Exam methods

• Inspection
  • With gloved hands, gently separate the buttocks. Inspect the sacral, coccygeal, and perianal areas for inflammation, lumps, lesions, masses, tenderness, or excoriation.
  • Inspect the skin over the buttocks. Note any lesions or masses.
  • Inspect the anus. Note any lesions, hemorrhoids, masses, fistulae, fissures or tenderness.
• Palpation
  • Explain to the patient that the examiner will be placing a lubricated 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 an anal fissure is suspected by history, inspection or if there is local tenderness upon insertion of the tip of a gloved finger, further digital examination should be deferred until the fissure is healed.
  • If the patient has a prostate, palpate for position, size, texture, mobility, tenderness, and any masses. Advise the patient they 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

• Hemorrhoids and anal fissures are the two most common causes of anorectal discomfort.
• 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 an optional adjunct to prostate-specific antigen (PSA) testing. Some society guidelines now do not recommend digital rectal exams for screening.
• Tenderness on palpation of the prostate may indicate prostatitis, with follow-up required.