Rectal Exam

A rectal exam should be performed on most patients with abdominal pain and any concern for blood loss. Here, we review some important steps of a compete rectal exam.

Positions

There are multiple positions that you can ask your patient to stand or lie. These include:

1. Standing position: patient standing with toes pointing in, then leans over a table
2. Right lateral decubitus (Sims position): patient lies on right side with right hip/leg straight and the left hip/knee is bent
3. Knee to chest: patient with lying on table facing down with knees up to chest bent forward

* (Both the standing and knee to chest positions are optimal for the prostate exam)

Inspection of Anus

Look for external hemorrhoids, fissures (90% of time they are located in midline posteriorly), skin tags, warts or discharge

Palpate Rectum and Prostate

1. Use a small amount of lubricant on the index finger and ask the patient to take a deep breath and insert the finger facing down (6 o'clock position)
2. Appreciate the external sphincter tone then ask the patient to bear down and feel for tightening of the sphincter
3. Palpate the prostate gland. Note the following:
   1. Approximate size of the prostate gland (normally about the size of a walnut, 2-3 cm but wider at the top)
   2. Feel for tenderness (prostatitis)
   3. Feel for nodules or masses
4. Palpate the rectal wall starting from the 6 o'clock position clockwise to the 12 o'clock position. Then return to the 6 o'clock position and palpate the other half of the rectal wall feeling for masses, nodules and tenderness.

Occult Blood Test

Check any fecal material for occult blood with a guaiac kit.