Digital Rectal Examination 🩺
Digital rectal examination (DRE / PR exam) based on Patient.info professional guidance. Anatomy, indications, technique, findings, and special populations for NCHDs.
📋 Overview
- Used to examine for gastrointestinal disease and disease in other pelvic organs.
- It is an intimate examination: perform it correctly for detection of disease and for patient comfort, and record findings accurately.
🧬 Anatomical Considerations
- The rectum is the curved lower terminal segment of large bowel, about 12 cm long, running along the concavity of the sacrum.
- Upper two thirds of the anterior rectum is covered by peritoneum; the posterior rectum is not.
- In men, anterior rectal peritoneum reflects onto the bladder base. In women, it forms the rectouterine pouch (pouch of Douglas), which contains loops of bowel.
- Anterior to the lower one third of the rectum: in men, prostate, bladder base, and seminal vesicles; in women, the vagina. The fingertip may feel the cervix and even a retroverted uterus.
- The anus is 3–4 cm long and joins the rectum to the perineum.
- Anal canal wall is supported by voluntary external and involuntary internal sphincter muscles, essential for defecation and continence.
🧠 Indications
- Assessment of the prostate, particularly with symptoms of outflow obstruction
- Rectal bleeding, prior to proctoscopy, sigmoidoscopy, and colonoscopy
- Constipation
- Change of bowel habit
- Problems with urinary or faecal continence
- In exceptional circumstances, to detect uterus and cervix when vaginal examination is not possible
- May also be done as part of a thorough screening examination when disease is not suspected
- Always explain the reasons for the examination and obtain verbal consent
🧰 Preparing for the Examination
- Explain the reasons for the procedure and what the procedure involves
- Offer a chaperone
- Warn that the examination may be uncomfortable but should not be painful
- Warn that they may feel rectal fullness and the desire to defecate
- Equipment: suitable gloves, lubricant, lighting, suitable soft tissues
- Position the patient comfortably (see procedure)
📝 Procedure
- Position comfortably in the left lateral position. Flex hips and knees; buttocks at the edge of the couch.
- Gently part the buttocks to expose the anal verge and natal cleft.
- Inspect the skin and anal margin with good light.
- Lubricate the examining index finger with water-soluble gel.
- Press the finger against the posterior anal margin (6 o’clock by convention).
- The finger should slip easily into the anal canal; direct the fingertip posteriorly, following the sacral curve.
- If appropriate, check anal tone by asking the patient to squeeze the finger with their anal muscles.
- Move the finger through 180°, feeling the walls of the rectum.
- Rotate the finger to the 12 o’clock position (often helped by bending the knees in a half-crouched position and pronating the examining wrist) to palpate the anterior wall.
- Rotation facilitates further examination of the opposing walls. Feel the rectal walls throughout 360°; small wall lesions may be missed if this is not done carefully.
- In men, the prostate is felt anteriorly. In women, the cervix and a retroverted uterus may be felt with the fingertip.
- On removal of the examining finger, check the tip of the glove for stool and blood.
🔎 Prostate Gland (Anterior)
- Normal size: about 3.5 cm wide, protruding about 1 cm into the rectal lumen
- Consistency: normally rubbery and firm, smooth surface, palpable sulcus between right and left lobes
- There should not be any tenderness
- There should be no nodularity
- Massage of the prostate may enable prostatic fluid to be examined at the urethral meatus
🕐 Describing Findings
- Describe findings by clock face in the lithotomy position: 12 o’clock is anterior, 6 o’clock is posterior.
👀 External Inspection May Reveal
- Skin disease (e.g. natal cleft dermatitis in seborrhoeic eczema)
- Skin tags
- Pilonidal sinus
- Genital warts
- Anal fissures
- Anal fistula
- External haemorrhoids
- Rectal prolapse
- Skin discolouration with Crohn’s disease
- External thrombosed piles
🩺 Internal Examination May Reveal
- Simple piles (but best examined at proctoscopy)
- Rectal carcinoma
- Rectal polyps
- Anal carcinoma
- Tenderness (e.g. with acute appendicitis)
- Diseases of the prostate gland
- Malignant or inflammatory conditions of the peritoneum (felt anteriorly)
- Loss of anal tone and sensation (cauda equina syndrome)
👶 Children
- Distressing examination for children and should be avoided.
- Few absolute indications.
- When deemed essential, it may be appropriate to use the fifth rather than the index finger.
🧓 Elderly Patients
- Often required because symptoms and disease arise more often in elderly patients.
- The left lateral position may be uncomfortable; take time to achieve a comfortable position that still allows adequate examination.
- Deafness may hamper explanations; take time to ensure the procedure and the reasons for it are understood.
Note Template
Ready-to-use clinical note structure
🕒 27 / 10 / 2026 — 19:23 ATRP / procedure note: digital rectal examination (DRE) Patient: [age] [sex] Indication: [prostate / PR bleed / constipation / change in bowel habit / continence / other] Consent: verbal consent obtained; reasons explained Chaperone: [offered — name / role present, or declined] 🩺 Examination (Patient.info technique): • Position: left lateral, hips and knees flexed, buttocks at edge of couch • External inspection (anal verge / natal cleft): [NAD / skin tags / fissure / fistula / haemorrhoids / prolapse / warts / other — clockface] • Anal tone / squeeze: [normal / reduced / absent] • Rectal walls (360°): [NAD / mass / polyp / tenderness / other — clockface, 12 anterior / 6 posterior] • Prostate (if male, anterior): size [~3.5 cm expected], consistency [rubbery/firm], surface [smooth/nodular], sulcus [palpable/obliterated], tenderness [Y/N] • Cervix / uterus (if relevant): [felt / not felt] • Glove tip: [clean / stool / blood] 📋 Impression: [findings summary] 📌 Plan: • [investigations / specialty review / escalate if cauda equina or concerning mass] 👤 [Your Name], [Role] IMC: _______
Educational reference only. Medical disclaimer