PR exam

Rectal examination is an important part of the abdominal examination and genitourinary examination. It is important in examining for gastrointestinal disease but also for the detection of disease in other pelvic organs. It is an intimate physical examination which should be conducted correctly for detection of disease and patient comfort. Findings should be accurately and correctly recorded.

Anatomical considerations:
  • The rectum is the curved lower, terminal segment of large bowel.
  • It is about 12 cms long and runs along the concavity of the sacrum.
  • The upper 2/3 of the anterior rectum is covered by peritoneum but the posterior rectum is not.
  • In men, the anterior rectal peritoneum reflects on to the surface of the bladder base.
  • In women, the anterior rectal peritoneum forms the rectouterine pouch (the pouch of Douglas). The pouch of Douglas is filled with loops of bowel.
Anterior to the lower 1/3 of the rectum lie different structures in men and women:
  • In men, anterior to the lower 1/3 of the rectum lie the prostate, bladder base and seminal vesicles.
  • In women, anterior to the lower 1/3 of the rectum lies the vagina. At the tip of the examining finger it may be possible to feel cervix and even a retroverted uterus.
  • The anus is 3-4 cms long and joins the rectum to the perineum.
  • The wall of the anus and anal canal is supported by powerful sphincter muscles..

These muscles are made up of:

  • Voluntary external sphincter muscles.
  • Involuntary internal sphincter muscles.

These muscles are essential in the mechanism of defaecation and the maintainance of continence.

Indications for rectal examination

This is an intimate and sometimes uncomfortable examination which is most often done when disease (usually gastrointestinal or genitourinary disease) is suspected or already identified. It may also be done as part of a screening examination when there is no suspicion or expectation of disease but the examination is performed as part of a thorough screening process. It is important in all cases to explain the reasons for the examination (see below) and to get verbal consent.

Examples of indications for examination include:
  • Assessment of the prostate (particularly symptoms of outflow obstruction).
  • When there has been rectal bleeding (prior to proctoscopy, sigmoidoscopy andcolonoscopy).
  • Constipation.
  • Change of bowel habit.
  • Problems with urinary or faecal continence.
  • In exceptional circumstances to detect uterus and cervix (when vaginal examination is not possible).
Preparing for the examination
  • The reasons for performing the procedure should be explained to the patient.
  • The procedure itself should be explained to the patient. Warn patients that:
  • The examination may be uncomfortable but should not be painful.
  • They may experience a feeling of rectal fullness and the desire to defaecate.
  • A chaperone should be offered.
Equipment:
  • Suitable gloves
  • Lubricant
  • Lighting
  • Suitable soft tissues.
  • Position the patient comfortably, as below.

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