Digital rectal examination

Definition

The digital rectal examination (DRE) is a routine part of the physical examination and includes manual examination of the rectum, anus and, in men, the prostate.

Purpose

The purpose of the digital rectal examination is to identify lesions within the rectum and the prostate. It is the most widely used and oldest technique for the detection of prostate cancer and is used in screening for colon cancer and for the detection of rectal polyps.

Description

Usually the patient is positioned on the left side with the knees close to the chest. Sometimes the patient is asked to stand up and lean over the examination table. For women, sometimes this examination is part of the routine gynecological exam, and it may be done in a different manner than described here.

During the examination, the health care practitioner examines the anus and the surrounding skin for hemorrhoids, tags, fissures and abscesses. After lubricating the gloved finger and anus, the examiner gently slides the finger into the anus and follows the contours of the rectum. The examiner notes the tone of the anus and feels the walls and the edges for texture, tenderness and masses as far as the examining finger can reach. The examiner evaluates the prostate for nodules and tenderness. Stool on the finger should be examined for blood, color, texture and tested for fecal occult blood.

The examination takes less than two minutes and can be uncomfortable when the patient is not relaxed or is anxious. Occasionally, when the DRE is performed on a man the penis may become erect. A gentle reminder and reassurance helps to relieve the embarrassment associated with the unexpected erection.

Preparation

The patient must be carefully positioned and the doctor should take care to explain the examination to the patient and to explain to the patient what to expect. The digital rectal examination may be uncomfortable and embarrassing. Much of the discomfort can be reduced by an understanding, unhurried and gentle examiner.

Precautions

When there are infections of the anus and of the rectum, the digital rectal examination should not be performed. Manipulation of the anal and rectal tissues increases the risk of infection and of bleeding.

Results

In the normal anus and rectum, there are no hemorrhoids or bleeding about the anus. The anal tone is not loose. The rectum is smooth and non-tender. No masses should be palpated, or felt.

The digital rectal examination is helpful in identifying areas of peritonitis or tender areas that can be felt through the wall of the rectum. It is used to identify perineal disease or deformity, abnormal location of the anus, rectal prolapse and atrophy of the gluteal muscle. Digital examination can detect a stenosis (or narrowing) of the anal canal, assess the tone and strength of the anal muscles or detect the presence of a rectal mass or fecal impaction.

Any masses, including hard stool, blood or tenderness is considered abnormal. Cancer masses may be flattened, nodular, cauliflower-like or ring-shaped. Polyps can be felt, but must be visualized using anoscopy or flexible sigmoidoscopy to be distinguished from other lesions, such as internal hemorrhoids or malignant growths. Hard masses of feces may be felt and may be removed.

Aftercare

Aftercare of the digital rectal examination is minimal. It requires removal of the lubricating jelly residue from around the anus. The lubricating jelly dissolves easily in water and may be washed off in bathing after the examination. It can be removed with toilet paper immediately after the examination.

See Also Rectal cancer

Resources

BOOKS

DeGowin, R. and D. D. Brown. DeGowin's Diagnostic Examination Seventh Edition. New York, New York: McGraw-Hill, 2000.

Yamada, Tadatake, ed. Textbook of Gastroenterology Volumes One and Two, 3rd Edition. Philadelphia: Lippincott, Williams & Wilkins, 1999.

Cheryl L. Branche, M. D.

KEY TERMS

Fissure

—Any cleft or groove, normal or otherwise, especially a deep fold in the anus.

Lesion

—Any pathological or traumatic discontinuity of tissues or loss of function of a part.

Palpation

—A simple technique in which a doctor presses lightly on the surface of the body to feel the organs or tissues underneath.

Peritonitis

—Inflammation of the peritoneum. It may be accompanied by abdominal pain and tenderness, constipation, vomiting and moderate fever.

Polyp

—Growth, usually benign, protruding from a mucous membrane.

Rectal prolapse

—Protrusion of the rectal mucous membrane through the anus.

Skin tag

—A small outgrowth of skin tissue that may be smooth or irregular, flesh-colored and benign.

Rectal Examination

Definition

Rectal examination or digital rectal examination (DRE) is performed by means of inserting a gloved, lubricated finger into the rectum and palpating (feeling) for lumps.

Purpose

DRE is used as a screening tool to locate rectal cancer and prostate cancer. It is also used as a diagnostic test to find non-cancerous abnormalities within the rectum like hemorrhoids, anal fissures, or congenital deformities that can cause chronic constipation.

Precautions

There are no precautions when performing DRE, aside from routine sanitary procedures.

Description

DRE is performed in most instances as an annual routine procedure in colorectal cancer screening. Digital palpitation of the rectum can often find abnormal growths which may require further testing or commonplace hemorrhoids. It is a critical initial clinical test and is important in the assessment of the size and location of tumors.

This procedure is often not performed routinely on patients over 70, even though this population is at high risk for colorectal cancer. It also is not done as often in elderly women as in elderly men.

DRE has also been used as a screening tool for prostate cancer. It seems to be very effective for larger masses found in the prostate and correlated well with higher prostate-specific antigens.

Of less predictive value was DRE in routine rectovaginal examinations of women under the age of 50. These instances of DRE did not locate colorectal cancer or any other abnormality.

More gastroenterologists are recommending that pediatricians and family physicians perform DRE on pediatric patients exhibiting chronic constipation before those patients are referred to intestinal specialists. The pediatrician or family physician could identify fecal compaction and treat it themselves, and then only refer patients who have a specific abnormality to gastroenterologists.

Preparation

The physician must conduct DRE using a gloved hand. Some sort of lubricant should be used so that penetration of the rectum is easier and does not create the damage that the procedure is seeking.

Aftercare

There is no aftercare after a DRE is performed.

Risks

There are no risks to DRE and it is virtually painless.

Normal results

The physician finds a normal rectal canal with no abnormalities.

Abnormal results

Growths, tears, anal fissures, or congenital structural defects can be found inside the rectum with DRE.

Resources

PERIODICALS

Kirchner, Jeffrey T. "Digital Rectal Examination in Children with Constipation." American Family Physician 60, no. 5 (October 1, 1999): 1530.

Schroder, Fritz H. "Evaluation of the Digital Rectal Examination as a Screening Test for Prostate Cancer." JAMA, The Journal of the American Medical Association 281, no. 7 (February 7, 1999) 594.

OTHER

Practice Parameters for the Treatment of Rectal Carcinoma American Society of Colon and Rectal Surgeons May 7, 2001. 〈http://www.asco.org/prof/me/html/abstracts/gasc/m_969.htm〉.

KEY TERMS

DRE— Digital rectal examination.

Gastroenterologist— A physician who specializes in diseases of the digestive system.

Rectum— The last eight to ten inches of the colon, of which the anus is a part and the opening through which wastes are removed from the body.