Lippincott Nursing Pocket Card - May 2022
Digital Rectal Exam
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Introduction
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Digital rectal examination begins with taking a health history, while ensuring privacy. While doing so, observe carefully for nonverbal cues of pain or discomfort. Obtain consent for the examination and secure a chaperone. Order of examination is performed as inspection and then palpation. Explain the steps of the examination to set patient at ease.
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Optimal Patient Gowning/Positioning
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- The patient should be provided privacy to change into a gown.
- A large drape or sheet should be provided to assist with draping for patient comfort.
- Examine the patient while supine on their left side, with buttocks close to the edge of the examination table.
- Legs should be flexed at the hips and knees, with patient draped exposing only the buttocks and anal area.
Exam methods
- Inspection
- Inspect the sacral, coccygeal, and perianal areas for inflammation, lesions, masses, tenderness, or excoriation.
- Inspect the skin over the buttocks, noting any lesions or masses.
- Inspect the anus noting any lesions, hemorrhoids, masses, fistulae or tenderness.
- Palpation
- Explain to the patient that the examiner will be placing a gloved finger into the rectum.
- Using a water-based lubricant, insert a gloved finger into the rectum, pausing to allow the sphincter to relax.
- Ask the patient to bear down to relax the sphincter and advise the patient that there may be a sensation of a bowel movement but that this is normal and will not happen.
- Insert finger toward the umbilicus, palpating circumferentially to identify any masses, tenderness, or mucosal lesions.
- If the patient has a prostate, palpate for position, size, texture, mobility, tenderness, and any masses. Advise the patient he may have an urge to urinate during the prostate exam.
- Ask the patient to squeeze their anus onto the gloved finger to assess rectal tone.
- Upon withdrawing the examining finger, note any gross blood. Test for occult blood.
- Offer patient soft tissues or a towel to wipe away any excess lubricant.
PEARLS
- Digital rectal examination may trigger a vagal response in some patients resulting in bradycardia or hypotension. This is usually self-limiting after aborting the examination.
- Digital rectal examinations, once a staple of preventative screening for prostate cancer in men over 50, is considered optional with PSA testing being favored.
- Tenderness on palpation of the prostate may indicate prostatitis, with follow up required.
Reference
Bickley, L. S., Szilagyi, P. G., Hoffman, R. M., & Soriano, R. P. (2021). Bate’s Guide to Physical Examination and History Taking (13th ed.). Wolters Kluwer Health: Philadelphia.