THE Red Section 1

see related editorial on page x

Rectal Exam: Yes, it can and should be done in

How I Approach It
a busy practice!
Satish S.C. Rao, MD, PhD, FRCP(LON), FACG, AGAF
Am J Gastroenterol https://doi.org/10.1038/s41395-018-0006-y

“Dr, I am constipated and feel tied to the bathroom” said Mrs.

Smith during an office consultation. “Let’s arrange a colonoscopy
to check your colon”, said her gastroenterologist. At follow-up,
“Mrs. Smith, good news, your colonoscopy is normal”. “But Dr, I
am very constipated”. “Well, I suggest you take polyethylene glycol
daily”. And that was it! 1 year later, she was referred to another
specialist, who performed a digital rectal examination (DRE),
whose findings (summarized below) changed the course of her
management.
Dyssynergic defecation, fecal incontinence (FI), and other ano-
rectal disorders are common problems that affect one third of the
US population [1]. DRE is a key component of physical examina-
tion [2, 3], but is rarely performed, except for perhaps a cursory
exam prior to colonoscopy [4]. This problem is further com-
pounded by a lack of knowledge on how to perform a comprehen-
sive DRE.
A survey of 256 final-year medical students revealed that 17%
had never performed a DRE, and 48% were unsure of their find-
ings [5]. Furthermore, in another survey of 652 faculty, fellows,
residents, and students, DRE was significantly underutilized [4].
While most students felt they were inadequately trained, most
physicians reported lack of confidence in performing DRE or mak-
ing a diagnosis [4]. The reasons for not performing DRE included
concerns such as “patient’s modesty”, “too invasive”, “limited value”,
“convenience”, and “gender/chaperone”. Thus, both training and
utilization of DRE remains a challenge [4–6], and underscores the
need for education and training at all levels. Training with man-
nequins significantly enhanced confidence for performing DRE
[7, 8].

DRE set-up
DRE requires a good light source to illuminate the perineum,
latex-free gloves, gauze, lubricating jelly, lidocaine jelly, Q-tip,
Fig. 1  a Digital rectal examination set-up showing the body position, bright
occult blood testing kit, and proctoscope (Fig.  1). Explain the
light source, and the basic equipment. b DRE equipment including latex-
procedure to allay any fears and anxiety. free gloves, lubricating and lidocaine gel, gauze swabs, Q-tip, occult blood
testing kit, and a lighted proctoscope

Division of Gastroenterology and Hepatology, Medical College of Georgia, Augusta University, Augusta, GA, USA.
Correspondence: S.S.R. (email: srao@augusta.edu)
Received 28 September 2017; revised 21 November 2017; accepted 11 December 2017

© 2018 the American college of Gastroenterology The American Journal of Gastroenterology

 2 THE Red Section

DRE methodology Assessment of perineal sensation and anocutaneous reflex

There are four basic steps (Table 1): (1) Inspection, (2) Assessment This is assessed with a cotton bud and by stroking the perianal
of anocutaneous reflex, (3) Digital palpation, and (4) Maneuvers skin towards the anus in each of four quadrants. Describe the
to assess anorectal function. findings as shown in Table  1. The anocutaneous reflex exam-
How I Approach It

Body position
The subject should lie in the left lateral position with hips flexed
to 90° (Fig. 1).
Inspection
Inspect the anus and surrounding tissue using bright light and
record findings as described in Table  1. Gently part the anal
mucosa to identify any anal fissure. If present, apply lidocaine gel
to facilitate finger insertion.
ines the integrity between the sensory nerves, S2, S3, S4 neurons
and motor innervation of anal sphincter. An impaired or absent
response suggests neuronal injury [9].
Digital palpation
A lubricated, gloved index finger is slowly advanced into the
rectum. Assess for any tenderness, spasm, mass, or stricture. If
present, note the amount and consistency of stool (Bristol stool
scale); lack of stool awareness suggests rectal hyposensitivity.
Hard, compacted stool indicates fecal impaction. In men, the

