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Define of rectal examination.

A rectal examination or rectal exam is an internal examination of the rectum by a


physician.

The digital rectal examination (DRE) is the simplest procedure. The patient is
placed in a position where the anus is accessible and relaxed (lying on the side,
squatting on the examination table, bent over the examination table, etc). The
physician inserts a gloved and lubricated finger into the rectum through the anus and
palpates the insides.

This examination may be used:

• for the diagnosis of appendicitis (a sharp pain experienced when the physician
presses a certain spot indicates acute appendicitis);
• for the diagnosis of rectal tumors and cancer;
• for the estimation of the tonicity of the anal sphincter;
• in males, for the diagnosis of prostatic disorders, notably tumors and cancer;
• in females, for gynecological palpations of internal organs

indication for the rectal examination

§ for the diagnosis of rectal tumors and other forms of cancer;


§ for the diagnosis of prostatic disorders, notably tumors and benign prostatic
hyperplasia;
§ for the diagnosis of appendicitis or other examples of an acute abdomen (i.e. acute
abdominal symptoms indicating a serious underlying disease);
§ for the estimation of the tonicity of the anal sphincter, which may be useful in case
of fecal incontinence or neurologic diseases, including traumatic spinal cord injuries;
§ in females, for gynecological palpations of internal organs
MoonDragon's ObGyn Information
RECTAL EXAMINATION
(Male & Female Exam)
This page contains graphically intense images

For "Informational Use Only".


For more detailed information, contact your health care provider
about options that may be available for your specific situation.

ANATOMY & PHYSIOLOGY

The gastrointestinal tract terminates in a short segment, the anal canal.


Its external margin is poorly demarcated, but generally the skin of the
anal canal can be distinguished from the surrounding perianal skin by
its moist, hairless appearance. The anal canal is normally held in a
closed position by action of the voluntary external muscular sphincter
and the involuntary internal sphincter, the latter an extension of the
muscular coat of the rectal wall.

The direction of the anal canal on a line roughly between anus and
umbilicus should be carefully noted. Unlike the rectum above it the
canal is liberally supplied by somatic sensory nerves, so that a poorly
directed finger or instrument will produce pain.

The anal canal is demarcated from the rectum superiorly by a serrated


line marking the change from skin to mucous membrane. This anorectal
junction (often called the pectinate or dentate line) also denotes the
boundary between somatic and visceral nerve supplies. It is readily
visible on proctoscopic examination but is not palpable.

Above the anorectal junction, the rectum balloons out and turns
posteriorly into the hollow of the coccyx and sacrum, forming almost a
right angle with the anal canal. In the male, the prostate gland is
palpable anteriorly as a rounded heart-shaped structure about 2.5 cm in
length. Its two lateral lobes are separated by a shallow median sulcus or
groove. The seminal vesicles, shaped like rabbit ears above the
prostate, are not normally palpable.

Through the anterior wall of the female rectum the uterine cervix can
usually be felt.
The rectal wall contains three inward foldings called valves of Houston.
The lowest of these can sometimes be felt, usually on the patient's left.

Although most of the rectum accessible to the examining finger does


not have a peritoneal surface, the anterior rectum, which the tip of the
examining finger reaches, usually does. This relationship makes it
possible to identify the tenderness of peritoneal inflammation or the
nodularity of peritoneal metastases by rectal examination.

TECHNIQUES OF EXAMINATION

MALE RECTAL EXAMINATION

Many examiners prefer to do a rectal examination on an ambulatory


patient when he is standing, with hips flexed and upper body resting
across the examining table. This position tends to flatten the buttocks
and make the anal canal and rectum more accessible to the examining
finger.

For the non-ambulatory patient, the lateral position is necessary and


some examiners may prefer to use it routinely. In this situation, ask the
patient to lie on his left side with his right hip and knee somewhat
flexed, his buttocks close to the edge of the examining table near you.

Adjust the lighting for good visualization of the anus and surrounding
area. Put a glove on your right hand and lubricate the index finger. With
your left hand, spread the buttocks apart.

Inspect the sacrococcygeal and perianal areas for lumps, inflammation,


rashes or excoriations. Palpate any abnormal areas, noting lumps or
tenderness.

