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.
The rectal exam has indications in many settings. 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.
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.
As an aside, 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 an 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.
It is advisable to have a healthcare team member supervise and assist, in particular when performing a digital rectal exam on a member of the opposite gender. In such a setting, the assistant should be the same gender as the patient.
The first step in the rectal exam is to have the proper tools. Tools needed include disposable exam gloves, lubricant jelly, and Q-tip with a soft end for measuring the anocutaneous reflex, and an adequate light source.
Have the patient lie down in the left lateral decubitus position. Shine the light directly on the anus, for careful inspection, including for fissures, hemorrhoids, skin tags, and other visible abnormalities. Next, using the soft end of the Q-tip, you can evaluate sensation in the four quadrants of the perianal area. After that, using lube on a gloved finger, insert the finger into the rectum after warning the patient. This allows you to palpate for any abnormalities such as a mass, stricture, as well as the prostate in men. Palpate for stool consistency, standardized per the Bristol Stool Scale. Then ask the patient to squeeze and hold, to assess strength and ability to hold and squeeze. Next, asked the patient to push and bear down, as if to simulate a bowel movement, while placing the opposite hand on the patient's abdomen to feel their contraction.
When performing a rectal exam in the case of suspected gastrointestinal bleeding, it is essential to look for gross blood (dark or bright), blood clots and melena. The blood may be observed on a visual exam, or seen on the glove during the digital rectal exam. Bright red blood usually suggests a distal GI source (or brisk upper GI bleeding), whereas melena is suggestive of a proximal GI source. For anal pain, the visual exam is particularly important to look for inflammation or a fissure. For constipation, the digital rectal exam helps evaluate for hyposensitivity as well as dyssynergia. In fecal incontinence, lack of tone on examination is telling.
As stated above, it is advisable to have another member of the healthcare team present when performing a digital rectal exam.
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