Table 1  Components of the digital rectal examination, technique, expected findings and grading of responses
Exam component Technique Findings and grading of response(s)

I. Inspection of the anus and
surrounding tissue
II. Testing of perineal sensation and
the anocutaneous reflex
III. Digital palpation
IV. Maneuvers to assess anorectal
function and dysfunction
  Resting tone
  Squeeze maneuver
  Sphincter defects
 Push and bearing down
maneuver
  Anorectal pain assessment
Place patient in the left lateral position with hips flexed to 90°.
Inspect perineum under good light
Stroke the skin around the anus in a centripetal fashion
(towards anus), in all four quadrants, by using a stick with a
cotton bud
Slowly advance a lubricated and gloved index finger into the
rectum and feel the mucosa and surrounding muscle, bone,
uterus, prostate, and pelvic structures
Assess strength of resting sphincter tone
Ask the patient to squeeze and hold as long as possible (up to
30 s)
Palpate anal sphincter muscle for defects during rest or
squeeze maneuver
In addition to the finger in the rectum, place the other hand
over the patients’ abdomen. Ask the patient to push and bear
down as if to defecate and assess changes in abdominal
muscle tightening, perineal descent and contraction or relaxa-
tion of anal sphincter and puborectalis
Palpate coccyx (bidigital) and palpate levator ani muscle in all
four quadrants
Skin excoriation, skin tags, anal fissure, scars or
external hemorrhoids, gaping anus, prolapsed
hemorrhoids or rectum, condyloma
Normal: brisk contraction of the perianal skin, the
anoderm and the external anal sphincter
Impaired: no response with the soft cotton bud, but
anal contractile response seen with the opposite
(wooden) end
Absent: no response with either end
Tenderness, mass, stricture, or stool and the consist-
ency of the stool (BSFS).
Examine prostate for nodules, mass, tenderness
Evaluate for retroverted uterus, rectocele
Normal, weak (decreased), or increased
Normal, weak (decreased), or increased
Describe as present or absent and degree of sphinc-
ter loss using a clock or in quadrants
(i) Abdominal push effort: normal, weak (decreased),
excessive
(ii) Anal relaxation: normal, impaired, paradoxical
contraction
(iii) Puborectalis relaxation: normal, impaired,
paradoxical contraction
(iv) Perineal descent: normal, excessive, absent
(v) Rectal mucosal intussusception/prolapse: pres-
ence or absence
Presence or absence of tenderness over coccyx and/
or levator ani muscle. If present, grade intensity on a
scale of 0–10, and whether sensation(s) experienced
at home is reproducible

