Rectal Examination

							Rectal Examination
                                                                                    Inspection
Anatomy                                                                             Position
                                                                                    Lateral decubitus position (with legs, knees flexed to abdomen)
                                                                                    Examination of anus, perineum
                                                                                    Warn patient on potential discomfort
                                                                                    Put disposable gloves
                                                                                    Hold buttocks with both hands, spread apart
                                                                                    Inspect anal verge (margin), surrounding perineum
                                                                                    Findings
                                                                                                     Normal                                  Abnormal
                                                                                    Anal skin is coarser, more pigmented      Skin rash (pruritis ani)
                                                                                    (like scrotal skin)                       Skin tags
                                                                                    Forms small folds that radiate away       External haemorrhoids
                                                                                    from anal verge (margin)                  Warts
                                                                                    No prolapsed rectal mucosa                Anal fistula
                                                                                    No internal haemorrhoids                  Anal fissure
                                                                                                                              Inflamed fluctuant swelling
                                                                                                                              Tenderness

                                                                                    Palpation
                                                                                    Apply water-soluble lubricant to index finger (of gloved finger)
                                                                                    Apply some lubricant to anus
                                                                                    As finger enters anal canal
                                                                                    Rotate 360°
                                                                                    Palpate annular sphincter muscle (feel its tone)
                                                                                    Findings
                                                                                                    Normal                                    Abnormal
                                                                                    Sphincter muscle – complete ring          Laxity, inability to tighten anal
                                                                                    Wall of anal canal, rectum                sphincter (myelopathy, neuropathy)
                                                                                    (smooth to palpation)                     Describe
                                                                                    Male                                      Characteristics of growth
                                                                                    Palpable prostate                         Distance from anal margin
                                                                                    Not palpable                              Shape, size
                                                                                         Vas deferens                        Consistency
                                                                                         Sminal vesicles                     Surface texture
                                                                                         Recto-vesical pouch                 Pedunculated
                                                                                    Female                                    Sessile
                                                                                    Palpable cervix                           Mobility
                                                                                    Palpable coccyx

                                                                                    Prostate
Examination
                                                                                    Determine
              Clinical Use                                Indication
                                                                                    Size, shape
Rectal tumour                             Complaints
                                                                                    Consistency
Spinal cord injury (fecal incontinence)        Upper GIT             Lower GIT
                                                                                    Surface texture
Examine hardness, color of feces            Bleeding peptic Change in               Presence of nodular
Prior to colonoscopy, proctoscopy           ulcer                bowel habit        Tenderness
Evaluate haemorrhoids                                            Rectal bleeding    Mobility
Male                                                             Anal, rectal       Findings
Prostatic disorders                                              irritation, pain
Tumours                                                                                             Normal                                    Abnormal
                                           Appendicitis, neoplasm
Benign prostatic hyperplasia                                                        Size – large chestnut                      Enlargement of lateral lobes palpable
                                          Lower GU tract complains                                                             Enlarged prostate
Female                                                                              Posterior surface is broader at its top-
                                               Difficulty passing urine
Gynecological palpations of organs                                                  end where it meets the bladder                  Prostatism
                                               Bladder habit changes
                                                                                    Lateral lobes                                   Benign (rubbery, smooth)
                                               Blood in urine                      Median lobe is not palpable through        Malignant until proven otherwise
                                               Pain on passing urine               rectum                                          Non-tender
                                          > 50 y/o - ↑ risk                         Normal gland is smooth to palpate               Hard nodule
                                               Rectal neoplasm                     Consistency – rubbery, firm, not hard           Distinct border
                                               Prostatic neoplasm                                                             Advanced carcinoma
                                                                                    Moderately mobile
                                                                                    Not palpable                                    Entire gland hard
                                                                                         Vas deferens                              Immobile
                                                                                         Seminal vesicles                     Infection
                                                                                    May cause vague discomfort                      Tenderness
                                                                                    Should not cause pain                           Bogginess (softening)

                                                                                    Inspection of Gloved Examination Finger
                                                                                    Visually examine glove – mucus, blood, pus
                                                                                    Occult blood testing
                                                                                    Findings
                                                                                             Normal                                 Abnormal
                                                                                    Feces clings to glove      Presence of mucus, blood, pus
                                                                                                               Blood
                                                                                                               Upper GIT – stool black, tar consistency
                                                                                                               Lower GIT – stool + unchanged blood (appear red)
                                                                                                               If amount of blood is small
                                                                                                               Presence may be occult (not grossly visible)