Learning_objectives

  • To understand the indications for performing a rectal examination.
  • To understand what is an appropriate environment for this examination.
  • To understand the need to request a chaperone.
  • To demonstrate the ability to perform a rectal examination on a model.

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:

  • Rectal bleeding
  • Perianal itching
  • Rectal/anal Pain
  • Abdominal Pain/ Pelvic pain (as part of an abdominal examination)
  • Passing blood/ mucus
  • Presence of lumps or other palpable abnormalities
  • Urinary symptoms
  • Neurological symptoms
  • Suspected prostate cancer

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.

  • There should be a good light source that will adequately illuminate the area being examined.
  • There should be screens offering privacy to the patient whilst they disrobe from the waist down with a clean gown or blanket available to preserve modesty.
  • If any samples or swabs are being taken, ensure you know how to complete the paperwork and forward those samples etc. to the correct lab’.
  • There should be handwashing facilities.

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

  • Patient should be asked to lie on their side, close to the edge of the bed with the hips and knees flexed. Expose only as much as necessary.
  • A blanket should be draped across the patient to minimize exposure and reduce level of patients vulnerability
  • Assistance by yourself or the chaperone should be offered to help the patient get into position
  • Have a clean tray containing water soluble gel and tissues

Inspection of the anus

  • Wash hands and don a pair of disposable gloves & apron
  • Gently separate the buttocks and inspect the natal cleft and anal verge
  • Look for fissures, rashes, haemorrhoids, warts etc
  • The position of an anal lesion is described in relation to the face of a clock
  • The anterior aspect of the anus is assigned to 12 o’clock

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:

  • Size
  • Presence of two equally sized lobes with a median sulcus
  • Consistency (firm)
  • Surface (smooth or nodular)
  • Tenderness

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