Rectal Examination (PR) – OSCE Guide

geekymedics.com/rectal-examination-pr/

Dr Lewis Potter

Rectal examination frequently appears in OSCEs and you’ll be expected to identify

relevant signs using your clinical examination skills. This guide provides a step-by-step
approach to performing a rectal examination in an OSCE setting, with an included video
demonstration.

Download the rectal examination PDF OSCE checklist, or use our interactive OSCE
checklist.

Gather equipment
Gather the appropriate equipment:

Non-sterile gloves
Apron
Lubricant
Paper towels

Gather equipment

Introduction
Wash your hands and don PPE if appropriate.

Introduce yourself to the patient including your name and role.

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 Confirm the patient’s name and date of birth.

Explain what the examination will involve using patient-friendly language: “Today I
need to perform a rectal examination. This will involve me inserting a finger into your anus
to feel for any abnormalities. It shouldn’t be painful, but it will feel a little uncomfortable.
You can ask me to stop at any point.”

Explain the need for a chaperone: “One of the other staff members will be present
throughout the examination, acting as a chaperone, would that be ok?”

Gain consent to proceed with the examination: “Do you understand everything I’ve said?
Do you have any questions? Are you happy for me to carry out the examination?”

Ask the patient if they have any pain before proceeding with the clinical examination.

Explain to the patient that they’ll need to remove their underwear and lie on the clinical
examination couch, covering themselves with the sheet provided. Provide the patient
with privacy to undress and check it is ok to re-enter the room before doing so.

Preparation
1. Don an apron and a pair of non-sterile gloves.

2. With the clinical examination couch flat, ask the patient to lie down in the left lateral
position with their knees bent up towards their chest.

3. Then ask the patient if it is ok to remove the sheet to begin the examination.

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* Rectal pmapse
• Abscess
Separate the buttocks and inspect the perianal region for relevant clinical signs:

Skin excoriation: secondary to anal pruritis which can be caused by haemorrhoids,

faecal incontinence or constipation.
Skin tags: minor projections of skin at the anal verge that are usually benign.
Perianal skin tags can, in some cases, be associated with inflammatory bowel
disease.

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 External haemorrhoids: located below the dentate line and innervated by somatic
nerves. On examination, they typically appear as a lump located just inside or
outside the anal verge.
Anal fissure: a tear in the tissue of the anal canal, typically located posteriorly in
the midline. Anal fissures most commonly develop secondary to constipation and
are very painful (often making rectal examination impossible).
External bleeding: may be caused by external haemorrhoids, anal cancer or brisk
gastrointestinal bleeding.
Anal fistula: a chronic abnormal communication between the internal anal canal
and the perianal skin. Fistulae may discharge pus and have surrounding
inflammation. Causes of anal fistulae include perianal Crohn’s disease, chronic anal
abscess and diverticulitis.

Ask the patient to cough and inspect for:

Rectal prolapse: on inspection, a mass with concentric rings of mucosa will be

visible protruding through the anus.
Internal haemorrhoids: located above the dentate line and innervated by visceral
nerves. On examination, bluish, bulging vessels covered by mucosa may become
visible when the patient coughs. Internal haemorrhoids are typically asymptomatic
due to their visceral innervation.

Inflammatory bowel disease

Inflammatory bowel disease (IBD) is a general term that is used to describe disorders
that involve chronic inflammation of the gastrointestinal tract. Ulcerative colitis and
Crohn’s disease are subtypes of IBD and differ in their clinical presentation.
④
•
Ulcerative colitis is the most common form of IBD and affects the colon and rectum. Bloody
Typical findings on rectal examination include loose bloody stool and excess mucous. Diarrhoea
-

•
Mucous
Crohn’s disease is another subtype of IBD which can affect any part of the
-

gastrointestinal tract from the mouth to the anus. Typical findings on rectal examination
may include- rectal bleeding, perianal fistulas, abscesses and multiple skin tags.
- - -

Inspect the perianal region

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 Anal fissure

External haemorrhoid

Illustration of haemorrhoids

Anal fistula

Palpation

First steps
1. Lubricate the examining finger.

