Digital Rectal Examination - GI

Question 1

What are the steps of the DRE?

Answer 1

Infection prevention and control

Introduction & Identification

Explanation & Consent

Chaperone & Consent

Position

Lighting & Equipment

Procedure

Perianal area

Preparing & finger insertion

Anal tone

Orientation

Posterolateral and Anterolateral walls

Rectal contents & masses

Finger withdrawal

Closure/completing the examination

Question 2

Explanation

Answer 2

Be formal in intimate examinations

Effective explanation is important for the patients to understand the reason for rectal examination and give consent for this

Advise the patient that they will find rectal examination uncomfortable and it some cases may be painful

Reassure the patient that if severe pain is experienced, you will stop the examination

Question 3

Chaperone

Answer 3

Required for all intimate examinations

Introduce and obtain clear consent

Question 4

Position

Answer 4

The patient should lie on their left side with hips and knees flexed and with the heels out of the way

Ensure the buttocks are positioned at the edge of the bed

Question 5

Lighting & Equipment

Answer 5

Good illumination and careful positioning will enable you to have a clear view of the perianal area

Make sure you have all the necessary equipment ready to use and within easy reach

Question 6

Procedure

Answer 6

Show respect for the patient by ensuring that only the area being examined is exposed

The patient should be examined from the right side of the bed

Put on gloves and place disposable towels under the patient and make sure there is adequate lighting

Squeeze a small amount of aqueous gel onto a tissue nearby so that you do not have to handle the tube when you need the gel after you have examined the perianal area (and thereby contaminated your gloves)

Question 7

Perianal area

Answer 7

Gently separate the buttocks to inspect the perianal area

Look at the shape of the anus and observe for normal anal tone i.e. anal closed - asking the patient to strain down may reveal abnormal descent of the anus or rectal prolapse

Question 8

Preparing and Finger insertion

Answer 8

Apply the aqueous gel lubricant you have previously squeezed on the tissue to the examining finger

Let the patient know you are about to start the rectal examination (placing your left hand over the patients hip area may help the patient feel less isolated)

First place the pulp of the index finger on the posterior anal margin, applying gentle pressure and wait until the anal sphincter begins to relax and insert the tip of the finger into the anal canal

Question 9

Anal tone

Answer 9

Gently push the finger through the anal canal and then assess anal tone by asking the patient to squeeze your finger with the anal muscles

Question 10

Orientation

Answer 10

Move the finger further into the rectum, following the sacral curve posteriorly - the posterior landmark

Question 11

Posterolateral walls

Answer 11

Gently sweep the finger through 90 degrees right (upwards) and left (downwards), exploring the right and left posterolateral walls (quadrants) of the rectum in turn

Question 12

Anterolateral walls

Answer 12

Rotate the wrist to palpate the anterior wall and then both left and right anterolateral rectal walls (quadrants) in tune

In men, the prostate gland with its central sulcus (the anterior landmark), will be palpable through the anterior wall of the rectum

In women, you may feel the cervix or a vaginal tampon through the anterior rectal wall

Question 13

Rectal content & Masses

Answer 13

Note the absence or presence of faeces in the rectum and note the stool consistency

Carefully examine any palpable abnormalities within the rectum (i.e. irregularity in the rectal wall or a mass within the lumen of the rectum)

With your finger inserted maximally, ask the patient to bear down, as this may bring down a lesion (polyp) from higher up the rectum to touch your finger

Question 14

Finger withdrawal

Answer 14

Once you have completed a thorough examination, slowly withdraw your finger, feeling for any irregularities within the anal canal

Examine your gloved finger for stool colour and for any blood, mucus and pus

Question 15

Closure/completing the examination

Answer 15

Inform the patient that you have finished the examination and wipe any excess gel from the perianal area and cover the patient appropriately

Allow the patient to use the tissues and to dress in privacy

Question 16

Communication & Documentation

Answer 16

Refrain from answering questions or delivering information while the patient is undressed and still lying on their side

Document findings

The anal clock face is used to document anal lesions (but not for rectal lesions, where quadrants are used)