This examination provides information on several important abdominal structures (e.g. peritoneum, pouch of Douglas) and organs (e.g. anus, rectum, prostate, uterus, parametrium). Examination of a patient with abdominal pain is therefore, in principle, incomplete without examination of the anus and a well-executed rectal examination. Rectal examination should be performed on children only if it is essential for diagnosis and treatment. For female patients, vaginal examination may also be indicated, particularly in cases where the symptoms may be caused by gynaecological factors.
Given the sensitive nature of the examination, adequate explanation and instruction are important before and during the examination, as well as a respectful approach to the patient and good technique. The degree of sensitivity regarding this issue varies considerably and is strongly determined by culture. If the patient is very anxious or uncooperative, the examination may be reconsidered or postponed. This is rarely necessary if the importance of the examination is explained carefully and the physician proceeds calmly.
Rectal examination is contra-indicated only in cases of anal fissures or perianal abscess (points to consider during inspection).
Rectal examination
– for adults: yes, with exceptions
– for children: no, with exceptions
Before the examination
- Explain to the patient what will happen.
Tell the patient that you are about to inspect the final portion of the intestine (and the prostate) by examining the anus and feeling inside the anus with a finger. Explain that, in principle, the examination is painless, but the patient may experience some urges (the urge to urinate during prostate examination or the urge to defecate during inspection of the intestinal mucous membranes). Also mention that this will not lead to actual miction or defecation. Ask the patient to warn you if they nevertheless feel any pain. - Only perform an internal examination in the presence of a third person
[Figure 50].
This can be someone who is accompanying the patient. If the patient is alone, ask an assistant to be present for the examination. This protects both the patient and the physician from ‘undesired intimacy’. - Have the patient remove their underwear (and trousers if they have not already removed them for the abdominal examination).
If necessary, ask the patient to dress their upper body again (T-shirt, shirt, etc.); this will help the patient feel less exposed.
Figure 50
Inspection
Inspection of the perianal region and perineum is best performed while the patient is standing, bending over, with arms resting on the examination table and feet slightly apart. This position is preferred if there are anal symptoms. Inspection is also possible while the patient is lying on their side with the legs bent and a slightly rounded back.
Procedure
- Put on (non-sterile) gloves.
- Ask the patient to place themselve in the preferred position.
- Sit on a stool behind the patient.
- Spread the buttocks and inspect the perianal region and perineum [Figure 51].
- Spread open the anus carefully and ask the patient to bear down lightly.
Figure 51
Focus points
- Check for skin abnormalities in the anal region, such as small wounds, signs of scratching, fistular openings, redness, or swelling.
Rectal examination is contra-indicated in patients with an anal fissure or perianal abscess. - Note the sphincter tension: is the anus closed or open?
Low sphincter tension can lead to visible (impending) prolapse when bearing down. - Note any abnormalities in the anal mucosa, such as fissures or haemorrhoids.
Fissures are very painful and often lead to increased sphincter tension. Due to the extreme painfulness of fissures, rectal examination is contra-indicated in these cases.
Rectal examination
The rectal examination can be performed while the patient is lying on their back or side.
Each position is associated with advantages and disadvantages.
Lying on the back
The patient lies on their back with the head supported at a 30-45 degree angle, knees half-bent, pelvis tilted, and legs spread (feet apart).
- Advantages: reasonably comfortable position for the patient; good contact / eye contact with the patient is possible (facial expressions can be observed); better accessibility of the prostate and the rectouterine pouch or rectovesicular pouch by rectal examination due to gravity; better accessibility of the lower abdomen and organs of the lesser pelvis by bimanual palpation; for female patients, it is possible to perform a rectal examination immediately after a vaginal examination.
- Disadvantages: inspection of the anus and perianal region is more difficult in this position; for overweight patients, finger insertion may be difficult.
Lying on the side
The patient lies on their left side with both knees pulled up as far as possible.
- Advantages: virtually all patients can assume this position; preferred position for patients with severe coxarthrosis and obesity; inspection is also possible in this position.
- Disadvantages: the rectouterine pouch and rectovesicular pouch are more difficult to reach with the finger, compared with lying on the back; bimanual examination is not possible; eye contact with the patient is not possible.
Procedure
- Have the patient assume the agreed position.
- Put on (non-sterile) gloves [Figure 52], then coat the entire gloved index finger of the right hand with Vaseline using the thumb of the same hand. Then apply a small amount of Vaseline to the anus [Figure 53]. Keep the left glove clean.
