Digital Rectal Exam

American Journal of Gastroenterology

C 2008 by Am. Coll. of Gastroenterology
Published by Blackwell Publishing
ISSN 0002-9270
doi: 10.1111/j.1572-0241.2008.01832.x
THE EXPERTS CORNER
How to Do and Interpret a Rectal Examination

in Gastroenterology
Nicholas J. Talley, M.D., Ph.D., F.A.C.P., F.A.C.G., F.R.A.C.P., F.R.C.P.
Department of Internal Medicine, Division of Gastroenterology & Hepatology, Mayo Clinic College of
Medicine, Jacksonville, Florida
(Am J Gastroenterol 2008;103:820822)
How to do a useful rectal examination may be becoming a

lost skill. At a recent major U.S. national meeting, an informal
poll of the audience revealed many busy gastroenterologists
failed to do a rectal despite the presence of lower gastrointestinal (GI) symptoms. However, the audience seemed thirsty for
knowledge on how to perform a decent GI rectal examination, and a number asked for instruction. The technique may
be often poorly taught in medical school; in some places,
urologists alone instruct students in how to do rectal examinations, which means the prostate may be better assessed
but the rest of the examination is largely ignored. Even in
GI Fellowship training, adequate instruction and experience
may often be lacking based on feedback to the author, albeit
anecdotal. A cursory examination at the time of colonoscopy
may often be inadequate for identifying key abnormalities,
as most of us are focused then on successfully completing
the endoscopy safely and as quickly as we can, to keep the
list moving. Yet the finger can obtain very useful information
quickly, easily, and safely. Indeed, in patients presenting with
unexplained chronic constipation or fecal incontinence, the
rectal examination can help dictate the most appropriate next
set of investigations.
The following simple 10-step approach may help to optimize the performance of an intelligent rectal examination in
gastroenterology practice (1):
A gaping anus often indicates lower resting pressures on

anorectal manometry (2). You may see prolapse of internal hemorrhoids. On straining, if there is rectal prolapse,
you may observe at the anal verge a dark red mass; radial folds are seen in mucosal prolapse and concentric
folds in complete prolapse. The mass is continuous with
the perianal skin; it is usually painless. In mucosal rectal
prolapse, you can feel the prolapsed mucosa between the
thumb and forefinger.
5. Test the anal wink: Stroke a cotton pad in all four quadrants around the anus. Usually you will see a brisk anal
contraction which indicates the sacral nerve pathways are
intact. Sometimes there is a weak response in health. The
absence of an anal wink, particularly in the setting of fecal incontinence, should make you suspicious that there
is a possible spinal cord problem, and this should direct
you to perform a more detailed neurological examination
and consider further investigations accordingly.
6. Start palpation: Place the tip of your gloved, index finger
gently over the anus. I ask the patient to breathe and try
to relax; this acts as a distraction. By slowly increasing
pressure with the pulp of the finger, the anal sphincter
usually relaxes slightly at which time the finger can be
painlessly advanced into the rectum. If there is excruciating pain on starting the examination, this strongly
suggests that there is an anal fissure in which case the remainder of the rectal examination should be abandoned.
Often the fissure can be seen on inspection; an anal fissure
can precipitate constipation but may be secondary to constipation itself. By liberally lubricating the rectum with
lidocaine jelly, it may still be possible to complete the rest
of the examination, but usually I perform anoscopy under appropriate sedation in this setting. Other causes of
significant anal pain during palpation include recently
thrombosed external hemorrhoids, an ischiorectal abscess, active proctitis, or anal ulceration from another
cause.
7. Assess resting sphincter tone: As you are moving your
finger through the rectum initially, you can gauge resting tone, which is predominantly (7080%) attributable
to the internal anal sphincter muscle (Fig.1). This should
alert you to the presence of reduced sphincter tone, which
may indicate a sphincter tear. A high anal resting tone
1. Reassure the patient: Explain what you are about to do

and why.
2. Position: Ask the patient to lie in the left lateral position. Having the patient stand to do the rectal examination, in the bent over position, may help provide good
information on the prostate, but will obscure some key
information for gastroenterologists.
3. Inspection: Look at the perineum by spreading the buttocks after donning a pair of gloves. Abnormalities such
as thrombosed external hemorrhoids, skin tags, rectal
prolapse, an obvious fissure, anal warts, or evidence of
pruritus ani usually from fecal soiling should be easily
appreciated. The presence of a scar at the anus correlates
with lower incremental anorectal squeeze pressures (2).
You wont see anything if you dont look.
4. Ask the patient to strain: Watch the perineum. You may
see leakage of stool, or the presence of a patulous anus.
820
Rectal Examination in Gastroenterology
Figure 1. The normal pelvic floor at rest during rectal examination. The internal anal sphincter muscle is normally hidden by
the external anal sphincter muscles and the puborectalis in the
lateral view portrayed; the insert demonstrates the internal anal
sphincter.
may be contributing to difficulties with evacuation. There

