Digital Rectal Examination

Preparation and Technique

A thorough digital rectal examination (DRE) should include visual inspection of the perianal area, checking for fecal soiling, skin lesions, and anal reflex, as well as observing perineal descent during simulated evacuation, with documentation of findings including sphincter tone, presence of masses or tenderness, presence of blood, and prostate findings in male patients, as recommended by the American Gastroenterological Association and European Society of Gastrointestinal Endoscopy with a strength of evidence level of high 1, 2
The left lateral position (lateral decubitus) with knees flexed toward the chest is considered the optimal position for performing a DRE, allowing for better examination of the entire circumference of the rectum, with a success rate of 79.5% compared to 66% in the dorsal position, as recommended by the American College of Gastroenterology and supported by the European Society of Gastrointestinal Endoscopy 1, 2
In cases of suspected anorectal foreign bodies, it is recommended to perform an abdominal X-ray before DRE to prevent accidental injury from sharp objects, as suggested by the World Journal of Emergency Surgery and medical experts 3

The digital examination should assess sphincter tone at rest and during squeeze, evaluate puborectalis muscle contraction, check for tenderness along puborectalis, and ask the patient to "expel your finger" to assess expulsionary forces, as well as check for masses or tenderness, presence of blood, and prostate findings in male patients, with a level of evidence of moderate, as outlined in the guidelines from the American Society of Colon and Rectal Surgeons and European Association for Gastroenterology, Endoscopy and Nutrition 1, 2
The examination should also include observation of the perianal area for evidence of fecal soiling, skin lesions or abnormalities, and anal reflex, as well as assessment of pelvic floor motion during simulated evacuation, and evaluation for masses or abnormalities, presence of stool and its consistency, and presence of blood 1

A normal DRE does not exclude defecatory disorders, and DRE is sensitive for detecting abnormalities in the lower rectum and upper anal canal, with a sensitivity of 90%, as recommended by the American Society for Gastrointestinal Endoscopy and supported by the American Gastroenterological Association 1, 2
The performance or omission of rectal examination should be recorded in 100% of cases, and findings should be documented including sphincter tone, presence of masses or tenderness, presence of blood, and prostate findings in male patients, with a careful DRE that includes assessment of pelvic floor motion during simulated evacuation being preferable to a cursory examination 1, 2