A 47-year-old female presented with a one-year history of rectal bleeding. Examination revealed a low rectal ulcer involving half the rectal circumference, from which fresh blood was observed. She was initially treated for hemorrhoids and dysentery without success. A colonoscopy was reported as normal except for internal hemorrhoids. Upon further examination, Dr. Al-Gailani discovered a rectal carcinoma. The patient was advised to undergo a biopsy of the rectal ulcer and staging scans before considering an abdomino-perineal resection of the rectum. The case highlights the importance of performing a thorough physical examination, including a digital rectal exam, for any patient presenting with rectal bleeding,

1. Back to Basics! PR Exam
DR. MOHAMAD AL-GAILANI FRCS
CONSULTANT SURGEON
MEDICAL EDUCATION & TRAINING DIRECTOR
SUWAIDI
RIYADH, KSA
MAY 2017

2. The Case of a 47 Year Old Female
 A 47 year old female patient presented with a One Year history of
Per Rectal (PR) bleeding.
 Bowels open 1-3 times per day, no constipation.
 No family history of bowel problems.
 Fit otherwise.
 Treated herself as a case of Haemorrhoids with no benefit.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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3. 47 Year Old Female:
Progress
 Treated initially as a case of Dysentery with no benefit.
 Seen by a surgeon (in another hospital), who then ordered a
Colonoscopy.
 The colonoscopy was reported as normal apart from internal
Haemorrhoids.
 Advised to have Haemorrhoidectomy.
 Presented to my clinic requesting that.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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4. 47 Year Old Female:
Clinical Examination
 Middle aged Female of Average Build.
 Pale.
 Abdomen: No Masses, No Organomegaly.
 No inguinal lymph Nodes.
 PR: Low Rectal Ulcer, Hard to Touch.
 Ulcer involving Ant wall extending nearly to half the
Rectal circumference.
 Fresh Blood on tip of the Finger
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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5. Diagnosis:
Rectal Carcinoma
 Advised to undergo Urgent:
1. Proctoscopy & Rectal ulcer Biopsy
2. Staging CT: Chest, Abdomen & Pelvis
3. Consider Abdomino-Perineal Resection Rectum
(APR)
 Patient requested time to first discuss with family.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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6. Bleeding PR & PR exam
 Patient had 1 year of bleeding per rectum assumed to
be piles!
 Did not seek any medical attention until recently!
 According to her, None of the doctors she saw did a
PR exam!
 A Colonoscope inserted without a prior PR exam could
bypass the rectum & miss low rectal pathology!
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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7. PR exam
Diagnosis & Assessment of:
 Hemorrhoids
 Anal Fissure
 Anal Fistulae
 Anal and Rectal cancers
 Anal condylomata
 Perianal Abscess
 Faecal incontinence
 Constipation
 Faecal Impaction
 Pruritus Ani
 Perianal Eczema
 Prostatitis
 Prostate cancer
 Benign prostatic hyperplasia
 Inflammatory bowel disease
 Neurologic deficits
 Acute Appendicitis
 Pelvic Tumours
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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8. PR exam:
Position & Technique
 Left lateral, both knees drawn towards abdomen.
 Feet pointing away from examiner.
 KY jelly gloved index finger pulp rests on anus.
 Once sphincter relaxes, finger inserted.
 On withdrawal, look for any blood on tip of finger.
DR. MOHAMAD AL-GAILANI Back to Basics! PR exam May
2017
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9. PR Exam: Procedure
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1 32
4 5 6
Preparation Part Buttocks & Inspect Apply KY Jelly
Rest Finger Pulp on Anus
Gently
Insert Finger & Examine Inspect Finger Tip for Blood

10. PR exam:
At the End, Don’t Forget To Clean Up!
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2017
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11. PR Bleeding:
Essentials
 Never assume PR bleeding is due to Haemorrhoids, especially above
the age of 40 years!
 For cases of Bleeding PR always do:
1. PR exam
2. Proctoscopy
3. Rigid sigmoidoscopy
 Arrange for Flexible Sigmoidoscopy if you suspect Proximal Pathology.
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2017
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12. Take Home Message
 PR exam is an Integral part of the Abdominal
Examination.
 PR exam MUST be done for PR Bleeding
 All Haemorrhoids bleed, but not all PR bleeds are
Haemorrhoids!
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2017
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13. Finally…
“The only reason why a PR
exam is not done is if the patient
has no rectum or the doctor has
no finger!”
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2017
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Dr. Mohamad Al-Gailani FRCS ‫د‬.‫الكيالني‬ ‫محمد‬
Consultant Surgeon
Medical Education & Training Director
SUWAIDI
www.alhammadihospital.com
RIYADH, KSA
Tel: +966 11 4250000