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Nick Purkis
Clinical skills
„ Lesson objectives:

Discuss the rationale for DRE

Exploration of consent issues
The correct method for performing the DRE
will be performed

„ An examination in which a doctor

inserts a lubricated, gloved finger into
the rectum to feel for abnormalities.

“Rectal examination is inexpensive, relatively

non-invasive, and non morbid.
Common reasons to perform the
„ Prostate cancer screening
„ Urological symptoms
„ Colorectal cancer screening
„ Part of a comprehensive abdominal
„ Other rectal pathology (e.g.. Haemorrhoids)
Reasons NOT to perform DRE
„ Paediatrics. Needs to be done by a
„ Non consenters
„ Think. –Is this necessary, WILL it make a
difference to my management, WILL the
pro’s of a DRE outweigh the risks
Communication: Requesting
„ Patient consent is imperative for all invasive
„ Verbal consent only for DRE, but do document in
the notes that you gained consent from the
appropriate person.
„ Research shows that patients attitude is affected
‹ Previous experiences, positive or negative.

‹ Cultural or religious beliefs.

Communication: Being sensitive
to the patients comfort /privacy
„ Imaging yourself in this situation
„ Ensure privacy. Is the bed behind some
flimsy curtains good enough?
„ Keep as much of the patient covered as
„ Maintain professionalism. Do not describe
any abnormalities until appropriate
Communication: Explain the procedure
„ Use clear and specific language that the
patient can understand
„ Use visual aids if necessary
„ Avoid medical jargon
„ Describe to the patient what they should
expect (don’t be over-graphic, though!)
„ If possible ask someone to assist and
accompany you
„ Possibly a nurse who would stand or sit
with the patient holding the hand.
Performing the DRE

„ Assess the patient’s mobility as to the

position adopted for this procedure
Performing the DRE
„ Ask the patient if they feel comfortable
before proceeding
„ Common positions for the DRE
‹ Left lateral position

‹ Modified lithotomy (patient on back,

knees flexed)
‹ Standing, hips flexed with upper body on
Performing the DRE

Most hospital patients will be lying on their

They will need to bring their knees right up to
their chest
Glove both hands
Gently separate the buttocks
Inspect the perineum
Palpate any abnormal areas, noting lumps or
Performing the DRE
„Ask the patient about any localized
feelings of pain or tenderness.
„Generously lubricate the gloved index finger
„Inform the patient that you are going to insert
your finger
„With your right hand insert your index finger into
the anus aiming for the ‘Belly Button’
„Perform a full 360 degree sweep assessing
Examining the rectum
„ Examine the posterior and lateral
walls of the rectum by rotating the
finger at 180 degrees
„ In order to palpate the entire rectum
you need to turn away from the
patient and pronate your wrist
„ Sweep your finger around the
anterior and anterolateral walls of the
„ Note the texture and elasticity of the
rectal lining
DRE: Possible findings
„ Normal mucosa feels uniformly smooth and
pliable to palpate
„ Polyps – may be attached by stalk or base
„ Masses or irregular shaped nodules
„ Areas of unusual hardness
„ Abscesses (perirectal sepsis) may be
indicated by extreme tenderness
„ Haemorrhoids (internal or external)
DRE: Examining the prostate
„ Inform the patient that you are going
to examine his prostate gland
„ Sweep your finger over the prostate
gland (anteriorly through the rectal
„ Identify the two lobes, and the
longitudinal groove (median sulcus)
„ Note the size, nodularity, consistency
and tenderness of the prostate
DRE: Prostate exam: Possible findings 1

Normal prostate;
„ About 2.5 cms across
„ Prominent median sulcus
„ Smooth, rubbery consistency
„ Tenderness not usual, but patients should
feel the need to urinate
DRE: Prostate exam: Possible findings 2

Benign Prostatic hypertrophy (BPH)

„ Enlargement of the gland is usually
„ Marked protrusion into the rectal lumen
„ Smooth with no nodularity
„ Median sulcus may be indistinguishable
„ Consistency is rubbery, or slightly elastic
DRE: Prostate exam: Possible findings 3

Prostate cancer
„ Asymmetric shape
„ Hard consistency
„ Discrete nodule may be palpable
„ Median sulcus often obscured
Concluding the examination
„ Inform the patient that you have finished
„ Note the colour of any soiling on your glove
„ Offer the patient a tissue
„ Allow the patient to get dressed, sit down and
prepare themselves for discussing results
„ Explain your findings to the patient
„ Negotiate a follow up plan / tests /investigations
„ Address the patients concerns
Summary of issues

„ Obtain consent
„ Chaperone if possible
„ Communication.