This document outlines the steps for performing a digital ano-rectal examination, including obtaining consent, positioning the patient, inspecting the anus and perianal region, palpating the anal canal, rectum, prostate, and pelvic structures, and completing the examination. Key steps involve inspecting for abnormalities, palpating the rectal walls and structures to evaluate for masses, tenderness, size, mobility, and consistency. Findings are noted that may indicate conditions like hemorrhoids, fistula, ulcerations, prostate enlargement, or masses.

1. Digital Ano-Rectal Examination
Step-I: Consent, Exposure, position & Equipment.
Step-II: Inspection
Step-III: Palpation
Step-IV: Completion
Step-I: Consent, Exposure, Position & Equipment.
o Tell the patient what to do.
o The patient should give clear consent.
o Offer a chaperone, and record if this is refused.
o Ensure adequate privacy and uncover the patient from the waist to mid-thighs.
o Left lateral decubitus position.
o With buttock at the edge of the couch, & the neck and Shoulder rounded so that the
chin rest on the chest.
o Hip flexed ≥ 90o
, and the knees flexed slightly < 90o
.
o Hells should be clear of the perineum.
o Plastic glove, some inert lubricating jelly and a good light.
Step-II: Inspection
o Lift the upper buttock with your left hand and inspect.
anus, perianal skin and perineum.
o Look for:
 Skin – (Rashes and excoriation).
 Discharge – (blood, mucus, fecal soiling).
 Lumps and bumps – (piles, prolapse, polyps, papilloma, perianal hematoma,
condylomas, or carcinoma).
 Any lesions – (Fissure, Fistula, Ulcer).
o Ask for:
 Cough – (causes normal anal sphincter to contract).
 Bear down, as it to openthebowl – (a test for Rectal prolapse and prolapsed piles).
Step-III: Palpation
o Adequately lubricate your finger with water-based gel.
o Ask the patient to strain and place the pulp of finger against the anus.

2. o Ask the sphincter relaxes, gently insert your finger into anal canal but at the same tie
press against the posterior wall of the anal canal & the underlying sling of puborectalis
muscle. This will overcome the tone and slip your finger in to rectum.
o The direction of advancing finger should be toward umbilicus.
o Ask the patient to relax and take deep breath, this will also relax sphincter.
o The Anal canal:
 Notes the tone of the sphincter – ask the patient to squeeze your finger.
 Note any tenderness, thickening or masses.
o The Rectum:
 Feel the rectum as high as possible.
 Rotate your finger clockwise to palpate the rectal surface on the right
side.
 Then, counterclockwise to palpate the surface posteriorly and on the left
side.
 If a mass found, then note:
 Distance from anal verge.
 The rectal circumference involved.
 Mobility of mass – (mobile or fixed to other structure e.g.
the sacrum).
 Mobility of mucosa over the mass:
 Mobile – mass is outside the wall.
 Immobile – mass is within the wall.
 Mass is ulcerated or a polyp.
 Note the Contents of the rectum:
 Full of feces (soft in normal or Hard & packed in Fecal impaction).
 Empty and collapsed – (normal).
 Empty but ballooned out – (Large bowel Obstruction).
 If the rectal abnormality is at the tip of your finger, ask patient to bear
down, this will move the mass down 1-2 cm.
o Prostate and seminal vesical:
 Palpate the prostate via the rectal wall, Note:
 Surface – (smooth in normal & BPH or Irregular in malignant).
 Symmetry – (symmetrical in normal or Asymmetrical in BPH &
malignant).
 Size – (normal 2-3 across or Large in BPH or Lateral extension in
malignant).
 Consistency (firm/rubbery in normal & BPH or Hard in malignant).
 Median sulcus – (shallow central in normal & BPH or Obliterated in
Malignant).

3.  Rectal Mucosa – (freely Mobile over prostate in normal & BPH or
Fixed in malignant).
 Lobes – (Bi-lobed in normal or Nodular/bosselated in BPH or
malignancy).
 If possible, extend the finger above the prostate to palpate the seminal
vesicles (not usually palpated, unless diseased).
o Cervix & Uterus:
 These structure can be felt per rectum.
 Once palpated, define the shape and size of uterus and any adnexal
masses.
o The Recto-vesical/Recto-uterine pouch:
 Turn the finger anteriorly to detect any masses outside rectum in
peritoneal pouch between the rectum and the Bladder (in male) or
vagina (in females).
 Note if the mass is:
 Tender and boggy – (pelvic abscesses).
 Hard and craggy – (malignant pelvic deposits).
o Bimanual examination:
 Examination of pelvis can be helped.
 Feel bimanually with your left hand on the abdomen and right index
finger in the rectum.
 If a mass I felt, note size, shape and nature of mass.
Step-IV: Completion of the examination:
o On completion of the exam, gently withdraw your finger.
o Always inspect the glove for the color of stool and presence of blood or mucus.
o Test the stool for occult blood (if indicated).
o Gently clean the area with a gauze.
o Thank the patient.