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Digital rectal examination

Introduction

  • Wash hands; Introduce self; ask Patient’s name, DOB and what they like to be called; Explain examination and obtain consent
  • Get a chaperone
  • Explain that procedure is intimate and why it is necessary
  • Explain what you want the patient to do: ‘Undress from the waist down, then lie on your left side, bringing your knees up to your chest.’ 
  • Allow the patient to undress in privacy and give them a sheet to cover up with
  • Use the patient’s name and take care to explain carefully what you are doing. Check they are OK throughout.

Equipment

  • Lubricant
  • Gauze
  • Paper towels
  • Put on gloves and apron

Inspection

  • Part the buttocks and look for: any blood, rashes, fistulae, fissures, excoriations, warts, haemorrhoids, skin tags
  • Ask the patient to bear down and look for rectal prolapse

Examination

  • Lubricate gloved index finger and approach anus from posteriorly. Pause when the finger is over the anus and wait until the sphincter relaxes.
  • Warn patient then advance finger into anus
    • Comment on consistency of any faeces
    • Ask the patient to bear down (brings high rectal lesions lower)
    • Ask the patient to squeeze your finger (tests anal tone)
  • Do a 360˚ sweep feeling for any masses or wall thickenings
  • In men, feel the two lobes of the anterior surface of the prostate and comment on any masses, symmetry, consistency and size
  • Remove finger and wipe on gauze – inspect for mucus, blood and melaena
  • Clean the anus
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Digital rectal exam

To complete

  • Thank patient and allow patient to get dressed in privacy
  • Dispose of waste
  • Wash hands
  • Document findings and note presence and identity of chaperone
  • Summarise and suggest further investigations you would do after a full history, for example:
    • Prostate surface antigen
    • Rectal ultrasound
    • FBC (anaemia)
    • Sigmoidoscopy
    • Colonoscopy

Try some questions

Please list some red flags for anal cancer?

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Can you list some differentials of fresh red PR bleeding?

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How would you expect a cancer of the prostate to feel on digital rectal examination?

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What symptoms may a patient with prostate cancer present with?

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Which scoring system may be used to grade prostate cancer and what does this take into account?

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Discuss the management options for prostate cancer

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