Digital rectal examination station

Introduction

Introduce yourself with your name, role and confirm the patient’s name and date of birth. Briefly explain the procedure and the degree of exposure required. The patient should be undressed from the waist down including any undergarments.

Obtain consent and proceed to wash hands. For this examination, it is essential to have a chaperone.

Position the bed flat and then put on a pair of non-sterile gloves and an apron. Instruct the patient to lie on the bed in the left lateral position with their knees bent up to their chest. Offer the patient a blanket to maintain their dignity. Ask if they are in any pain and are comfortable.

Left lateral position.

Many patients will feel uncomfortable with the process of a digital rectal examination, so it is important to have good communication skills to keep them at ease. Be clear and to the point with your explanations; do not hesitate. It is important that you reassure the patient that this is a normal examination.

A good way of explaining the procedure is as follows:
“In this examination, I will be using my gloved hand to insert a lubricated finger into your back passage. This allows me to check for any abnormalities of the local area and the prostate. This may be a little uncomfortable. If at any point you wish to stop for a moment, please do let me know.”

Equipment

Before you begin your examination, prepare the following equipment in a plastic tray:

Non-sterile gloves.
Disposable apron.
Tissues.
Lubricating jelly.

Inspection

Warn the patient that you are about to look around the area.

Separate the buttocks using your non-dominant hand and inspect the anus and natal cleft. Inspect for the following signs:

External haemorrhoids (see “haemorrhoids” below).
Skin tags (fleshy extra skin hanging from anus): These are usually harmless growths that may be mistaken for warts or haemorrhoids. They can be caused by inflammation, injury or leftover skin after haemorrhoid removal.
Excoriation marks (scratch marks): These are as a result of anal itchiness, which can be due infection, haemorrhoids, bowel incontinence, long-term constipation/diarrhoea or repeated glyceryl trinitrate cream topical application (used to treat anal fissures).
Anal fissures (skin tear): These occur with long term straining of hard faeces such as with chronic constipation or in inflammatory bowel disease.
Anal fistulae (small opening often with discharge): These can also be present in inflammatory bowel disease (particularly Crohn’s disease). Other causes include abscesses that have failed to heal and diverticulitis.

Ask the patient to cough and check for any internal haemorrhoids or rectal prolapse.

Haemorrhoids are disrupted and dilated anal vascular cushions which are prone to rupture. There are three anal cushions located at 3, 7 and 11 o’clock (with 12 o’clock being closest to the genital area). They are classified according to their location. Internal haemorrhoids are found above the dentate line and have visceral innervation. They are usually painless (unless prolapsed). External haemorrhoids are found below the dentate line and have somatic innervation. They can be quite painful.

Internal haemorrhoids can further be classified as follows:

First degree: No prolapse, just dilated blood vessels.
Second degree: Prolapse upon straining, but reduce spontaneously.
Third degree: Prolapse upon straining and require manual reduction.
Fourth degree: permanently prolapsed and cannot be reduced.

This is a group of two disorders that cause chronic inflammation of the gastrointestinal tract:

Ulcerative colitis: A relapsing and remitting condition (the patient is relatively well between attacks), of the colonic mucosa and submucosa. It starts at the rectum and spreads proximally and continuously. Patients will experience bloody diarrhoea with mucus and tenesmus.

Crohn’s disease: A chronic disease that has skip lesions (patchy unharmed regions) which can affect any part of the gastrointestinal tract. There are non-caseating granulomas which are transmural (through the entire wall of the organ) in nature; as a result, Crohn’s disease can lead to fistulae and fissures. Patients also suffer from ulcers, strictures and abscesses. These patients are likely to have weight loss and will be more systemically unwell at presentation.

Anal tone

Lubricate the index finger of your dominant hand with some lubricating jelly and place your other hand on the patient’s hip. Place one finger on the anal orifice and lightly palpate for induration (a hardened/fibrous section under the skin), which is associated with inflammatory conditions such as Crohn’s disease.

Ask the patient to breathe in deeply and then relax to loosen the sphincter.

Warn the patient that they may feel some cold jelly, and then advance your index finger into the anal canal. Ask the patient to bear down on your finger to assess anal tone. Decreased anal tone may be due to long-term diarrhoea, diabetes, spinal trauma or simply old age.

Palpation

Anal canal

Sweep 360° around the full rectum. The anterior walls may be more easily examined by rotating your body and wrist. Check for any lumps; these may be haemorrhoids, polyps or a tumour. Feel for palpable faeces and tenderness. If the patient is in severe pain during the examination, consider an anal fissure, abscess or ulcer.

Note the location, using a clock face, and texture of anything you find. e.g. 1cm irregular mass at 9 o’clock.

After advancing your finger, it may be worth pausing for a few seconds to allow the patient to acclimatise and relax.

During palpation look at the patient’s face for signs of distress/pain.

Prostate

With males, identify the prostate, its central sulcus and assess the size. A normal prostate is smooth and walnut sized. Check for symmetry, the presence of any nodules and any tenderness. Abnormalities in these features can give indications towards pathology:

Enlarged with a deep sulcus: Benign prostatic hyperplasia.
Enlarged and very tender: Prostatitis.
Enlarged with a rough nodule: Unilateral cancer.
Hard, asymmetrical and irregular with an impalpable sulcus: Prostate cancer.

Benign prostatic hyperplasia: A common condition that is defined as the slow, progressive nodular hyperplasia of the peri-urethral zone. It is a common cause of lower urinary tract symptoms in men and can often be treated with a combination of an -blocker (tamsulosin) and a 5-reductase inhibitor (finasteride).

Prostatitis: Swelling and inflammation of the prostate gland characterised by pain around the perineum and penis, more commonly in younger men. It can be divided into acute and chronic:

In acute prostatitis, patients also experience urinary symptoms including retention and a thick urethral discharge. Treatment with analgesia and prompt antibiotics.
In chronic prostatitis, patients experience dysuria, pelvic pain and erectile dysfunction. These patients should be given analgesia, an α-blocker (tamsulosin) and referred to a urologist.

Prostate cancer: This is the second most common cause of cancer death in males and it is also often asymptomatic until the late stages. It presents with urinary tract symptoms, such as dysuria and hesitancy, until metastatic spread, where the patient will also experience bone pain, cord compression and systemic symptoms (fever, lethargy, weight loss).

Completion

Inspection of the gloved finger

Withdraw and inspect the gloved finger for blood or mucus, suggesting ulcerative colitis. Thank the patient, remove your gloves and place them in a clinical waste bin. Wash your hands.

Wipe away the jelly from the anus and offer the patient some extra tissues for their own comfort. Give the patient privacy to get dressed.

Post-examination

Offer to take a focussed history, an abdominal exam and the appropriate tests depending on the pathology.

Gastrointestinal presenting complaint:

Stool culture.
Blood tests (full blood count and faecal occult blood test).
Sigmoidoscopy.

Urinary presenting complaint:

Urine dipstick.
Blood tests (full blood count and prostate specific antigen).
Transrectal ultrasound (TRUS) biopsy.

PSA is produced by produced by the epithelial cells in the prostate and is used in screening, despite being a notoriously poor marker. The test has a high specificity, yet low sensitivity meaning that up to 1 in 7 men with prostate cancer may receive a false negative result.

Other conditions which increase PSA include benign prostatic hyperplasia and prostatitis. It can also be increased after vigorous exercise or ejaculation.

Concise history

Below are some the key elements to be addressed when taking a focussed DRE history depending on what the presenting complaint is.