Ask the patient to strain down. Inspect the anus, noting any lesions.

As the patient strains, place the pad of your lubricated and gloved index
finger over the anus. As the sphincter relaxes, gently insert your
fingertip into the anal canal, in a direction pointing toward the umbilicus.

An example of an abnormality may be swollen, thickened, fissured skin


with excoriations in pruritus ani. See more examples of abnormalities
are included below under "Abnormalities of the Anus, Surrounding Skin
and Rectum.

Instruct the patient to relax. Explain that this examination will make him
feel as if he is moving his bowels.

Note:
• The sphincter tone of the anus.
• Tenderness.
• Irregularities or nodules.

Examples of abnormalities include sphincter tightness in anxiety,


inflammation or scarring, laxity in some neurological disease and with
habitual anal intercourse.

Insert your finger further into the rectum so that you can examine as
much of the rectal wall as possible. Palpate in sequence the right lateral,
posterior and left lateral surface, noting any nodules or irregularities.
Then turn your hand so that your finger can examine the anterior
surface. Identify the lateral lobes of the prostate and the median sulcus
between them. Note the size, shape and consistency of the prostate and
any nodularity or tenderness.

If possible, extend your finger above the prostate to the region of the
seminal vesicles and peritoneal cavity. Note nodules or tenderness.

Rectal lesions just beyond your fingertip can sometimes be felt by


asking the patient again to strain down. Use this maneuver if there is
any suspicion of cancer.

Gently withdraw your finger and test any fecal material adherent to it for
occult blood.

FEMALE RECTAL EXAMINATION

The rectum is usually examined after the female genitalia, while the
patient is in the lithotomy position. This position is essential for
bimanual palpation. If a rectal examination alone is indicated, the lateral
position offers a satisfactory alternative and affords much better
visualization of the perianal and sacrococcygeal areas.

The technique is basically similar. The cervix is usually readily felt


through the anterior rectal wall. Sometimes a retroverted uterus is also
palpable. Neither of these, nor a tampon, should be mistaken for a
tumor.

BIMANUAL VAGINAL INSPECTION

Apply a small amount of lubricant to the index and middle fingers of


the dominant hand.

 Uncover the vulva and lower abdomen by moving the center of the
drape away from the examiner.
 The midwife announces what she is going to do and then touch the
patient on the thigh with the back of the hand before proceeding.

Perform a bimanual examination. From a standing position, introduce


the index and middle finger of the gloved and lubricated hand into the
vagina, again exerting pressure primarily posteriorly. Avoid the anterior
structures. The thumb should be abducted, the ring and little fingers
flexed into the palm. Note any nodularity or tenderness in the vaginal
wall, including the region of the urethra and bladder anteriorly.

Identify the cervix, noting its position, shape, size, consistency,


regularity, mobility and tenderness. Palpate the fornix around the cervix.
Note that during pregnancy, the cervix will be softer in consistency (like
palpating the lips) as compared to non-pregnancy (like the end of the
nose). If the woman is in the latter stages of her pregnancy, the cervix
may be very "squishy" feeling and pliable. Dilation and/or effacement
(opening and thinning) of the cervix may have already began.

Place the abdominal hand about midway between the umbilicus and
symphysis pubis and press downward toward the pelvic/vaginal hand.
The pelvic/vaginal hand should be kept in a straight line with the
forearm, and inward pressure exerted on the perineum by the flexed
fingers. Support and stabilize the arm by resting the elbow either on the
hip or on the knee which is elevated by placing the foot on a stool.
Continue to lift the cervix with the vaginal hand. Identify the uterus
between the hands and note its size, shape, consistency, mobility,
tenderness and masses. This procedure may cause some discomfort for
the client. Uterine enlargement suggests pregnancy, benign or
malignant tumors.

Palpating Uterine Fundus


Palpating Behind Uterus

 Place the abdominal hand on the right lower quadrant, the pelvic
hand in the right lateral fornix. Maneuver the abdominal hand downward
3 or 4 cm medial to the iliac crest, and using the pelvic hand for
palpation, identify the right ovary and nay masses in the adnexa. Gently
"trap" the ovary between the fingers of both hands (if possible). Three to
five years after menopause, the ovaries have usually atrophied and are
no longer palpable. If you can feel an ovary in a post-menopausal
woman, suspect an ovarian tumor.

