2. Learning Objectives
By the end of semester 2 you should be able to...
• Perform a systematic digital rectal examination
• Describe the reason for performing a rectal
examination
• Explain what you are doing and why
• Explain the potential clinical findings that may
occur
• Identify abnormalities and describe clinical
findings
• Explain the potential causes of various common
pathologies
3. Indications
Diagnosis of perianal lesions (abscess, hemorrhoids,
fissures and fistulae).
Diagnosis of rectal tumors (polyps, cancer) and
carcinoma of anal canal.
Diagnosis of prostatic disorders ( carcinoma &
benign prostatic hyperplasia).
Estimation of the tone of the anal sphincters
( internal & external sphincters).
In females, bimanual palpations of tubes, uterus
and ovaries.
Prior to a colonoscopy or proctoscopy.
Finally, PR is an important step in abdominal
examination For any abdominal complaint.
4. Discuss the procedure
with the patient.
Explain that She/he will
feel pressure and
some discomfort
during examination.
Ensure that you have taken a full verbal
consent for the procedure
Wash your hands
Introduce yourself and confirm the
patients I.D.
Before procedures
5. Prepare for PR Examination
Care for privacy, Ensure you
have a nurse with you.
Tools:
Apron
Clean gloves
Water soluble lubricant (KY Jelly)
Tissue paper
Anoscopy & proctoscopy
Minor surgical set for biopsy
Good illumination ( a flexible wall
hung lamp).
7. Positions of the patient:
1- Left lateral position
(Sim;s position), in which
the patient lies on his or
her left side with the hips
and knees flexed and
parallel
2
-
Knee elbow
position
8. 4- Lithotomy position (in OR)
Suitable for PR exam and anal surgery
3- Dorsal position
Suitable for prostatic exam
9. Inspection
:
Wearing the clean gloves
(without lubricant):
First inspect the
underwear of the patient
for any soiling ( blood,
mucous or pus )
Separate buttocks and
Inspect the perianal
area for skin color
changes, swellings,
fistulas or sinuses,
discharge, scars of
previous surgery.
10. Inspection:
Inspect the anal opening for:
Swellings: Anal warts , Carcinoma ,Prolapse of
mucous membrane (piles, partial rectal
prolapse, complete rectal prolapse)
Anal fissure , Anal fistula
Ask the patient to strain and inspect for
prolapse with straining, or incontinence
Look for spontaneous reduction after straining.
13. Palpation the perianal area:
Wearing a disposable
glove (without
lubricant);
Palpate the perianal
area for:
Swellings
Tenderness
Indurations
14. Digital examination of the rectum
Then, Lubricate the Index
finger and tell the patient that
you are going to insert your
finger gently assuring him
that there will be little pain.
Ask the patient to relax
Press with the pulp of your
finger against the posterior
margin of the anal verge for a
few seconds and then slide
your finger gently into the
anal canal.
15. By the tip of your finger,
assess the internal
sphincter tone.
Then; Examine each side
of the anal canal & rectum
by sweeping 2/3 of your
finger around the entire
circumference (180 degrees
to the right and another 180
degrees twist to the left).
16. Palpate the four sides of the anal canal and lower rectum
for:
1- Intraluminal: hard stool, foreign bodies
2- Intramural (Wall): Swellings, ulcers, indurations
(around internal fistulous opening), tenderness of
submucous abscess.
17. 3- Extraluminal:
A) Anterior for Males:
1- Prostate & look for preservation of the
sulcus(normal size 4x4cm, rubbery), presence of
any masses or nodules:
Hard nodule (prostate cancer, prostatic calculi, TB
nodule).
Tenderness (prostatitis).
2- Tumors at the Base of urinary bladder
3- Seminal vesicles, normally not felt(felt only if
calcified in bilharziasis).
B) Anterior for females; Any lesion in the posterior
wall of vagina & cervix
18. C) Insert the whole length of your finger
deeply into the rectum ; examine for:
1- Tumours of the lower third of the
rectum(adenoma, carcinoma)
2- Fullness in rectovesical pouch in males (fluid,
blood, pus, malignant deposits.
3- Fullness in rectovaginal pouch in females
(Douglas pouch).
Finally; Ask the patient to contract his
sphincter(to strain) and palpate the tone of
the Ano-rectal ring (deep part of external
sphincter)
19. Inspect withdrawn
fingertip for:
Blood, Pus, Mucous.
Send a sample from any
discharge for
bacteriological &
cytological exam.
20. Further Examination by Proctoscopy
Using the rigid proctoscope:
The instrument is lubricated with KY jell and is inserted into the
rectum and air is gently pumped in which allows a clearer view of the
interior part of the rectum.
Under direct vision, advance the scope into the middle of the
expanded segment of the rectum.
A slight lateral angulations of the scope is used to pass the
instrument through the rectal valves
Inspect the interior of the rectum in all of its circumference (360
degrees) and if there is a lesion, you can take biopsy.
Further examination may be performed using a flexible proctoscope.
Upon complete removal of the scope, wipe off the perianal area and
return the patient to a more comfortable position
21. Aftercare
Clean the perianal area
with tissue papers, and
allow the patient to put on
clothes and cover him
Thank him/her and apologize
for the patient for any
inconvenience.
Wash your hands
Document the date of
examination and your
provisional diagnosis.
Send the biopsy taken for
histopathological examination.
