Lippincott Nursing Pocket Card - April 2023

Digital Rectal Exam



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.


Optimal Patient Gowning/Positioning

  • 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
    • Gently separate the butt cheeks. 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, fissures 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 an anal fissure is suspected by history, by inspection or by local tenderness upon insertion of the tip of a gloved finger, further digital examination should be deferred until healing.
    • 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.


  • 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 optional with PSA testing being favored.
  • Tenderness on palpation of the prostate may indicate prostatitis, with follow up required.

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.
Stewart, D.B. (July, 2022).  Approach to adult patients with anorectal complaints. UpToDate.