Ultimate guide to Digital Rectal Examination (DRE)

 Introduction

Digital Rectal Examination also known as DRE or Digital Anorectal Examination, is part of abdominal examination that assess internal organs like anus lower rectum and prostate gland.

Indications for digital rectal examination

DRE is done routinely as part of abdominal examination. But must be done in the following conditions

• Prostatic pathology (causes bladder outlet obstruction): 
• Benign prostatic hypertrophy (BPH)
• Prostate cancer 
• Prostatitis, 
• Prostatic abscess.
• Anal and perianal pathology: 
• Haemorrhoid 
• Anal cancer
• Anal polyp
• Imperforate anus
• Ischiorectal abscess
• Fistula in ano.
• Anal fissure
• Rectal & colonic pathology:
• Hirschsprung disease
• Ulcerative colitis
• Colorectal tumours
• Polyposis syndrome
• Neurological pathology:
• Spina bifida 
• Spinal injuries
• Gynaecology: 
• Pelvic inflammatory disease
• Endometriosis

Requirements

• Screen
• Couch
• Lubricants e.g. xylocaine gel/KY jelly
• A pair of plastic/latex gloves
• A good source of light

Positions

• Left lateral (commonest)
• Lithotomy
• Knee/elbow
• Prone

Preparations

• Explain the examination, its relevance and indication to the patient.
• Screen the patient and expose him/her from waist to mid thigh
• He/she is asked to lie in left lateral position with chin touching the chest and either;
•  Flex the hips to 90º and knees to <90°
• Or
• Straighten the left (directly in contact with the couch) lower limb & flex the right lower limb (hip = 90º, knee <90°)
• He/she is asked to move his/her buttock to reach the edge of the couch
• Wear the pair of gloves and put the lubricant on the pulp of right index finger

Inspection

• Lift up the uppermost buttock with left hand to see the anus, perianal skin and perineum clearly.
• Ask the patient to bear down and look for the following
• Skin rashes and excoriation
• Faecal soiling, and excoriation
• Scarring, or opening of a fistula
• Lumps and bumps
• Ulcers especially fissures, protrusion (haemorrhoids, anal tags).

Palpation

• Place the pulp of the right index finger on the centre arms with the finger parallel to the skin of the perineum and in midline.
• Press gently into the anal canal then backward. This overcomes anal tone and allows finger to straighten and slip into the rectum.
• Note the following in anal region; 
• Fissures
• Tone of the sphincter (reduced in patulous anus) in LMN lesions and increased in UMN.
• Tenderness and if there is a fissure or an abscess.
• Any thickening or mass (commonly haemorhoid).
• Rectum:
• Texture of the rectal wall (smooth or rough)
• Presence of a mass; if mass is felt move the rectal wall over it (if it moves over it - extrarectal, if it moves together, rectal).
• Palpable rectovesical pouch (is it tender? is it bulging?)
• Is the mass indentable? (Yes, faeces)
• Content
• Faeces (hard or soft);
• Empty and collapsed - indicate proximal obstruction
• Empty and ballooned out
• Faecal matter and ballooned out - indicate paralytic ileus
•  Cervix & Uterus
• Shape and size
• Adnexal masses - indicate PID
• Prostate
• An enlarged, firm rubbery mass with central sulcus and unattached to rectal wall - indicate BPH
• A hard & craggy mass with irregular edge, obliterated central sulcus and attached to rectal wall - indicate prostate cancer.

Conclusion

• Look at your finger after removing it
• Colour of faeces
• Presence of blood or mucous
• Clean and cover up your patient
• Thank your patient

Reference

Browse, Norman L. (Norman Leslie). (1998). Browse's introduction to the symptoms and signs of surgical disease / Norman L. Browse [and others]. (4th). London: Arnold.

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