familiar with the examination and can ensure that nothing inappropriate occurs by either party. The

chaperone can be a useful resource, not just being present to ensure the patient is treated appropriately, but to help

and support the patient.

Procedure.

General Inspection

Look at the patient and their environment at the beginning of the examination.

In the environment there may be many relevant indicators of possible gastrointestinal / urinary conditions

including:

Urine bottles

Medications related to GI / urinary systems

Supplemental nutrition including tube feeding paraphernalia

Commode

The patient may show some signs of possible gastrointestinal disease including:

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Cachexia: wasting of the body due to severe chronic illness.

Urine or faecal soiling of bed linen or clothing.

Signs of pain including facial expression and patient positioning

The patient should be asked to undress from the waist down and lay on their left hand side with the hips and

knees flexed. Their lower half should be covered with a sheet until you are ready to start the examination and

then you should only expose the areas you need to.

Inspection

With your gloves on gently separate the buttocks and inspect the buttocks, natal cleft (between the buttocks),

perineum and anus.

Look for:

Rashes which may occur due to poor hygiene, atopic dermatitis (eczema caused by friction in anal area such

as rough wiping after defecation), sexually transmitted diseases, worms and warts.

Fissures: tears which may occur in the anal canal due to chronic constipation, chronic diarrhoea, sexually

transmitted diseases, trauma, pregnancy / childbirth and inflammatory bowel conditions.

Haemorrhoids (distended veins) associated with straining at the stool, pregnancy, heavy lifting, age, genetic

predisposition and obesity.

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Perianal abscesses which occur as a result of simple skin or anal gland infection. These may lead to the

formation of an anal fistulae which manifests as one or more chronic tracts from the anal canal to the

perianal skin.

Pilonidal cyst which form in the natal cleft due to an infection or pilonidal sinus when infection which erodes

a tract into the skin from a cyst.

The position of any anal lesion may be described in relation to the face of a clock. The anterior aspect of the

anus (the position of the genitalia) is assigned to 12 o’clock (see image).

Internal palpation of the rectum and its contents

Lubricate the gloved index finger of one hand, separate the buttocks if required with your other gloved hand.

Align the index finger which will be used to perform the examination with the natal cleft and place the pulp of

your index finger onto the anal verge overlying the anus. Inform the patient you are going to insert your finger

and slowly apply light pressure to the anus through the fingertip, at this point the patient will tense. Continue to

apply the pressure and the anus will begin to relax. Slowly bring the wrist through an arc of 90 degrees and your

finger will enter the rectum. Continue to insert the entire finger as far as it will go, following the sacral curve.

Note the tone of the sphincter as you insert your finger. Avoid using force during insertion, wait for the

sphincter to relax. If still difficult do not continue with the examination as there may be an obstruction in the

rectum, you should inform a senior member of the medical team. In cases where rectal pain is a presenting

complaint a local anaesthetic agent may be required. Upon correct insertion the pulp of the finger (the soft

palmer surface) is deemed to be at the 6 O’clock position as it relates to the clock face mentioned earlier.

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When the finger has been inserted if indicated (neurological symptoms, trauma or incontinence) you should ask

the patient to squeeze your finger by contracting their anal canal. This will allow you to assess anal tone and

therefore the innervation of the muscles.

You should now examine the contents of the rectum. Normally, the rectum would be empty as faeces passes

into it from the large intestine once or twice daily. Exceptions would include when the patient is constipated,

suffers with a form of irritable bowel disease, has not taken the opportunity to defecate or there is an abnormal

mass such as haemorrhoids or a large tumour. If the rectum is not empty you should assess the contents of the

rectum to determine the cause. Such as;

Faeces can be fluid to hard in consistency, as the faeces becomes firmer it becomes possible to indent

and may leave residue on the glove.

A large tumour protruding into the rectum from the rectal wall would not be indentable and may range

from soft to hard in consistency and covered in mucous dependant on type.

Once the content of the rectum have been assessed the rectal wall need to be examined (normally soft

and pliant with mucosal folds) in a systematic methodical manner. Starting with the examining finger at

the 6 O’clock (towards the coccyx) systematically feel the rectal wall for changes in the surface and

swellings. Rotate the examining hand at the wrist to ensure that the entire rectal wall is palpated. In a

male patient you will examine the prostate gland; in a female patient the cervix is usually palpable.

