Continuing Education Activity
The rectal exam is an oft-overlooked part of the physical exam. For those practitioners who understand how to interpret it, a lot of information can is obtainable from this simple exam. Anecdotally, we have all heard during our training from experienced physicians about the utility of the rectal exam and how it should be a part of the physical exam on every patient. And while it is true that in the era of the focused physical exam, the rectal exam is no longer performed on every patient, it still has many utilities and is definitely underutilized. It is a valuable diagnostic process in cases including, but not limited to, gastrointestinal bleeding, inflammatory bowel disease, hemorrhoids, constipation, trauma, and neurological disorders.
- Describe the indications for a rectal exam.
- Review the preparation for a rectal exam.
- Summarize the steps and expected normal and abnormal findings in performing a rectal exam.
- Outline how the interprofessional team can facilitate communication to optimize the care of patients needing a rectal exam.
The rectal exam is an oft-overlooked part of the physical exam. For those practitioners who understand how to interpret it, a lot of information can is obtainable from this simple exam. Anecdotally, we have all heard during our training from experienced physicians about the utility of the rectal exam, and how it should be a part of the physical exam on every patient. And while it is true that in the era of the focused physical exam the rectal exam is no longer performed on every patient, it still has many utilities and is definitely underutilized. It is a valuable diagnostic process in cases including, but not limited to, gastrointestinal bleeding, inflammatory bowel disease, hemorrhoids, constipation, trauma, and neurological disorders.
Anatomy and Physiology
The rectum is the terminal segment of the large bowel. It is approximately 12 cm long and runs along the concavity of the sacrum. 
- The upper 2/3 of the anterior rectum is covered by the peritoneum.
- In males, the anterior rectum peritoneum reflects on the surface of the bladder base.
- In females, the anterior rectum peritoneum forms the pouch of Douglas (rectouterine pouch) which is filled with bowel loops.
- The anterior lower 1/3 of the rectum.
- In males, anterior to the rectum lies the bladder base, prostate, and seminal vesicles
- In females, anterior to the rectum lies the vagina, and at the fingertip the cervix and uterus.
- The anus is 3-4 cm long and connects the rectum to the perineum.
- The anal wall and anal canal are supported by voluntary external sphincter muscles and involuntary internal anal sphincter muscles with are essential for defecation and maintenance of continence.
This is an uncomfortable procedure for the patient. It is most often done when disease is suspected. It may also be done as part of a screening process. 
The examiner should explain the reasons for the procedure and obtain verbal consent. Reasons to perform the procedure include:
- Change in bowel habit
- Prostate evaluation
- Rectal bleeding
- Urinary or fecal incontinence
- A secondary approach to vaginal and cervical exam
It is, of course, useful and should be performed in patients with a GI bleed, where the practitioner can look for hemorrhoids, fissures, and gross blood. It is also helpful in evaluating constipation, to evaluate sensation, tone, and coordination of contraction. For fecal incontinence, again evaluating rectal tone is essential.
Rectal Exam in Children
This exam should be avoided; if essential, use the fifth rather than the index finger.
Rectal Exam in Elderly
Rectal examination is more often required in elderly patients because diseases affecting the bowel arise more often in elderly patients. The left lateral position may be uncomfortable. Time should be taken to achieve a comfortable position that allows examination.
The main contraindication to the digital rectal exam is if a patient is immunocompromised, which runs the risk of introducing infection in these patients and can be potentially life-threatening. If a prostate infection is suspected, the examination is offered deferred as it may lead to bacterial seeding of the bloodstream. 
- Absence of anus
- Immunosuppressed patient
- Imperforate anus
- Prolapsed thrombosed internal hemorrhoids
- Severe anal pain
- Unwilling patient
- Acute abdomen
- Major rectal trauma
- Post-operative anal surgery
- Recent acute myocardial infarction
- Valvular heart disease or prosthetic valves
Explain the reasons for performing the procedure to the patient. A chaperone should be present. Inform patients that the examination may be uncomfortable and they may feel an urge to defecate.
Rectal examination findings include:
- Anal fissures
- Anal fistula
- Genital warts
- External hemorrhoids
- Pilonidal sinus
- Skin disease (seborrhoeic eczema, skin cancer, natal cleft dermatitis)
- Skin tags
- Skin discoloration with Crohn disease
- Rectal prolapse
- Internal hemorrhoids
- Rectal carcinoma
- Rectal polyps
- Tenderness with prostatitis or acute appendicitis
- Malignant or inflammatory conditions of the peritoneum with anterior palpation
Enhancing Healthcare Team Outcomes
The fecal occult blood test (FOBT) has no role in the evaluation of acute gastrointestinal bleeding. The test has low specificity, and reasons for false-positive include medications, digital manipulation, diet, and more. The FOBT can be used in annual colon cancer screening, as recommended by the interprofessional taskforce. A positive test may also confirm the need for endoscopic evaluation in a patient with chronic anemia. However, patients with unexplained iron deficiency anemia should already be considered for endoscopy regardless of the outcome from FOBT.