The document provides guidance on performing a digital rectal examination (DRE). It outlines the objectives, equipment needed, definitions, indications, contraindications, and steps to perform the examination. The key steps include obtaining consent, positioning the patient, inspecting the anal area, palpating the rectum and prostate, and documenting any abnormalities. DRE is an important clinical skill used to assess conditions like prostate cancer, hemorrhoids, and inflammatory bowel disease.

1. Prostrate Examination
Dr Shamshad
Majmaah Medical College
KSA

2. Objectives
1. Identify the common indications for digital rectal examination
(DRE).
2. Identify the correct steps of digital rectal examination e. g
(obtaining consent, explaining the procedure to the patient
and correct positioning).
3. Apply correct technique of digital rectal examination.
4. Detect common abnormalities of prostate.
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S no. Equipments/ instruments required for the skills
1. Hand sanitizer
3. Prostate manikin
5. Disposable gloves
6. Xylocain Lubricant ,Betadine lotion, sponge holder
7. Cotton gauge, green hole towel,
8. Good exposure of light (Lamp)

4. Definition: Digital Rectal Examination [DRE]
The medical expert performs a physical examination by
inserting a gloved index finger into an anal orifice to assess
anal/rectal/ prostatic pathology, or anal sphincter tone.
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Anoscopy
Examination of anal canal using a small ,Rigid , tubular
instrument called anoscope or anal speculum.
Proctoscopy
Examination of anal cavity, rectum, sigmoid colon or
prostrate using a short, straight, rigid, hollow tube, with a small light
bulb mounted at the end called proctoscope . Approx. 5 inches long.

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Anoscope Proctoscope
10 cms size 13 cms size

6. Indication of Digital Rectal Examination [DRE]
 Hemorrhoids, altered bowel habits, Neurologic deficits
 [Male] Prostatitis, Prostate cancer, Benign prostatic hyperplasia
Anal and rectal cancers or bleeding, Anal condyloma, Fecal
incontinence, Anal fissures,
 Inflammatory bowel disease, : Ulcerative colitis & Crohn disease
 Urinary symptoms
 American Urological Association (AUA): DRE is indicated for
all men, starting at age 40, for a baseline determination of
prostate status.
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7. Contraindication of Digital Rectal Examination [DRE]
 Imperforate Anus
 Immunocompromised patient
 Anal Stricture
 Severe to moderate anal pain
 Prolapsed thrombosed internal hemorrhoids
 Post-abdomino-perineal resection /Post-operative anal
surgeries
 Recent acute MI
 Acute abdominal pain
 Unwilling patients
 Major rectal trauma
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8. Digital Rectal Examination [DRE]
1. Inspection
2. Palpation .
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9. Initial etiquettes
1. Wash your hands, wear gloves, introduce yourself to the
patient and clarify their identity.
2. Explain the procedure and post examination complication
3. Prepare the patient to tolerate slight discomfort or pain.
4. Arrange for a chaperone MUST during examination.
5. Obtain consent. Reassure the patient about privacy
6. Arrange for good light exposure .
7. Expose the part to be examined.[Do not over or under expose]
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10. Positioning of the patient
1. Ask them to lie on their left hand side
2. With hips flexed to 900, knees less flexed to 1100.
3. With their knees drawn up towards their chest,
4. Feet pushed forwards and their anus exposed. Buttocks at
edge of the examination table
5. Scrub the anal part with povidine solution and then with
alcohol swab.
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Examination of anus and perineum region
 Describe the abnormalities
including skin tags,
hemorrhoids and fissures, fecal
matter fresh bleeding,,,, etc
 Anterior aspect as 12 &
posterior as 6 o clock position
as shown in figure.

12. Inspection of anus and perineum region
 Separate the buttocks and inspect the area around the anus.
 Look for any abnormalities including skin tags, hemorrhoids
and fissures, fecal matter fresh bleeding,,,, etc…
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13. …Inspection of anus and perineum region
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Ask the patient to cough and inspect for:
 Rectal prolapse: A mass with concentric rings of mucosa
will be visible protruding through the anus.
 Internal haemorrhoids: Bluish, bulging vessels covered
by mucosa become visible when the patient coughs.

14. Palpation
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1. Lubricate your gloved index finger with Xylocaine ointment .
2. Inform the patient you are about to start the procedure.
3. Place your pulp of your finger posterior anal verge so that it
points anteriorly
4. Apply pressure to the midline of the anus..

15. ..Palpation
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5. As you insert your finger, pull backwards to counteract the tone
in the puborectalis muscle.
6. Maintain the pressure so that your finger enters the rectum.
7. Initially you need to assess anal tone by asking the patient to
squeeze your finger.

16. ….Palpation
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8. Avoid force .Wait for the sphincter to relax.
9. If still difficult do not continue with the
examination.
10. Rotate your finger 360 degrees to assess
the entirety of the rectum:
This is done by sweeping the finger both
clockwise and anti-clockwise around the
entire circumference.
Feel for any abnormalities such as impacted
faeces, masses or ulcers..
Sweep clockwise
Sweep anti-clockwise

17. ….Palpation
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Note:
 The size, location (e.g. 9 o’clock) and texture (e.g. smooth,
irregular) of any rectal lumps (e.g. tumour, polyp, internal
haemorrhoids).
 Feel for any hard stool present in the rectum.
 Any tenderness, indicate an anal fissure or thrombosed internal
haemorrhoids.

