Clinical Examination Guide
Digital Rectal Examination
Background and orientation
Digital Rectal Examination is an intimate examination that requires the presence of a chaperone. When conducted by a student, a qualified supervisor (who may also act as a chaperone) is also required. A key aspect of this examination is examining the patient in the left lateral position and keeping a running commentary all through the examination. The clock face is traditionally used to describe lesions found during digital rectal examination, with 12 o’clock noting the anterior position (vaginal/scrotal), 6 o’clock for the posterior aspect (spinal). Note the orientation when the patient is in the left lateral position
Components of the examination
• Introduction and explanations. • Gather equipment and PPE • External inspection • Internal palpation • Prostate examination • Conclusion
Introduction and Explanations
• Introduce yourself, confirm patient ID • Explain the following as part of gaining informed consent: - The nature of the examination using non-technical language – exposure, external inspection and internal examination with a single gloved finger. - That it should not be painful but may cause some discomfort - The need for a qualified supervisor who will also act as a chaperone. - The patient may choose an additional chaperone if they wish. • Explain the left lateral position (lying on the left side with knees together and pulled up close to abdomen, buttocks close to the edge of the bed, facing away from you).
Document Owner: Clinical Skills/LK Last Updated: Feb 2018 Example of what you might say: • “I need to perform an internal examination of the • “It will probably feel a little uncomfortable, but I back passage. Please can I explain what this will be as gentle as I can, and you can ask me to involves?” stop at any point.”
• “I will need you to remove your trousers/skirt and • “Because this is an intimate examination, and I underpants completely. I will need you to lie on am a student it is important that my supervisor, the couch facing away from me, with your
• Ensure the examination area has appropriate privacy • Position the couch flat, give the patient a sheet and leave them to get undressed.
Gather Equipment and PPE
• Prepare a disposable tray with lubricating jelly on a tissue and spare tissues • Clean hands and put on gloves and apron • If applicable, ask the patient’s permission before entering the curtained area
External Inspection
Explain to the patient what you are doing all times during the examination, using non-technical language
• Ask the patient if they are in any pain. Say that you • Ask the patient to bear down and observe the are going to lower the sheet and start the anus. Note the presence or absence of any examination by looking at the skin around the - incontinence bottom and you need to separate the buttocks. - prolapse of internal haemorrhoids • Separate the buttocks and inspect the anus and - mucus leakage. surrounding skin. Note the presence or absence of any: - prolapse - external haemorrhoids or other external masses - indication of fissures/ fistulae - abscesses - anal warts, skin tags or rashes.
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Internal Palpation
• Scoop some lubricating jelly from the tissue. • Tell the patient you are going to insert your finger a • Tell the patient you are about to start the internal little deeper. examination. • With the pulp of the finger facing the 6 o’clock • Place the fingertip of your right index finger at the position, insert the full length of your index finger posterior aspect of the anal sphincter and say palpate the posterior rectal wall. “This is my finger”. • Supinate your arm, sweeping the finger across to • Wait for the involuntary contraction and relaxation the 9 o’clock position, thus examining through to of the sphincter before saying “I am now going to the right wall. gently insert it into your bottom” and proceed to • Pronate to return to the 6 o’clock position and gently push your fingertip onto the anal canal. sweep on through to the 3 o’clock position to • Note any immediate tenderness which may indicate examine the left posterolateral rectal wall. an anal fissure and prevent further examination at • Continue pronating your arm round to the 12 this time. o’clock position, and beyond this to the 9 o’clock • Note any masses or swelling. position to examine the anterolateral rectal walls. • Assess anal tone by asking the patient to squeeze • Return to the 12 o’clock position. In a male patient your finger. this is anterior to the prostate.
Prostate Examination
From the 12 o’clock position and ensuring adequate finger pressure palpate the prostate and note the following: • size – normally 2-3 cm wide • surface - smooth or irregular? • tenderness • nodules or masses. A hard, irregular • consistency - hard, firm, or soft / boggy. A asymmetrical prostate, with the sulcus not tender, boggy prostate might reflect prostatitis, palpable between the lobes may be suggestive of • presence of medial sulcus and symmetry either prostate cancer. side
Completing the examination
• Remove your finger and look for blood, mucus or faeces on the glove. • Discretely wipe away jelly/detritus and remove dirty tissues and gloves away from the area. • Tell the patient the examination is finished and leave them with clean tissues and privacy to get dressed, offering help as appropriate. • Dispose of PPE and wash hands. • Offer patient to wash hands as appropriate.
Conclusion
• Document that consent was given, the name and role of the supervisor and any other chaperone, and examination findings. Images adapted from: Shirley and Brewster, Journal of Clinical Examination, 2011(11): 1-12
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