2. Warn the patient you are about to insert your finger.

3. Insert your finger gently into the anal canal.

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 Lubricate the examining finger

Insert the finger gently into the anal canal

Prostate examination
4. In males, palpate the prostate gland anteriorly and assess the size, symmetry and
texture of the gland:

A normal prostate is approximately walnut-sized with a palpable midline sulcus.

It should be symmetrical and its consistency should be similar to that of the tip of
the nose.

Palpate the prostate anteriorly

Anal canal examination

5. Rotate your finger 360 degrees to assess the entirety of the rectum:

Note the size, location (e.g. 9 o’clock) and texture (e.g. smooth, irregular) of any
rectal lumps (e.g. tumour, polyp, internal haemorrhoid).
Feel for any hard stool present in the rectum, which may indicate constipation.
Note the location of any tenderness, which may indicate an anal fissure or
thrombosed internal haemorrhoids.

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 Rotate the finger 360° to assess the rectum

Rotate the finger 360° to assess the rectum

Anal tone assessment

6. Assess anal tone by asking the patient to bear down on your finger. Causes of reduced
anal tone include spinal cord pathology (e.g. cauda equina syndrome), inflammatory
bowel disease and previous rectal surgery.

Assess anal tone

Final steps
7. Withdraw your finger and inspect for blood or mucous:

Dark sticky blood is known as melaena and is associated with upper

gastrointestinal bleeding (e.g. stomach ulcer).
Fresh red blood is associated with lower gastrointestinal bleeding (e.g. rectal
malignancy, fissure).
Excess mucous can be associated with inflammatory bowel disease (e.g.
ulcerative colitis).

8. Clean the patient using paper towels.

9. Cover the patient with the sheet, explain that the examination is now complete
and provide the patient with privacy so they can get dressed.

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10. Dispose of the used equipment into a clinical waste bin.

Withdraw and inspect finger

Clean the patient

Re-cover the patient

Dispose of used equipment into the clinical waste bin

To complete the examination…

Thank the patient for their time.

Dispose of PPE appropriately and wash your hands.

Document the procedure in the medical notes including the details of the chaperone.

Summarise your findings.

Example summary

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“Today I examined Mr Smith, a 28-year-old male. On general inspection, the patient
appeared comfortable at rest. There were no objects or medical equipment around the
bed of relevance.“

“There were no abnormalities noted on inspection of the perianal region, rectal

examination revealed a normal-sized prostate and no evidence of hard stool or
masses in the rectal canal. No rectal bleeding was noted. “

“In summary, these findings are consistent with a normal rectal examination.”

“For completeness, I would like to perform the following further assessments and
investigations.”

Further assessments and investigations

Abdominal examination: if there were concerns about intraabdominal pathology
(e.g. appendicitis).
Blood tests: including FBC, haematinics and U&Es if there were concerns about
gastrointestinal bleeding.
Faecal occult blood testing: if there were concerns about lower gastrointestinal
malignancy.
Flexible sigmoidoscopy/colonoscopy: if there were concerns about lower
gastrointestinal bleeding or malignancy.
CT abdomen and pelvis: if there were concerns about lower gastrointestinal
malignancy.

Reviewer

Dr Ally Speight

Consultant Gastroenterologist

References
1. Bernardo Gui. Adapted by Geeky Medics. Anal fissure.

2. Απόστολος Σταματιάδης. Adapted by Geeky Medics. External haemorrhoid. Licence:

CC BY-SA.

3. WikipedianProlific. Adapted by Geeky Medics. Illustration of haemorrhoids. Licence:

CC BY-SA.

4. Internet Archive Book Images. Adapted by Geeky Medics. Anal fistula.

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