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Rectal Examination

From Mediwikis

aka PR/DRE

The key to this examination, (as in all of them), is providing adequate explaination before the examination of what you are going to do. Make sure that you are in the most private space possible.

  • Wash hands
  • Introduce yourself to the patient and confirm their name, age and DOB
  • Explain what you are about to do and the need for a chaperone (get said chaperone or document comprehensively in the notes that the chaperone was refused)
  • Consent the patient

Preparation

  • Get the patient to undress from the waist down and cover themselves with a sheet, (offer to leave the room and come back when they have done that)
  • Get the patient up on the bed then position them lying on their side, and shuffle towards the edge of the bed so that their buttocks are at the edge.
  • Ask the patient to draw their knees up towards their chest as far as they can manage but keep their feet away from their buttocks

Examination

  • Put your gloves on, uncover the patient (as little as possible and for the shortest amount of time possible)
  • Warn the patient that you are going to put your hand on them
  • Lift the upper buttock and making sure you have enough light, examine the perianal skin for:
  1. Skin lesions
  2. External haemorrhoids
  3. Fistulae

Palpation

  • Make sure that your gloved index finger is well lubricated with water based gel
  • With your index finger and thumb pointing out and other fingers drawn in, warn the patient what you are about to do and then place the pulp of your index finger at the anal margin, with the finger pointing forward (the same way that the patient is facing)
  • Wait a few seconds to allow the patient to relax
  • Gently and steadily push your finger through the sphincter and into the rectum (if resistence/pain is experienced, see instructions below)
  • Test the integrity of the anal sphincter by asking the patient to squeeze your finger
  • Get them to relax again and go on to palpate the rectum, make sure that you don't miss anywhere by working in a pattern, sweep the posterior and lateral walls and then rotate your wrist round to sweep the anterior wall
  • If any masses are found then examine them in more detail including description of its approximate position
  • In the anterior wall of the rectum identify the prostate/cervix
  • Examine the prostate in detail, commenting on the size, surface, shape, consistency and whether the patient thinks it is tender

Completion

  • Tell the patient what you are going to do and then slowly and steadily withdraw your finger, look at the glove and assess it for:
  1. Stool colour
  2. Mucus
  3. Blood (think about sending for FOB - faecal occult blood - testing)
  • Offer the patient something to wipe themselves with and cover them up again
  • Thank the patient, summarise your findings and go and wash your hands (dispose of the gloves appropriately)

Troubleshooting

Anal spasm/pain

If, when you try and enter your finger through the anal sphincter, there is spasm or the patient complains of pain then try and get the patient to relax and take some deep breaths. A local anaesthetic suppository will have to be administered before trying again. Remember if the patient still complains of experiencing pain the examination can be performed under general anaesthetic.

Faeces in the Rectum

If, when palpating the rectum, you feel that you cannot comment on the presence of any masses because of the presence of faeces in the rectum the examination will need to be repeated after the patient has defecated.