The American Journal of Gastroenterology www.nature.com/ajg


Fig. 2  a A schematic illustrating the anatomical components of the DRE
examination in the resting state. b This schematic illustrates the abnormal
paradoxical contraction of the external anal sphincter and puborectalis
muscles with fingertip being displaced anteriorly during attempted defeca-
tion, suggesting dyssynergic defecation
prostate should be palpated and in women, a retroverted uterus
may be felt (Table 1).
Maneuvers to assess anorectal function
After insertion, the sphincter tone, length of anal canal, and
acuteness of anorectal angle are assessed (Fig. 2a). Next, the sub-
ject is asked to squeeze and hold for 30 s. The resting and squeeze
sphincter tone are categorized as normal, weak (decreased), or
increased (Table 1). Also, feel for any anal sphincter defect(s) and
describe its location (Table 1).
Next, assess the push effort. Place the left hand on the
patient’s abdomen and ask the subject to push and bear down as
if to defecate. The ability to generate a good push is assessed by
feeling the abdominal muscles, and anal sphincter and degree
of perineal descent by the finger in the rectum. Repeat once.
A normal response consists of abdominal muscle contraction
together with the anal sphincter and puborectalis relaxation
and perineal descent. The presence of two or more of the fol-
lowing findings suggests a diagnosis of dyssynergia: (i) the
inability to contract the abdominal muscles, (ii) inability to
relax the anal sphincter and/or puborectalis, (iii) paradoxical
contraction of the anal sphincter or puborectalis (Fig.  2b), or
(iv) absence of perineal descent. Also, during push, a bulge felt
at the tip of the finger suggests rectal mucosal intussusception
© 2018 the American college of Gastroenterology
THE Red Section 3
whereas an outward bulge that exceeds 3 cm suggests excessive
perineal descent [10].
Assessment for anorectal pain, and rectocele
How I Approach It
First, carefully palpate the puborectalis/levator ani muscle in each
of four quadrants, by gently stroking the muscle, and recording
the presence and intensity of pain/discomfort on a scale of 0–10.
Additionally, palpate the anterior and posterior rectal wall for
any rectal, vaginal wall or prostate tenderness. Next, advance the
finger posteriorly, above the puborectalis muscle and palpate the
coccyx, both internally with the right index finger and externally
with left index finger, i.e., perform bidigital palpation. If pain is
evoked during this maneuver it suggests coccygodynia. Finally,
rotate the finger and let it rest anteriorly, and ask the subject to
push or bear down. If the tip of the finger dips into an indentation
of the rectal wall, a rectocele is present.
How useful is digital rectal examination?
The accuracy of DRE in FI patients has been assessed in several
studies; both adequate correlation for resting and squeeze tone
[11, 12] and poor correlation [13–15] has been reported. A DRE-
scoring system has been proposed using a scale of 0–5 with good
correlation with anorectal manometry [16]. One study compared
sphincter defects between DRE and ultrasound, with good corre-
lation for large defects (150–270°), and poor correlation (for those
<90° [17], while another found good sensitivity (90%) but poor
specificity (28%) [18]. Finally, trainees seem to lack DRE skills
for recognizing sphincter tone in FI despite coaching, suggesting
need for long-term mentorship [19].
Thus, DRE is less reliable in FI, prone to inter-observer differ-
ences and may be influenced by the size of the examiner’s finger,
technique, experience, and the patient’s cooperation. Recent stud-
ies show improved correlations when performed by single or well-
trained examiners [16, 20].
In contrast, a prospective study showed that the sensitiv-
ity and specificity of DRE for identifying dyssynergia when
compared to anorectal manometry were 75 and 87%, respec-
tively, and the positive predictive value was 97% [21]; findings
confirmed by another study [15]. With regards to rectocele,
moderate agreement was found for DRE when compared to
imaging [22]. Thus, DRE is a reliable bedside tool for identify-
ing dyssynergia, and for selecting patients for physiologic test-
ing [15–17, 21].
DRE done by Mrs. Smith revealed normal anocutaneous reflex,
increased sphincter tone, and paradoxical anal contraction. Ano-
rectal function tests confirmed dyssynergic defecation. The patient
underwent successful biofeedback therapy with normalization of
bowel habit.
DRE is a useful bedside clinical tool for the evaluation of
anorectal disorders and should be performed in routine prac-
tice. It can reveal significant findings that can guide management
including selection of appropriate tests. A normal examination
will mostly exclude anorectal dysfunction. Recent studies provide
credible evidence for its clinical utility when compared to
The American Journal of Gastroenterology
 4 THE Red Section
objective anorectal tests, but emphasize that there is a learning
curve, and that apprenticeship-based training is key for mastering
this technique.
“If you don’t put your finger, you will put your foot in it”—Bailey
How I Approach It
& Love’s textbook of surgery.
Acknowledgments
I am grateful to Mrs. Helen Smith for secretarial assistance.
CONFLICT OF INTEREST
Guarantor of the article: Satish S.C. Rao, MD, PhD, FRCP(LON),
FACG, AGAF.
Specific author contributions: SSCR wrote the article.
Financial support: This work was supported in part by NIH Grant
R21-DK 104127-02, and U-34, 1434-DK109191-01.
Potential competing interests: None.
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