Digital Rectal Examination Guidelines

Pre-Examination Steps

Ensure adequate lighting and have the patient empty their bladder if evaluating for urinary retention, as recommended by the American Gastroenterological Association 1

Separate the buttocks and observe the perianal area for fecal soiling, skin excoriation, hemorrhoids, fissures, or fistulas, as suggested by the American Gastroenterological Association 2
Observe perineal descent during simulated defecation, with normal descent being 1-3 cm, and excessive descent (>3 cm) suggesting pelvic floor dysfunction, according to the American Gastroenterological Association 2
Check for anal patulous opening during straining, which may indicate neurogenic dysfunction, or observe for mucosal prolapse, as recommended by the American Gastroenterological Association 2
Test the anal reflex by light scratch or pinprick of perianal skin, with absence suggesting neurologic pathology, as suggested by the American Gastroenterological Association 2

Assess resting anal sphincter tone immediately upon insertion, noting if tone is normal, increased, or decreased, as recommended by the American Gastroenterological Association 2
Evaluate squeeze pressure by asking the patient to squeeze, assessing the strength and duration of contraction of both internal sphincter and puborectalis muscle, according to the American Gastroenterological Association 2
Palpate the puborectalis muscle posteriorly, with acute tenderness suggesting levator ani syndrome, as suggested by the American Gastroenterological Association 2

Sweep the finger circumferentially to examine all quadrants of the rectal wall, up to the examining finger's length (approximately 8-10 cm), as recommended by the British Society of Gastroenterology 3
Palpate for masses, polyps, strictures, or areas of induration, with DRE being sensitive for detecting abnormalities in the lower rectum and upper anal canal, according to the British Society of Gastroenterology 3, 4

Palpate the prostate anteriorly through the anterior rectal wall, assessing size, symmetry of both lobes, consistency, and presence of nodules or induration, as recommended by the American Urological Association 5, 1
Evaluate for asymmetry, firmness, or nodularity that may suggest prostate cancer, with DRE being performed by clinicians skilled in detecting subtle abnormalities, according to the American Urological Association 5
Note that DRE tends to underestimate prostate size, and if the prostate feels large on DRE, it is usually significantly enlarged on ultrasound, as suggested by the American Urological Association 5
DRE should not be used as a stand-alone screening test but should be combined with PSA measurement for prostate cancer screening, as recommended by the American Urological Association 5

Instruct the patient to push out the finger as if having a bowel movement to assess the coordination of defecatory effort, as suggested by the American Gastroenterological Association 2

Document findings systematically, including sphincter tone, masses, tenderness, prostate characteristics, stool characteristics, and any abnormalities detected, as recommended by the British Society of Gastroenterology 3, 4

When DRE is performed as part of colonoscopy preparation, it should be recorded in 100% of cases, whether performed or omitted, as recommended by the British Society of Gastroenterology 3, 4, 6
DRE serves dual purposes: preparing the anal canal for scope insertion and examining for pathology that may be missed by endoscopy alone, according to the British Society of Gastroenterology 3, 4

Prostate assessment should begin at age 50 for average-risk men, age 45 for African Americans or those with family history, as recommended by the American Cancer Society 7, 5
Pre-colonoscopy assessment is recommended as standard practice before lower GI endoscopy, as suggested by the British Society of Gastroenterology 3, 4, 8