'Per rectum' examination

Question 1

PR exam: before you begin

Answer 1

Explain to the patient what is involved and obtain verbal consent.
Choose your words carefully, adjusting your wording to suit the patient.
Favourite phrases include ‘tail-end’, ‘back-passage’, and ‘bottom’.
Say that you need to examine their back passage ‘with a finger’.
Warn that it ‘shouldn’t hurt’ but may feel ‘cold’ and ‘a little unusual’.
You should ask for another member of staff to chaperone.
As you proceed, explain each stage to the patient.

Question 2

PR exam: equipment

Answer 2

Chaperone.
Non-sterile gloves.
Tissues.
Lubricating jelly (e.g. Aquagel).

Question 3

PR exam: technique

Answer 3

With informed verbal consent obtained, ensure adequate privacy.
Uncover the patient from waist to knees.
Ask the patient to lie in the left lateral position with their legs bent such that their knees are drawn up to their chest and their buttocks facing towards you- preferably projecting slightly over the edge of the bed.
Ensure that there is a good light source- preferably a mobile lamp.
Put on a pair of gloves.
Separate the buttocks carefully by lifting the right buttock with your left hands.
Inspect the perianal area and anus.
Look for rashes, excoriations, skin tags, anal warts, fistulous openings, fissures, external haemorrhoids, abscesses, faecal soiling, blood, and mucus.
Ask the patient to strain or ‘bear down’ and watch for the projection of pink mucosa of a rectal prolapse.
Lubricate the top of your right index finger with the jelly.
Begin by placing the pulp of your right index finger against the anus in the midline and press in firmly but slowly.
Most anal sphincters will reflexly tighten when touched but will quickly relax with continued pressure.
When the sphincter relaxes, gently advance the finger into the anal canal.
Assess anal sphincter tone by asking the patient to clench your finger.
Rotate the finger backwards and forwards covering the full 360 degrees, feeling for any thickening or irregularities.
Push the finger further- up to the hilt if possible- to the rectum.
Examine all 360 degrees by moving the finger in sweeping motions.
Note: the presence fo thickening or irregularities of the rectal wall, the presence of palpable faeces and its consistency, and any points of tenderness.
Next, in the male, identify the prostate gland which can be felt through the anterior rectal wall.
The normal prostate is smooth-surfaced, firm with a slightly rubbery texture measuring 2-3cm diameter, it has 2 lobes with a palpable central sulcus.
Gently withdraw your finger and inspect the glove for faeces, blood, or mucus and note the colour of the stool, if present.
Tell the patient that the examination is over and wipe any faeces or jelly from the natal cleft with the tissues. Some patients may prefer to do this themselves.
Thank the patient and ask them to redress. You may need to help.

Question 4

PR exam: inspection

Answer 4

Put on a pair of gloves.
Separate the buttocks carefully by lifting the right buttock with your left hands.
Rashes.
Excoriations.
Skin tags.
Anal warts.
Fistulous openings.
Fissures.
External haemorrhoids.
Abscesses.
Faecal soiling.
Blood.
Mucus.

Question 5

PR exam: findings

Answer 5

If any mass or abnormality is identified on the exterior or interior of the areas examined, its exact location should be noted.
It is conventional to record as the position on a clock face with 12 o’clock indicating the anterior side of the rectum at the perineum.
Benign prostatic hyperplasia: the prostate is enlarged but the central sulcus is preserved, often exaggerated.
Prostate cancer: the gland loses its rubbery consistency and may become hard; the lateral lobes may be irregular and nodular; there is often distortion or loss of the central sulcus; if the tumour is large and has spread locally, there may be thickening of the rectal mucosa either side of the gland creating ‘winging’ of the prostate.
Prostatitis: the gland will be enlarged, boggy, and very tender.

Question 6

PR exam: procedure tips (pain)

Answer 6

If the patient experiences severe pain, with gentle pressure on the anal opening, consider: anal fissure, ischiorectal abscess, anal ulcer, thrombosed haemorrhoid, or prostatitis.
In this situation, you may have to apply local anaesthetic gel to the anal margin before proceeding. If in doubt, ask a senior