Digital Rectal Examination

A digital rectal examination affords access to several key structures (see the image below) and enables an observant clinician to identify several disease processes pertaining to the rectum, the anus, the prostate, the seminal vesicles, the bladder, and the perineum. In females, it can be performed in conjunction with a pelvic examination. Before the advent of serum prostate-specific antigen (PSA) testing in 1986, the digital rectal examination was the sole method of screening men for prostate cancer.

A digital rectal examination 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 digital rectal examination include, but are not limited to, the following:

• Hemorrhoids

• Prostatitis

• Prostate cancer[1]

• Benign prostatic hyperplasia[2]

• Anal and rectal cancers

• Anal condyloma

• Constipation

• Fecal incontinence

• Anal fissures

• Inflammatory bowel disease, including ulcerative colitis and Crohn disease

• Neurologic deficits

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 digital rectal examination 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.

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Although there are no circumstances in which a digital rectal examination is overtly contraindicated, caution should be exercised in examining infants and young children, and vigorous manipulation, specifically of the prostate, should be avoided in severely neutropenic patients and patients with prostatic abscesses or prostatitis. The old medical adage often holds true: The only reason not to do a digital rectal examination is if the patient is without a rectum or the clinician is without a finger.

The examination should be performed with the patient in a safe position in case vasovagal syncope should occur (not an uncommon event, particularly in younger males). Ensuring a safe position may include providing a soft surface and limiting the distance the patient falls if syncope occurs.

If the patient has neutropenia or acute prostatitis and there is a need to check for a fluctuant prostate signifying abscess, antibiotic therapy should be started before the examination and after all cultures are obtained. The examination in a patient with prostatic abscess or acute bacterial prostatitis should be gentle and may consist of nothing more than feeling a hot, boggy prostate with a fingertip, then stopping the examination. Prostatic massage is only rarely indicated in patients without suspected chronic bacterial prostatitis.

Anesthesia

No anesthesia is needed, although in some patients, it may be easier to perform digital rectal 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.

Positioning

Multiple positions may be used to accomplish a digital rectal examination. 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, he or she should be afforded privacy and security in a relaxed environment.

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.

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.

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.

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.