Digital Rectal Examination

Indications:

1. Assessment of perianal disease.

2. Assessment of rectal bleeding and masses PR.

3. Assess red flags for colorectal cancers.

4. Assess for faecal impaction.

5. Assessment of a male patient with lower urinary tract symptoms.

6. Assessment of the prostate for benign prostatic enlargement, prostatitis and cancer.

7. A DRE is always done before a transurethral resection of the bladder/prostate (TURBT / TURP).

Procedure:

1. Counsel the patient - explain the position (sim’s position) and that it will be slightly uncomfortable. Explain that lubricating jelly will be used, and you will be as quick as possible.

2. Chaperone - always ask the patient if he/she would like a chaperone and document this clearly.

3. Sims' position - with the patient exposed from below the waist, ask them to turn into the left lateral position and draw the right knee towards their chest while keeping the left lower limb extended.

4. Don non-sterile gloves, and ensure that there is good lighting.

5. Assess the anus and perianal region for fissures/haemorrhoids/fistulas/scars/lumps. Patients with an anal fissure will never tolerate a DRE and may be regarded as a contraindication to the same.

6. Lubricate the index finger and insert it gently with the pulp of your finger facing backwards. This assesses the posterior aspect of the rectum.

7. Rotate the finger, assessing all walls of the rectum, and finally feeling the prostate, which lies anteriorly.

8. Remove the palpating finger and inspect the glove for blood.

9. Assess for anal tone by asking the patient to squeeze down on your finger, as well as perianal sensation, if there are concerns of cauda equina syndrome.

Prostate:

The normal prostate:

1. The size of a walnut.

2. Should not feel hard (typically feels like the soft tip of your nose).

3. Both lobes should be equally smooth.

4. A median sulcus (groove between both lobes) may be palpable.

5. Nontender and no boggy swelling appreciated, which are features of prostatitis and a prostate abscess, respectively.
   

-A useful, although unreliable method of estimating weight is with the fingerprint method - 1 fingerprint placed on the prostate is roughly equal to 10g. Experience in estimating prostate size is best gathered along the way, by collaborating your clinical findings with scans and discussions with your colleagues.
-DREs for the assessment of prostate volume often underestimate the prostate volume.

Red flags on DRE:

1. A hard/craggy prostate that feels irregular and bumpy

2. A rectal lump

3. Blood on the glove where colorectal cancer is suspected

Patients usually ask about how their prostate feels. If something sinister is suspected but you are unsure, it is always best to inform them that there may be something abnormal going on and that further investigation may be needed. It is also worth letting the patient know that your senior colleague may have a feel of the prostate as well.

Useful links:
Video on DRE - https://youtu.be/JXQrhIaEN4E?si=PsMpZ6MR2CKJHRlm

Images:
Thumbnail image - Used under the Creative Commons license. Akcmdu9 (https://commons.wikimedia.org/wiki/File:Normal-vs-enlarged-prostate.jpg), „Normal-vs-enlarged-prostate“, https://creativecommons.org/licenses/by-sa/3.0/legalcode