A rectal examination is one that is commonly undertaken. There are many conditions, which if suspected, may require a rectal examination to be performed. Some common examples are shown to the right. 

 

A rectal examination is an intimate examination. Therefore a chaperone should be present for the protection of both the patient and the practitioner.

Position

Prior to commencing the examination, consideration should be given to the position of the patient - they should be able to relax to ease any stress, as well as making the examination easier and more comfortable for the patient. Patients should lie in the left lateral position, facing away from the practitioner. Either both or just the right hip should be flexed, depending on patient comfort, bringing the knee(s) up towards the chest. This will expose the area to be examined. Out of respect for the patient's privacy, the examination area should be divided from the main ward/room area by a curtain. For their comfort, the area should be well heated.

 

Left lateral position

Preparation

There is a risk of cross-infection during a rectal examination, and certain steps should be taken to protect both patient and practitioner:

  • hands should be clean and gloves worn
  • arms should be bare below the elbows, remove watches, rings etc.
  • apron or other protective clothing should be worn.

 

As in all examinations, the practitioner should explain to the patient what will happen to them, why the examination is being done, explain to them that any findings will be kept confidential, and obtain consent. They must be prepared to respond to the any discomfort appropriately (fissures cause severe pain on entry of a finger.)

 

Inspection

As with all physical examinations, the first step is to inspect the area. A pen torch may be useful. First, gently part the buttocks, and inspect the anus and perianal area. Common findings include:

  • redness or excoriation indicating pruritis or discomfort
  • blood, faeces or mucus around the area
  • haemorrhoids
  • skin tags
  • anal fissures
  • warts or abscesses, which may indicate infection
  • anal fistulae.

 

Asking the patient to strain downwards, as if going to the toilet, may reveal a rectal prolapse or haemorrhoids. Haemorrhoids can be classified according to a four-stage system:

  • Grade 1: no prolapse
  • Grade 2: prolapse on straining but then reduce in size
  • Grade 3: prolapse on straining and require manual reduction
  • Grade 4: prolapsed, and cannot be reduced, even manually.

 

Palpation

Following inspection, palpation of the rectum should be performed. Before commencing, it is important to lubricate the gloved index finger - this prevents unneccessary discomfort for the patient, and eases examination.

 

Part the buttocks, and gently press on the anal sphincter with the index finger; whilst explaining to the patient what is being done. Asking the patient to breathe out on entry will help to relax the external anal sphincter. When the sphincter has suitably relaxed, inform the patient you will gently be inserting a finger - the finger will face the posterior wall of the rectum.

Before palpating any further, it is important to check the tone of the external anal sphincter. This can be done by asking the patient to squeeze the finger using the anal muscles.

 

Slowly and gently palpate the wall, feeling for any abnormalities such as hard lumps. Consider that faeces may be present, so do not confuse this for part of the rectal wall. Describe any unusual mass in the following way:

  • the approximate size
  • the location
  • the shape
  • the surface texture - smooth or nodular
  • whether it has invaded the lumen or is submucosal.

 

Rotate the finger so it is facing the left lateral wall of the rectum, and repeat the palpation process. Repeat again for the right lateral wall, and again for the anterior wall.

 

In male patients, the prostate may require examination. For ease of examination, it is advised to kneel down to the level of the patient. The prostate gland can be located on the anterior wall of the rectum, and in normal cases will be smooth, rubbery, regular in shape and rounded. The median sulcus, which separates the two lateral lobes of the gland, should be palpable. Patients may feel the urge to urinate at this point.

 

When the internal examination is complete, inform the patient you will gently be removing your finger. Inspect the glove for any mucus, blood or faecal matter, as this may be indicative of any problems.

 

To Complete My Examination....

The patient should be provided with tissues or gauze with which to clean themselves, and given privacy to dress.

 

A record of any findings should be noted. Results and any necessary investigations/follow-up should be discussed with the patient.

 

Common conditions

Benign Prostatic Hyperplasiasymmetrical enlargement of the two lobes should be palpable, it will remain smooth and of a rubbery consistency. The median sulcus may or may not be palpable.

Prostatic Cancerasymmetrical enlargement of the two lobes with a hard and nodular consistency. Single or multiple areas of hardness may be felt, consider inflammation and prostatic stones as part of the differential diagnoses.

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