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

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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Practice now with a mock OSCE station

1. Digital rectal exam
2. You’ll find hundreds more stations here