Documentation of a Normal Digital Rectal Examination
In a 58-year-old man with hypogastric pain and obstipation, document your normal digital rectal examination by systematically recording external inspection, sphincter tone at rest and with squeeze, absence of masses or tenderness, and functional assessment—this structured approach ensures complete documentation and meets quality standards for gastrointestinal evaluation. 1, 2
Pre-Procedure Documentation
Document the following before performing the examination:
- Patient position: Left lateral decubitus position (most common for routine examinations) 2
- Indication: Evaluation of hypogastric pain and obstipation 1
- Consent: Verbal consent obtained and procedure explained 2
External Inspection Findings
Record your observations with the buttocks separated:
- Perianal skin: Normal appearance without fecal soiling, lesions, excoriation, fissures, or fistulas 1, 2
- Anal reflex: Intact when tested with light pinprick or scratch 1, 2
- Perineal descent: Normal descent during simulated evacuation (bearing down) 1, 2
- Perineal elevation: Normal elevation during squeeze maneuver 1, 2
- Anal verge: No patulous opening during simulated defecation 1, 2
- Prolapse: No prolapse of anorectal mucosa during straining 1, 2
Digital Palpation Findings
Sphincter Assessment
Document tone systematically:
- Resting tone: Normal anal sphincter tone at rest 1, 2
- Squeeze tone: Appropriate augmentation of sphincter tone with voluntary squeeze effort 1, 2
- Puborectalis muscle: Contracts normally during squeeze maneuver 1, 2
- Tenderness: No localized tenderness to palpation along the puborectalis muscle (absence of levator ani syndrome) 1, 2
Rectal Vault Assessment
- Masses: No palpable masses or abnormalities 2
- Stool: Document presence or absence of stool in the rectal vault (relevant for obstipation evaluation) 1
- Blood: No gross blood on examining finger 1
Functional Assessment
- Expulsionary effort: Patient able to integrate expulsionary forces appropriately when instructed to "expel my finger" 1, 2
- Pelvic floor relaxation: Ability to relax pelvic floor muscles during simulated defecation 2
Sample Documentation Template
"Digital rectal examination performed in left lateral position. External inspection: perianal skin normal, no soiling or lesions, anal reflex intact, normal perineal descent with bearing down and elevation with squeeze, no patulous opening or mucosal prolapse. Digital palpation: normal resting sphincter tone with appropriate augmentation on squeeze, puborectalis contracts normally, no tenderness, no masses palpable, [presence/absence of stool in vault], no gross blood on examining finger. Patient able to appropriately expel examining finger. Examination well tolerated."
Critical Documentation Standards
Recording requirements per endoscopy quality guidelines:
- Digital rectal examination or its omission should be recorded in 100% of cases 1
- Document all components systematically to ensure completeness 1
- Include patient tolerance of the procedure 1
Important Clinical Caveats
Limitations of Normal Findings
- A normal digital rectal examination does not exclude pelvic floor dysfunction—additional testing may be required if clinical suspicion remains high despite normal examination 1, 2
- A normal examination does not exclude all pathology, particularly early or subtle conditions 2
- In the context of obstipation, absence of stool in the rectal vault may suggest more proximal impaction or other pathology requiring imaging 1
When to Pursue Further Evaluation
Despite a normal DRE in this 58-year-old man with hypogastric pain and obstipation, consider:
- Imaging studies: Plain abdominal radiography to exclude bowel obstruction given the pain component 1
- Colonoscopy: Age >50 years warrants structural evaluation, particularly with new-onset obstipation 1
- Transit studies: If constipation persists despite normal examination, consider colonic transit testing 1
Quality Indicators
Your documentation should support: