Techniques of Examination

For most patients the rectal examiantion is probaly the least popular segment of the entire physical examination. It may cause discomfort for the patient, perhaps embarrassment, butif skillfully done, should not be truly painful in most circumstances. Although you may choose to omit a rectal examination in adolescents who have no relevant complaints, you should do one in adult patients. In middle-aged and older persons omission risks missing an asymptomatic carcinooma. A successful examination requies gentleness, slow movement of your finger, a calm demeanor, and an explanation to the patient of what he or she may feel.

Male

The anus and rectum may be examined with the patient in one of several positions. For most purposes, the side-lying position is satisfactory and allows good visualization of the perianal and sacrococcygeal areas. This is the position described below. If you suspect a cancer high in the rectum, the lithotomy position may help to bring it into reach. By placing your opposite hand on the patient’s abdomen you can also perform a bimanual examination in this position, thus delineating a pelvic mass.

Ask the patient to lie on his left side with his buttocks close to the edge of the examining table near you. He should flex his legs at hips and knees. Drape the patient appropriately and adjust the lighting for good visuallization of the anus and surrounding area. Put a glove on your right hand. With your left hand spread the buttocks apart.

Inspect the sacrococcygeal and perianal areas for lumps, ulcers, inflammation, rashes, or excoriations. Adult perianal skin is ormally more pigmented and somewhat coarser than the skin over the buttocks. Palpate any abnormal areas, noting lumps or tenderness.

Lubricate your gloved index finger, explain to the patient what you are going to do, and tell him that the examiantion maymake him feel as if he were moving his bowels but that he will not do so. Ask him to strain down. Inspect the anus, noting any lesions.

As the patient strains, place the pad of your lubricated and gloved index finger over the anus. As the sphincter relaxes, gently insert your fingertip into the anal canal, in a direction pointing towards the umbilicus.

If you feel the sphincter tighten, pause, reassure the patient, and, when in a moment the sphincter relaxes proceed. Occasionally an acutely tender lesion such as an anal fissure prevents you from completing your examination. Do not try to force it. Local anaesthesia or consultation may be necessary.

Irregularities or Nodules.

Insert your finger farther into the rectum so that you can examine as much of the rectal wall as possible. Palpate in sequence the right lateral, posterior, and left lateral surfaces, noting any nodules or irregularities. Then turn your hand so that your finger can examine the anterior surface and the prostate gland. Tell the patient that you are going to feel his prostate gland and that it may make him want to urinate but he will not.Identify the lateral lobes of the prostate and the median sulcus between them. Note the size, shape, and consistency of the prostate, feel for anynodules, and note any tenderness.

If possible, extend your finger above the prostate to the region of the seminal vesicles and peritoneal cavity. Note nodules or tenderness.Rectal lesions just beyond your fingertip can sometimes be felt by asking the patient to strain down again. Use this maneuver if there is any suspicion of cancer.

Gently withdraw your finger, and wipe the patient’s anus or give him tissues to do it himself. Note the color of any fecal matter on your glove, and test it for occult blood.

Female

The rectum is usually examined after the female genitalia, while the patient is in the lithotomy position. This position is essential for bimanual palpation. If a rectal examination alone is indicated, the lateral position offers a satisfactory alternative and affords much better visalization of the perianal and sacrococcygeal areas.

The technique is basically similar to that described for males. The cervix is usually readily felt through the anterior rectal wall. Sometiems a retroverted uterus is also palpable. Neither of these, nor a tampon, should be mistaken for a tumor.