Learning_objectives Theory_and_background Underpinning a rectal examination which is part of the gastrointestinal system, knowledge of the anatomy & physiology of the rectum together with applying the basics of the examination, knowing why you do and knowing how to do this examination are essential. Indications The following are a list of indications for potentially doing a rectal examination, the list is by no means exhaustive; The patient may present with any of the following: The right environment The room that the examination is taking place in should be warm and private, with the examination couch off set from the centre of the room. This prevents anyone being unnecessarily exposed if somebody inadvertently enters the room. Ideally the patient should be relaxed and in a warm environment, they should lie on their left hand side with their knees drawn up (flexed) towards their chest. The patient should ideally be positioned as close to the right edge of the examination couch. The chaperone may be able to assist with positioning and helping the patient. Patient safety Procedure Preparation of the patient Inspection of the anus Rectal examination Lubricate (gloved) index finger Place pulp of index finger on the perineum, anterior to the anal verge then follow the curve of the perineum into the anus. Press gently on the anus and slip the tip of the index finger into the anal canal by increasing the angle of the finger Avoid using force, wait for the sphincter to relax, if still difficult do not continue with the examination Insert the index finger into the rectum as far as it will go, following the sacral curve. Note the tone of the sphincter as you insert your finger, to assess anal tone ask the patient to squeeze the examining finger to assess anal squeeze. This is to assess if the patient is in control of their anus, and may often be done at the end of the examination Examine the posterior and lateral walls of the rectum for palpable lumps or tears (rectal walls should be smooth) Assess the presence or absence of faeces: palpable as a mobile putty-like substance (in constipation may be hard), which you can indent with your fingertip. Rotate wrist so that finger pulp faces anteriorly and examine the anterior rectal wall. In the male the prostate gland (see next page re prostate) may be palpated. In the female the cervix may be palpable. Rotate wrist, so that your examining finger is facing posteriorly again and then withdraw finger. On withdrawal reassure patient that you are removing your finger, check gloved finger for stool (normal colour, pale stool, melaena etc) and any blood or mucus. Clean patient, dispose of gloves & apron and wash hands. Prostate examination The prostate gland is examined during a male rectal examination. A normal prostate measures approximately 3.5cm from side to side and protrudes 1cm into the rectum. It can be felt through the anterior rectal wall and has a median sulcus separating the two lobes. The prostate should not be tender to palpation but the patient may experience discomfort or an urge to urinate. Palpation of the prostate gland Palpation of the prostate gland aims to assess the prostate for: Do remember however that assessment of prostatic size is often learnt through experience Recording_your_findings Don’t forget when recording your findings to include the patient identifiers, date (and time), your signature and printed name at end. When documenting or describing your findings remember to comment on the anus (inspection), anal tone (if performed), rectal walls, and contents of rectum (stool etc.), the prostate and any abnormal masses palpated. Remember to describe your findings as fully as possible: eg size, position (relative to face of clock), shape of a swelling etc. A diagram may often be useful in written notes