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

Proper Technique for Digital Rectal Examination (DRE)

The optimal technique for performing a digital rectal examination (DRE) involves positioning the patient in left lateral position with knees flexed toward the chest, followed by visual inspection of the perianal area, lubrication of the gloved index finger, gentle insertion through the anal sphincter, and systematic palpation of the entire rectal circumference. 1

Patient Preparation and Positioning

• Optimal position: Left lateral (lateral decubitus) position with knees flexed toward chest
  • Success rate of 79.5% compared to 66% in dorsal position 1
  • For obese patients: Have them raise knee(s) toward chest to improve complete palpation in 95% of cases
• Explain the procedure to the patient to reduce anxiety
  • Patient expectations about DRE are often negative before examination but improve significantly afterward 2
• Ensure privacy and maintain patient dignity throughout the examination

Examination Technique

1. Visual inspection first:

   • Observe perianal area for fecal soiling, skin lesions, and anal reflex
   • Note any external abnormalities or signs of pathology

2. Preparation:

   • Put on gloves
   • Apply adequate lubricant to index finger
   • Important safety note: In cases of suspected anorectal foreign bodies, perform abdominal X-ray before DRE to prevent accidental injury from sharp objects 3

3. Insertion technique:

   • Place fingertip gently against anal verge
   • Ask patient to bear down slightly to relax sphincter
   • Insert finger slowly and gently in direction of umbilicus
   • Pause after passing the sphincter to allow for relaxation

4. Systematic assessment:

   • Evaluate sphincter tone at rest and during squeeze
   • Assess puborectalis muscle contraction
   • Check for tenderness along puborectalis
   • Ask patient to "expel your finger" to assess expulsionary forces 1
   • Rotate finger to examine entire circumference of rectum

5. Specific structures to evaluate:

   • Rectal walls for masses, tenderness, or irregularities
   • Presence of blood or abnormal stool consistency
   • In men: Prostate size, consistency, nodules, and tenderness
   • Pelvic floor motion during simulated evacuation 1

Documentation Requirements

• Document performance or omission of rectal examination in 100% of cases 1
• Record findings including:
  • Sphincter tone
  • Presence of masses or tenderness
  • Presence of blood
  • Prostate findings in male patients
  • Pelvic floor motion during simulated evacuation

Common Pitfalls and Considerations

• Inadequate lubrication: Can cause unnecessary discomfort and patient resistance
• Rushing the examination: A careful DRE that includes assessment of pelvic floor motion is preferable to a cursory examination 1
• Pain perception: Contrary to common belief, pain during examination is typically minimal (mean pain score of 1.69 on a 0-10 scale) 2
• Limited diagnostic value in certain populations: DRE may have limited diagnostic yield in otherwise healthy female patients under 40 years 4
• Remember: A normal DRE does not exclude all defecatory disorders, though it has approximately 90% sensitivity for detecting abnormalities in the lower rectum and upper anal canal 1

Special Circumstances

• In trauma patients: DRE is most valuable in cases with penetrating injuries near the lower gastrointestinal tract, questionable spinal cord damage, and severe pelvic fractures 5
• For suspected anorectal foreign bodies: Perform DRE carefully and consider imaging first to prevent injury 3

The DRE remains an essential clinical skill that requires proper training and practice. When performed correctly, it can provide valuable diagnostic information comparable to specialized physiologic tests like anorectal manometry 6.