Any findings should be described in full including size, shape, position (related to the clock face and how far into

the rectum), surface, consistency etc. Findings may include;

Fistula (which may not be evident on inspection) is an abnormal channel which forms between 2 hollow

spaces (the rectum is a hollow space) and may be a result of infection or surgery. A fistula may feel like a

small dip in the rectal wall.

Rectal wall tumours may vary in consistency.

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Haemorrhoids may be soft therefore impalpable or difficult to palpate or they may be hard (thrombosed

/ clotted) which can be palpated close to the anal sphincter and dilated vessels may be evident at the

anus on inspection.

Ulcers associated with inflammatory bowel may be felt as flat areas with a slightly irregular surface and

possibly slightly firmer than surrounding tissue due to the inflammatory changes in the rectal mucosa.

Pain from the above findings may inhibit the performance of a rectal examination unless appropriate

analgesia is provided.

On completion reassure the patient and inform them that you are removing your finger, check gloved finger for

stool (normal colour, pale stool, malaena (black tarry stool (partially digested blood)) etc.), mucus or any fresh

blood

Clean area with a tissue, cover patient, provide the patient with further tissues, ask them to dress, dispose of

your gloves etc. and finally wash your hands again.

Prostate Examination Specifics

The prostate gland is examined during a rectal examination in the male patient. If you suspect a cancerous

change in the prostate you should take blood for prostate specific antigen before performing the examination. A

normal prostate measures approximately 3.5cm from side to side and protrudes 1cm into the rectum. It can be

felt through the anterior rectal wall (between 1 o’clock and 11 o’clock) and has a median sulcus separating two

lobes.

The median sulcus is a groove between the lobes of the prostate. The sulcus may become more pronounced in

bilateral prostatic hypertrophy, less pronounced in unilateral prostatic hypertrophy or obliterated in unilateral

and bilateral carcinoma (dependant on size of tumour).

The prostate should not be tender on palpation but the patient may experience discomfort or an urge to urinate

when it is palpated.

Palpation of the Prostate Gland

Palpation of the prostate gland aims to assess;

Prostate Gland

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Size, assessment of prostatic size is learnt through experience, it would normally be approximately 3.5

cm in width and pushes against the anterior rectal wall protruding into the rectum approximately 1 cm.

The presence of two equal normal sized lobes with a median sulcus

Consistency – the prostate gland should feel soft or slightly firm like the tip of your nose

The surface should feel smooth of nodular

Note the presence of any tenderness - to differentiate from the discomfort of the examination apply

pressure laterally

Assessment of prostatic size is learnt through experience

Abnormalities of the Prostate

Benign Prostatic Hyperplasia (BPH) is common in men over the age of 60 years. The enlargement is smooth and

usually bilateral, the gland feels rubbery but may be firmer if very large.

A cancerous prostate may feel asymmetric, with a stony hard in consistency with the presence of palpable

nodules.

Both of these conditions may affect 1 or both lobes and be termed unilateral or bilateral correspondently.

This image depicts the shape of prostate glands, the upper part of each image is what would be the palpable

part of the gland felt through the rectal wall.

For example the normal prostate with two smooth defined lobes with a small median sulcus (dip / groove)

compared to the bilateral benign tumour with two enlarged lobes and a pronounced median sulcus.

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Tenderness of the prostate may be due to prostatic inflammation or infection.

All findings must be documented and further investigations (prostate specific antigen (blood test) and

urodynamics (urinary flow studies)) may be indicated / treatment and further management must be considered

in light of history and examination / investigation findings.

Recording your findings

Don’t forget when recording your findings to include the patient identifiers, date (and time), your signature and

printed name at the end.

When documenting or describing your findings remember to comment on the anus (inspection), position of any

abnormalities seen, anal tone (if performed), rectal walls, contents of rectum (stool etc.), the prostate size,

consistency etc. and a description of any abnormal masses palpated.

Remember to describe your findings as fully as possible: e.g. size, position (relative to the clock face as

previously described) and the shape of a swelling etc.

Warning: it is easy to confuse left and right sided findings because you are examining the patient from behind

so ensure that you are reporting correctly.

A diagram may often be useful in written notes

Further Reading

NICE prostate Cancer guidance

https://www.nice.org.uk/guidance/cg175

https://www.nice.org.uk/guidance/conditions-and-diseases/cancer/prostate-cancer

https://www.nice.org.uk/news/article/a-new-option-for-men-with-enlarged-prostate