View from the right side.

 Note the size, shape, consistency, mobility and tenderness of any


palpable organs or masses. The normal ovary is somewhat tender.
Repeat the procedure on the left side.

MoonDragon's ObGyn Information: Adrenal Masses

FEMALE VAGINAL-RECTAL EXAM


Withdraw your fingers, removing your gloves and throwing them away
after the vaginal exam. Re-glove using fresh, clean gloves. Place
lubricant (K-Y Jelly) on internal exam glove. Another method is to
double glove and then remove the outer glove after the vaginal exam
before proceeding with the rectal exam. This prevents cross
contamination of any infectious organisms.

 Then slowly reintroduce the index finger into the vagina, the middle
finger into the rectum. Ask the client to strain down as the
midwife/examiner does this so that her anal sphincter will relax. Tell her
that this examination may make her feel as if she has to move her
bowels - but, reassure her that she will not.

 Repeat the maneuvers of the bimanual examination, giving special


attention to the region behind the cervix which may be accessible only
to the rectal finger. In addition, try to push the uterus backward with
your abdominal hand so that your rectal finger can explore as much of
the posterior uterine surface as possible. Check the rectum itself and
other nearby structures for any abnormalities.

Vaginal-Rectal Exam
The risk of spreading infection
between vagina and rectum
should always be considered.
Gonorrhea may infect the rectum
as well as the female genitalia.
This fact, together with the rising
prevalence of gonorrhea, has led
to the recommendation that
gloves be changed between
vaginal and rectal examination in
order to avoid spreading of
gonococcal infection. In order to
avoid fecal soiling, gloves should
always be changed if for some
reason the practitioner examines
the vagina after the rectum.
Another helpful suggestion is to
double glove (put one glove over
another) so that after the exam,
the used glove is easily removed
and discarded while still having a
clean glove underneath. It saves
time for the examiner.

 Replace the drape and assist the client to remove her feet from the
stirrups and sit up.

 Reassure the patient, if the exam is normal, say so.

 Leave the room and allow the patient to dress before continuing with
the consultation.

Pictorial Description of Female Pelvic Exam

Pelvic Examination and Pap Smear (Cervical Smear)

Pictorial Description of Pap Smear (Cervical Smear)

Sister Zeus: Learning How to Use a Speculum (Do-it-yourself


Cervical Exam)

AFTER EXAMINATION

After the examination, wipe off the external genitalia and anus or offer
the client some tissue with which to do it him or herself. Throw away
any used disposable items and clean up supplies.

Tenderness with cervical motion is an important sign of pelvic disease.


You should both observe the clients's face and ask her if the
examination is painful in any way.

Your ability to palpate the uterus and ovaries will depend on the client's
anatomy, the size of your hands, and your level of skill.

ABNORMALITIES OF THE ANUS, SURROUNDING SKIN &


LESIONS, CYSTS, TUMORS

This page will discuss a few of the abnormalities that frequently effect
the anus and surround areas. I will not discuss the treatment in detail.
For more information about various types of abnormalities, consult with
your health care provider or do an internet search for more information.
It is very important that treatment should be decided in consultation
with a health care practitioner. It depends on many factors and the final
decision should be made after a discussion between health care
provider and patient.

PILONIDAL CYST & SINUS

A pilonidal cyst is a fairly


frequent, probably congenital
abnormality located in the
midline superficially identified by
the opening of a sinus tract. This
opening may exhibit a small tuft
of hair and be surrounded by a
halo of erythema. Although
generally asymptomatic except
perhaps for slight drainage,
abscess formation and
secondary sinus tracts may
complicate the picture.
ANORECTAL FISTULA

An anorectal fistula is an
inflammatory tract or tube, one
end of which opens into the anus
or rectum, while the other end
opens onto the skin surface, as
shown here, or into another
viscus. An abscess usually
antedates such a fistula. Look for
the fistulous opening or
openings anywhere in the skin
around the anus.

