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Digital Rectal Examination Technique

  • Author: Adam Warren Ylitalo, DO; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Aug 12, 2015
 

Approach Considerations

According to current recommendations, digital rectal examinations should be performed yearly; however, they may be performed more frequently, depending on individual patients’ conditions and needs. No special materials are required, other than a finger (with nails trimmed appropriately and any jewelry removed), a rectum, personal protective equipment (gloves), and generous lubrication. The video below depicts a digital rectal examination being performed.

Video of a digital rectal examination being performed on a patient in a left lateral decubitus position prior to prostate biopsy. Video courtesy of Adam Warren Ylitalo, DO.
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Digital Examination of Rectum

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). Note should be made of sphincter tone, which can be lax or absent in neurologic diseases. Palpation of the internal structures then proceeds in a systematic fashion.

Digital rectal examination. Drawing shows gloved a Digital rectal examination. Drawing shows gloved and lubricated finger inserted into rectum to feel prostate. Image courtesy of National Cancer Institute.

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.[4] Prostate cancer typically feels like a harder nodule, and an abscess is typically fluctuant. In acute prostatitis, the gland can be quite tender, which can be a diagnostic finding; however, care should be taken not to manipulate the prostate vigorously, because of the risk of bloodstream infection.

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.

Occasionally, in obese patients and those who find it difficult to relax their buttocks, a digital rectal examination may be difficult to perform, and it may not be possible to palpate all of the structures.

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Complications

One possible complication of digital rectal examination is vasovagal syncope, which is typically treated with rest and administration of fluids. Disseminated infection resulting from prostatic abscess or acute prostatitis that was massaged too vigorously is treated with culture-specific antibiotic therapy narrowed from broad-spectrum urinary coverage and supportive care, depending on the nature and severity of the illness.

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Contributor Information and Disclosures
Author

Adam Warren Ylitalo, DO Resident Physician in Urological Surgery, Detroit Medical Center, Michigan State University College of Osteopathic Medicine

Adam Warren Ylitalo, DO is a member of the following medical societies: American College of Surgeons, American Medical Association, American Osteopathic Association, American Urological Association, Endourological Society, Michigan State Medical Society, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, Societe Internationale d'Urologie (International Society of Urology), American Urological Association

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors wish to thank all of the great physicians who have taught and continue to teach the importance and clinical intricacies of the digital rectal examination.

Medscape Reference also thanks Adam Warren Ylitalo, DO, Resident Physician in Urological Surgery, Detroit Medical Center, Michigan State University College of Osteopathic Medicine, for assistance with the video contribution to this article.

References
  1. Roobol MJ, van Vugt HA, Loeb S, Zhu X, Bul M, Bangma CH, et al. Prediction of Prostate Cancer Risk: The Role of Prostate Volume and Digital Rectal Examination in the ERSPC Risk Calculators. Eur Urol. 2012 Mar. 61(3):577-83. [Medline].

  2. Ahmad S, Manecksha RP, Cullen IM, Flynn RJ, McDermott TE, Grainger R, et al. Estimation of clinically significant prostate volumes by digital rectal examination: a comparative prospective study. Can J Urol. 2011 Dec. 18(6):6025-30. [Medline].

  3. Barry, John. AUA Releases Statement Clarifying Prostate Cancer Testing Recommendations. Available at http://www.auanet.org/content/press/press_releases/article.cfm?articleNo=156. Accessed: April 13, 2011.

  4. Gerber GS, Brendler CB. Evaluation of the Urological Patient: History, Physical Exam, and Urinalysis. Campbell-Walsh Urology, 9th ed. Available at http://www.campbellsurology.com. Accessed: April 13, 2011.

 
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A sagittal midline view of the male pelvic anatomy that may be examined with a digital rectal examination in relation to all surrounding structures.
Video of a digital rectal examination being performed on a patient in a left lateral decubitus position prior to prostate biopsy. Video courtesy of Adam Warren Ylitalo, DO.
Digital rectal examination. Drawing shows gloved and lubricated finger inserted into rectum to feel prostate. Image courtesy of National Cancer Institute.
 
 
 
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