appears to be a good correlation between absent, decreased, and normal resting and squeeze pressures with
anorectal manometry (2).
8. Palpate the rectal walls: The anterior wall is palpated for
the prostate gland in men and the cervix in women. While
just examining the prostate is not an adequate screen
for prostate cancer, I believe we have an obligation to
identify obvious abnormalities and refer these patients
if indicated. The presence of a mass above the prostate
or cervix may be a sign of a metastasis (on Blumers
shelf). Rotate the finger clockwise so the lateral walls
and posterior walls can be palpated in turn, then advance
the finger high into the rectum and slowly withdraw it
along the wall; this approach will help identify lesions
such as polyps or rectal cancer if they are large enough
and in reach. Determine if there may be a rectocele or
intussusception. Rotate your examining finger anteriorly.
You may feel a defect in the anterior wall of the rectum
which suggests a large anterior rectocele.
9. The pelvic floorspecial tests for pelvic floor dysfunction: The first test is simple: ask the patient to strain and
try to push out your finger. Normally, the anal sphincter
and puborectalis should relax and the perineum should
descend by 13.5 cm. If the muscles seem to tighten, particularly when there is no perineal descent, this suggests
paradoxical external anal sphincter and puborectalis contraction, which in fact are blocking normal defecation
(pelvic floor dyssynergia). Perineal descent assessed by
examination correlates with descent assessed by dynamic
MRI (3). Second, note if palpation produces pain when
pressing on the posterior rectal wall; this suggests puborectalis muscle tenderness, which can also occur in
pelvic floor dyssynergia. Third, assess whether the anal
sphincter and the puborectalis contract when you ask
821
your patient to contract or squeeze the pelvic floor muscles. Puborectalis contraction is perceived as a lift, that
is, the muscle lifts the examining finger toward the umbilicus. Many patients with fecal incontinence cannot
augment anal pressure when asked to squeeze. Finally,
place your other hand on the anterior abdominal wall
while asking the patient to strain again. This provides
some information on whether the patient is excessively
contracting the abdominal wall (e.g., by doing an inappropriate Valsalva maneuver) and perhaps also the pelvic
floor muscles while attempting to defecate, which may
impede evacuation. However, the exact value of this test
is unclear.
In 100 patients presenting to a tertiary care center for
evaluation of constipation, the rectal examination had an
impressive sensitivity of 81% for identifying dyssynergia using anorectal manometry as the gold standard (4).
Pelvic floor dysfunction causing constipation responds
to biofeedback in about 70% of cases, and this treatment
can result in a laxative-free existence for patients with
troubling outlet constipation (5); the diagnosis should
be entertained in all patients with chronic constipation
presenting to gastroenterologists, and a good rectal examination can help guide you as to whether anorectal
manometry testing is warranted.
10. Finishing up: Remove the finger and inspect for obvious
blood, mucus or pus, and note the feces color. I do not
perform guaiac testing; it is often misleading (6). If there
is persistent gaping of the anal canal after withdrawal,
this suggests there may be an external anal sphincter or
neurological defect.
Perhaps the issues surrounding rectal examinations and
physician reluctance really have not changed. In the last century William Mayo said, The examining physician often hesitates to make the necessary examination because it involves
soiling the finger. The only valid reasons why a gastroenterologist should fail to perform a proper rectal examination
as part of the clinical evaluation in 2008 are (a) the gastroenterologist has lost all of his or her fingers or (b) the
patient is acutely ill and therefore there is a clear cut temporary contraindication. Your physical examination is usually
incomplete without performing the rectal!
Reprint requests and correspondence: Nicholas J. Talley, M.D.,
Ph.D., Mayo Clinic College of Medicine, Jacksonville, Florida, 4500
San Pablo Rd, Jacksonville, FL 32224.
REFERENCES
1. Talley NJ, OConnor S. Clinical examination: A systematic
guide to physical diagnosis, 5th edition. Sydney: Churchill
Livingstone: Elsevier, 2006 1601.
2. Dobben AC, Terra MP, Deutekom M, et al. Anal inspection and digital rectal examination compared to anorectal physiology tests and endoanal ultrasonography in evaluating fecal incontinence. Int J Colorectal Dis 2007;22:
78390.
822
Talley
3. Bharucha AE, Fletcher JG, Seide B, et al. Phenotypic variation in functional disorders of defecation. Gastroenterology
2005;128:1199210.
4. Rao P, Tantiphlachiva K, Attaluri A, et al. How useful is the
rectal examination in the diagnosis of dyssynergia? Am J
Gastroenterol 2007;102:S268.
5. Rao SS, Seaton K, Miller M, et al. Randomized controlled
trial of biofeedback, sham feedback, and standard therapy for dyssynergic defecation. Clin Gastroenterol Hepatol
2007;5:3318.
6. Longstreth GF. Checking for the occult with a finger. A procedure of little value. J Clin Gastroenterol 1988;10:1334.
CONFLICT OF INTEREST
Guarantor of the article: Nicholas J. Talley, M.D., Ph.D.
Specific author contributions: N/A.
Financial support: None.
Potential competing interests: None.

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American Journal of Gastroenterology

THE EXPERTS CORNER

How to Do and Interpret a Rectal Examination

How to do a useful rectal examination may be becoming a

A gaping anus often indicates lower resting pressures on

1. Reassure the patient: Explain what you are about to do

Rectal Examination in Gastroenterology

may be contributing to difficulties with evacuation. There

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