ANAL FISSURE

An anal fissure is a very painful oval


ulceration of the anal canal, most
commonly found midline posteriorly,
less commonly in the midline anteriorly.
Its long axis lies longitudinally.
Inspection may reveal a "sentinel" skin
tag just below it, and gentle separation
of the anal margins may reveal the
lower edge of the fissure. The sphincter
is spastic; the examination painful.
Local anesthesia may be required.
RECTOCELE

A rectocele is
formed by the
anterior and
downward
bulging of the
posterior
vaginal wall
together with
the rectum
behind it. To
identify it,
spread the
patient's/client'
s labia and ask
her to strain
down.
MoonDragon's ObGyn Information: Uterine Prolapse (Including
Cystocele, Rectocele)
EXTERNAL HEMORRHOID

Hemorrhoids are varicose veins.


External hemorrhoids originate
below the anorectal line and are
covered by anal skin. When
uncomplicated they may not be
visible at rest, but a thrombosed
hemorrhoid presents as a
painful, bluish, shiny, ovoid mass
at the anal margin. Flabby or
fibrotic skin tags may mark the
location of previously
thrombosed or inflamed
hemorrhoids.

INTERNAL HEMORRHOID

Internal hemorrhoids originate


above the anorectal junction and
are covered by mucous
membrane, not skin. They are not
visible unless they prolapse
through the anus, nor are the soft
swellings normally identifiable by
palpation. Proctoscopic
examination is usually required
for diagnosis.

MoonDragon's ObGyn Information: Hemorrhoids

MoonDragon's Health & Wellness: Varicose Veins


PROLAPSE OF THE RECTUM

On straining for a bowel movement, the rectal


mucosa, with or without its muscular wall,
may prolapse through the anus, presenting as
a doughnut or rosette of red mucosa. A
prolapse involving only mucosa is shown
here. When the entire bowel wall is involved,
the prolapse is larger; and circular rather than
radiating folds are seen.

POLYPS OF THE RECTUM

Polyps of the rectum are fairly


common. Varying considerably in
size and number, they can
develop on a stalk
(pedunculated) or may lie close
to the mucosal surface (sessile).
They are soft and may be difficult
or impossible to feel even when
in reach of the examining finger.
Proctoscopy is usually required
for diagnosis, as is biopsy for the
differentiation of benign from
malignant lesions.
CARCINOMA OF THE RECTUM

Asymptomatic carcinoma of the


rectum makes routine rectal
examination mandatory for
virtually all adults. As noted
above, polypoid masses may be
malignant. Another common
form of presentation is the firm
nodular rolled edge of an
ulcerated malignancy.

PERITONEAL
METASTASIS

Widespread peritoneal
metastasis from any
source may develop in the
area of the peritoneal
reflection anterior to the
rectum. A firm to hard
nodular rectal "shelf" may
be just palpable with the
tip of the examining finger.

ABNORMALITIES OF THE PROSTATE


NORMAL PROSTATE

As palpated through the anterior rectal wall,


the normal prostate is a rounded heart-shaped
structure about 2.5 centimeters in length,
projecting less than 1.0 centimeter into the
rectal lumen. The median sulcus can be felt
between the two lateral lobes. Only the
posterior surface of the prostate is palpable.
Anterior lesions, including those that may
obstruct the urethra, may not be detectable by
physical examination.

BENIGN PROSTATIC
HYPERTROPHY

A very common condition in men


over 50 years of age, benign
prostatic hypertrophy presents
as a firm smooth symmetrical
and slightly elastic enlargement
of the gland. It may bulge more
than a centimeter into the rectal
lumen. The hypertrophied tissue
tends to obliterate the median
sulcus.
CARCINOMA OF
THE PROSTATE

A hard irregular
nodule, producing
asymmetry of the
gland and a
variation of its
consistency, is
especially
suggestive of
carcinoma. Prostatic
stones and chronic
inflammation can
produce similar
findings, and
differential
diagnosis often
depends upon
biopsy. Later in its
course, the
carcinoma grows in
size, obliterates the
median sulcus and
may extend beyond
the confines of the
gland producing a
fixed, hard, irregular
mass.

PROSTATITIS

The acutely inflamed prostate


gland is swollen, tender and
often somewhat asymmetrical.

The gland of chronic prostatitis


is variable: it may (1) feel normal,
(2) be somewhat enlarged, tender
and body, or (3) contain
scattered firm areas of fibrosis.