If a tube of Vaseline is available, the same gloves used during examination of the groin and external genitalia can be used. If a pot of Vaseline is used, use a new pair of gloves, given that the same Vaseline source is used for multiple patients.
Figure 52
Figure 53
- Stand to the right of the patient.
- Ask the patient to breathe calmly.
- Male patients may be asked to lift the scrotum themselves [Figure 54].
- Look at the patient regularly during the rectal examination to see how they are reacting and ask whether the examination is tolerable.
Figure 54
- Apply the Vaseline found on the tip of the index finger to the anus (in the case of considerable hair growth, also apply Vaseline to the surrounding area).
- Place the extended index finger on the perineum (i.e. between the anus and scrotum or vagina), with the tip of the finger precisely on the anus [Figure 55].
The left hand can be used to spread the buttocks and, after inserting the finger, is best laid on the closest knee of the patient. This will steady your stance while maintaining a natural distance from the patient.
Figure 55
- Press with the entire finger against the perineum and anus in the direction of the anal canal.
This will reduce the tension in the anal sphincter muscle. - As the tension of the anal sphincter muscle eases, slide the finger inside over the rim of the anus. After checking that everything is in order, let the finger slide as far as possible into the rectum. [Figure 56].
Figure 56
- For men, assess the prostate.
Normally, the seminal vesicles cannot be reached. They can only be reached if they are swollen and by feeling as far as possible. - Insert the finger as far as possible and check whether this is painful or if a palpable mass can be felt.
The pouch of Douglas is usually impalpable unless a disorder is present. For example, a spherical Douglas pouch indicates fluid or pus in the abdominal cavity, and irregular firm masses are consistent with carcinomatous peritonitis. - Assess the sphincter tension by asking the patient to briefly mimic holding back a bowel movement.
- Gradually retract the finger while rotating the entire hand and assess the rectal mucosa (left, right, ventral and dorsal!) and rectal contents [Figure 57].
Figure 57
- Remove the finger from the anus and inform the patient that the examination is over.
- Check if there is blood, mucous, or pus on the glove, determine the characteristics of any faeces clinging to the glove, [Figure 58] and then remove the glove [Figure 59].
Do not inspect the glove while the patient is watching. - Ask the patient to dress themselves.
Offer the patient gauze or wipes to remove any excess Vaseline. - Wash your hands while the patient dresses.
- Discuss the findings with the patient.
Figure 58
Figure 59
Focus points
- Assess the following aspects of the prostate:
- symmetry:
under normal circumstances, palpation reveals two approximately equally sized-lobes on opposite sides of the median line and separated by a groove known as the median sulcus (similar to the groove of an apricot or peach); - size:
a normal prostate is the size and shape of a chestnut; the diameter from left to right is approximately 3 centimetres; - borders:
normally, the cranial end of the prostate lies just beyond the reach of the tip of the finger; in any case, try to assess the lower, left, and right borders; - consistency:
prostate consistency is usually firm and rubbery, similar to the ball of the thumb; - surface:
under normal conditions, the prostate surface is smooth and the rectal mucosa can glide easily over the prostate; - palpation tenderness:
a healthy prostate is not painful to palpation.
- symmetry:
- During the prostate examination, be aware of any discharge from the penis and record its appearance.
- Check whether deep palpation is painful and whether palpable masses are present.
The pouch Douglas is usually impalpable and does not cause pain. If the peritoneum is irritated at the site of the Douglas pouch (e.g. appendicitis), deep palpation may be painful (and elicit a cry of pain from the patient [cri du Douglas]). If pus or tumour tissue is found in the pouch of Douglas, it will protrude into the rectum. - Assess sphincter tension.
Passive sphincter tension can be assessed throughout the entire examination. It is sufficient to describe the tension as increased, normal or low. Subsequently, active sphincter tension can be tested if indicated (e.g. for patients with incontinence) by asking the patient to contract the sphincter as if holding back a bowel movement. Note any areas of poor contractility and pain. - When assessing the rectum, note the following:
- whether there is faeces in the rectum;
assess the quantity and consistency of faeces; - the mobility of the rectal mucosa in relation to the underlying layer of tissue:
normally, the mucosa moves easily; - pain during palpation of the rectal mucosa:
under pathologic conditions, the underlying layer of tissue can be painful to palpation; the rectal mucosa itself has no feeling; - masses:
Always indicative of pathology; characterise palpable masses.
- whether there is faeces in the rectum;