What is the proper technique for performing a digital rectal examination (DRE)?

Proper Technique for Digital Rectal Examination (DRE)

Digital rectal examination (DRE) should be performed as a standard part of endoscopic examination of the lower gastrointestinal tract to prepare the anal canal for scope insertion and examine the anal canal and lower rectum for pathology. 1

Patient Positioning and Preparation

• Position the patient in the left lateral position with knees flexed toward the chest (lateral decubitus position) 1, 2
  • Research shows the lateral position allows for more thorough examination of the entire circumference of the rectum compared to the dorsal position (79.5% vs 66%) 2
• Ensure adequate privacy and explain the procedure to the patient to reduce anxiety
• Use appropriate lubricant on the examining finger

Step-by-Step Technique

1. Visual Inspection

   • With buttocks separated, observe the perianal area for:
     • Evidence of fecal soiling
     • Skin lesions or abnormalities
     • Anal reflex (test with light pinprick or scratch) 1
   • During simulated defecation, observe:
     • Descent of the perineum
     • Any patulous opening of the anal verge
     • Prolapse of anorectal mucosa 1

2. Digital Examination

   • Insert a well-lubricated, gloved index finger gently into the anal canal
   • Assess the resting tone of the sphincter and its augmentation during squeeze 1
   • Evaluate the puborectalis muscle (above the internal sphincter), which should contract during squeeze 1
   • Check for localized tenderness along the puborectalis (may indicate levator ani syndrome) 1
   • Palpate the entire circumference of the rectum systematically 2

3. Functional Assessment

   • Ask the patient to "expel my finger" to integrate and assess expulsionary forces 1
   • Assess pelvic floor motion during simulated evacuation 1
   • Evaluate for:
     • Masses or abnormalities
     • Presence of stool and its consistency
     • Presence of blood (visible on glove after examination)

Documentation Requirements

• The performance or omission of rectal examination should be recorded in 100% of cases 1
• Document findings including:
  • Sphincter tone (normal, weak, absent)
  • Presence of masses or tenderness
  • Presence of blood (gross or occult)
  • Prostate findings in male patients
  • Rectal vault integrity 3

Clinical Significance and Indications

• DRE is sensitive for detection of abnormalities in the lower rectum and upper anal canal 1
• A careful DRE that includes assessment of pelvic floor motion during simulated evacuation is preferable to a cursory examination 1
• Particularly important in evaluating:
  • Constipation (to identify pelvic floor dysfunction)
  • Fecal incontinence
  • Suspected rectal masses
  • Penetrating injuries to perineal/pelvic area 3

Common Pitfalls and Caveats

1. Inadequate Assessment: A normal digital rectal examination does not exclude defecatory disorders 1

2. Skill Development: Confidence in diagnosis with DRE is strongly associated with number of examinations performed annually 4

3. Patient Refusal: Higher refusal rates correlate with lower comfort level of the physician in performing the examination 4

4. Trauma Cases: DRE may have limited value when applied indiscriminately to all trauma patients; most beneficial in cases with:

   • Penetrating injuries near the lower GI tract
   • Questionable spinal cord damage
   • Severe pelvic fractures with potential urethral disruption 3

5. Foreign Bodies: In cases of suspected anorectal foreign bodies, perform DRE carefully and possibly after obtaining abdominal X-ray to prevent accidental injury from sharp objects 1

By following this structured approach to digital rectal examination, clinicians can maximize diagnostic yield while ensuring patient comfort and dignity during this essential clinical examination.