Skill Checkup: Digital Rectal Examination

Bradley Schwartz, DO

Disclosures

September 23, 2019

A digital rectal examination (DRE) affords access to several key structures and enables an observant clinician to identify several disease processes pertaining to the rectum, anus, prostate, seminal vesicles, bladder, and perineum. In females, it can be performed in conjunction with a pelvic examination. A recent observational, retrospective study showed that clinical stage classification for prostate cancer via DRE is significantly prognostic in terms of overall survival among men with high-risk localized disease.

Indications 

DRE is indicated as part of a full physical examination and is often incorporated in a focused urologic, gynecologic, gastrointestinal, and neurologic examination. Disease processes that may be investigated with a DRE include but are not limited to:

An examination may also confirm proper Foley catheter placement and facilitate placement of rectal tubes and suppository medication. According to the American Urological Association (AUA), a DRE may be indicated for prostate cancer screening. This is only after discussing and determining the risks and benefits of screening with the patient using the process of shared decision-making.

Procedure

The examination should be performed with the patient in a safe position in case vasovagal syncope should occur. Ensuring a safe position may include providing a soft surface and limiting the distance the patient falls if syncope occurs.

No anesthesia is needed, although in some patients, it may be easier to perform DRE examination concomitantly with other procedures that require general or intravenous sedation. Empirically, patients seem to tolerate procedures without anesthesia best when they are fully informed about expectations and are aware of exactly what is being done and when.

Multiple positions may be used to accomplish a DRE. The easiest for the examiner is to have the patient tuck the knees up to the chest, either in the dorsal lithotomy position or the lateral recumbent position. However, the traditional practice in the office-visit setting is to have the patient bend over a table at the waist with the knees slightly flexed, the feet shoulder-width apart, the toes pointed inward, the waist within inches of the table edge, and the forearms resting on the table. The patient should be made to feel as comfortable as possible; to this end, they should be afforded privacy and security in a relaxed environment.

No special materials are required, other than a finger (with nails trimmed appropriately and any jewelry removed), personal protective equipment (gloves), and generous lubrication. The video below depicts a DRE being performed.

The buttocks are spread apart, and the anus, posterior perineum, and gluteal folds are visually inspected to identify pathologic conditions such as condyloma, external hemorrhoids, abrasions, decubitus ulcers, abscesses or cellulitis, and, occasionally, malignancies (eg, melanoma and anal or rectal carcinoma).

The nondominant hand is then placed on the patient’s anterior pelvic bone to provide countertraction while the dominant hand, with the help of generous lubrication, slowly advances only the index finger through the sphincter and into the rectum. After a few seconds, the sphincter should relax slightly, at which point the digit is advanced further (see the image below). Sphincter tone should be noted; it can be lax or absent in neurologic diseases. Palpation of the internal structures then proceeds in a systematic fashion.

Figure 1.

Palpation begins at the apex of the prostate and progresses toward the base to determine the size of the gland and assess its consistency, which, in a normal gland, resembles that of the thenar eminence when the thumb and little finger are opposed.

Note is made of the central sulcus of the prostate, and the lateral lobes are evaluated with respect to size and consistency. The seminal vesicles, located proximal to the base of the prostate, should be assessed because these structures may be absent in certain conditions or involved in invasive cancers.

Circumferential palpation of the rectal vault is also performed to identify any internal hemorrhoids that may be present and thrombosed, to determine whether the consistency is smooth, and to detect any stool present and assess its consistency. Upon removal of the finger, the stool on the finger is evaluated for blood and can be sent for studies, including occult blood.

After the examination, a generous supply of tissues should be made available to the patient, along with a sink with soap and water, privacy for cleaning up, and space for dressing.

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