18. ….Palpation
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11. In males assess the prostate gland. This lies anteriorly and
feel for it.
Check the size, symmetry , texture , consistency & presence of
the midline groove.
A normal prostate is approximately walnut-sized with a palpable
midline sulcus.
It is symmetrical and its consistency similar to that of the tip of
the nose.

19. ….Palpation
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12. Anal tone assessment
Assess anal tone by asking the patient to bear down on your
finger.
Causes of reduced anal tone include spinal cord pathology (e.g.
cauda equina syndrome), inflammatory bowel disease and
previous rectal surgery.

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The Digital Rectal Examination Scoring System (DRESS)
Resting Score for anal tone
0 No discernable tone at rest, an open or patulous anal canal
1 Very low tone
2 Mildly decreased tone
3 Normal
4 Elevated tone, snug
5 Very high tone, a tight anal canal, difficult to insert a finger .
Squeeze Score
0 No discernable increase in tone with squeezing effort
1 Slight increase 2 Fair increase but below normal 3 Normal
2 Fair increase but below normal
3 Normal
4 Strong squeeze
5 Very strong squeeze, to the point of being painful to the examiner

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The Digital Rectal Examination Scoring System (DRESS)
interpretation
The system utilizes an analog scale of 0 to 5
Anal tone :
A score of 3  Normal
A score of 5  Very high pressures & tight anal canal
A score of 0  An open or patulous anal canal at rest with
separation of the buttocks.
Squeeze score :
A score of 5 Very strong squeeze, almost painful to examiner
A score of 0 No discernable increase in pressure from rest with
maximal patient effort.

22. ….Palpation
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13. After examining the anal canal and rectum. Place your other
hand on the abdomen and examine the contents of the pelvis
bimanually.

23. Final steps
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1. Withdraw your finger and inspect for blood or mucous and
colour of any faeces stains
Interpretation :
 Dark sticky blood [melena] up. GI bleeding (stomach ulcer).
 Fresh red blood low. GI bleeding (rectal malignancy, fissure).
 Excess mucous  inflammatory bowel disease (ulcerative
colitis).

24. ..Final steps
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2. Clean the patient using paper towels.
3. Remove and dispose your gloves along with used disposable
equipments in the clinical waste bin.
4. Cover the patient with the sheet, inform that procedure is
complete and Allow the patient to dress in privacy.
5. Thank the patient.
6. Wash your hands and report your findings to the examiner.

25. Reference:
1.http://www.osceskills.com/e-learning/subjects/rectal examination/#sthash.yG3uvPXH.dpuf
2.Oxford Handbook of Clinical Examination and Practical Skills, by Vishal, 1st edition (2007).
3. http://www.uptodate.com.
4. Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice, 22nd edition
(2007), by Michael Glynn and William M Drake.
5: The digital rectal examination scoring system (DRESS) December 2010Diseases of the Colon
& Rectum 53(12):1656-60 DOI: 10.1007/DCR.0b013e3181f23c85
SourcePubMed Bruce OrkinBruce OrkinSvetlana B SinykinPatricia C Lloyd
6: Figure from internet .
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26. 10/1/2022 26
Equipments/ instruments required for the skills
Hand sanitizer, Prostate manikin ,Disposable gloves ,Lubricant ,Betadine lotion, sponge holder
Cotton gauge, green hole towel.
Introduce yourself. Confidentiality and respect patient privacy.
Try to see from patient point of view. Listening
Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and
summarizing.
Always record personal details: name, age, address, sex, ethnicity, occupation, religion, Marital
status.
Record date of examination
1. Wash your hands, introduce yourself to the patient and clarify their identity. Explain what
you would like to do and obtain consent. This is a slightly uncomfortable procedure so you
should warn the patient of this. A chaperone is required for this examination.
2. Positioning of the patient in this procedure is very important. Ask them to lie on their left
hand side with their knees drawn up towards their chest, their feet pushed forwards and
their anus exposed.
3. Having washed your hands and put on your gloves, separate the buttocks and inspect the
area around the anus. Look for any abnormalities including skin tags, haemorrhoids and
fissures.
4. After inspecting, lubricate your right index finger.
5. Tell the patient you are about to start the procedure. Place your finger on the anus so that it
points anteriorly and apply pressure to the midline of the anus.
Examination Prostrate by DRE

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6. Maintain the pressure so that your finger enters the rectum. Initially you need to assess
anal tone by asking the patient to squeeze your finger
7. Next you need to systematically examine each part of the rectum. This is done by
sweeping the finger both clockwise and anti-clockwise around the entire circumference.
8. You should be feeling for any abnormalities such as impacted faeces, masses or ulcers.
9. One of the main reasons for performing a rectal examination in males is to assess the
prostate gland. This lies anteriorly and should always be felt. You should check the size,
consistency and presence of the midline groove.
10. Remove your finger and examine the glove for the colour of any faeces as well as the
presence of any mucus or blood.
11. Clean off any lubricant left around the anus and remove and dispose of your gloves in
the clinical waste bin.
12. Allow the patient to dress and thank them.
13. Wash your hands and report your findings to the examiner.
Rectal (PR) examinations are performed for a number of clinical reasons e.g. altered bowel
habit, rectal bleeding, urinary symptoms and is a skill surgeons perform on all patients and it is
an important skill to know