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

ines the integrity between the sensory nerves, S2, S3, S4 neurons
Body position and motor innervation of anal sphincter. An impaired or absent
The subject should lie in the left lateral position with hips flexed response suggests neuronal injury [9].
to 90° (Fig. 1).
Digital palpation
Inspection A lubricated, gloved index finger is slowly advanced into the
Inspect the anus and surrounding tissue using bright light and rectum. Assess for any tenderness, spasm, mass, or stricture. If
record findings as described in Table  1. Gently part the anal present, note the amount and consistency of stool (Bristol stool
mucosa to identify any anal fissure. If present, apply lidocaine gel scale); lack of stool awareness suggests rectal hyposensitivity.
to facilitate finger insertion. 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 Place patient in the left lateral position with hips flexed to 90°. Skin excoriation, skin tags, anal fissure, scars or
surrounding tissue Inspect perineum under good light external hemorrhoids, gaping anus, prolapsed
hemorrhoids or rectum, condyloma
II. Testing of perineal sensation and Stroke the skin around the anus in a centripetal fashion Normal: brisk contraction of the perianal skin, the
the anocutaneous reflex (towards anus), in all four quadrants, by using a stick with a anoderm and the external anal sphincter
cotton bud
Impaired: no response with the soft cotton bud, but
anal contractile response seen with the opposite
(wooden) end
Absent: no response with either end
III. Digital palpation Slowly advance a lubricated and gloved index finger into the Tenderness, mass, stricture, or stool and the consist-
rectum and feel the mucosa and surrounding muscle, bone, ency of the stool (BSFS).
uterus, prostate, and pelvic structures
Examine prostate for nodules, mass, tenderness
Evaluate for retroverted uterus, rectocele
IV. Maneuvers to assess anorectal
function and dysfunction
  Resting tone Assess strength of resting sphincter tone Normal, weak (decreased), or increased
  Squeeze maneuver Ask the patient to squeeze and hold as long as possible (up to Normal, weak (decreased), or increased
30 s)
  Sphincter defects Palpate anal sphincter muscle for defects during rest or Describe as present or absent and degree of sphinc-
squeeze maneuver ter loss using a clock or in quadrants
 Push and bearing down In addition to the finger in the rectum, place the other hand (i) Abdominal push effort: normal, weak (decreased),
maneuver over the patients’ abdomen. Ask the patient to push and bear excessive
down as if to defecate and assess changes in abdominal
muscle tightening, perineal descent and contraction or relaxa-
tion of anal sphincter and puborectalis
(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
  Anorectal pain assessment Palpate coccyx (bidigital) and palpate levator ani muscle in all Presence or absence of tenderness over coccyx and/
four quadrants or levator ani muscle. If present, grade intensity on a
scale of 0–10, and whether sensation(s) experienced
at home is reproducible

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 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-
Fig. 2  a A schematic illustrating the anatomical components of the DRE lation for large defects (150–270°), and poor correlation (for those
examination in the resting state. b This schematic illustrates the abnormal
paradoxical contraction of the external anal sphincter and puborectalis
<90° [17], while another found good sensitivity (90%) but poor
muscles with fingertip being displaced anteriorly during attempted defeca- specificity (28%) [18]. Finally, trainees seem to lack DRE skills
tion, suggesting dyssynergic defecation 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-
prostate should be palpated and in women, a retroverted uterus ences and may be influenced by the size of the examiner’s finger,
may be felt (Table 1). technique, experience, and the patient’s cooperation. Recent stud-
ies show improved correlations when performed by single or well-
Maneuvers to assess anorectal function trained examiners [16, 20].
After insertion, the sphincter tone, length of anal canal, and In contrast, a prospective study showed that the sensitiv-
acuteness of anorectal angle are assessed (Fig. 2a). Next, the sub- ity and specificity of DRE for identifying dyssynergia when
ject is asked to squeeze and hold for 30 s. The resting and squeeze compared to anorectal manometry were 75 and 87%, respec-
sphincter tone are categorized as normal, weak (decreased), or tively, and the positive predictive value was 97% [21]; findings
increased (Table 1). Also, feel for any anal sphincter defect(s) and confirmed by another study [15]. With regards to rectocele,
describe its location (Table 1). moderate agreement was found for DRE when compared to
Next, assess the push effort. Place the left hand on the imaging [22]. Thus, DRE is a reliable bedside tool for identify-
patient’s abdomen and ask the subject to push and bear down as ing dyssynergia, and for selecting patients for physiologic test-
if to defecate. The ability to generate a good push is assessed by ing [15–17, 21].
feeling the abdominal muscles, and anal sphincter and degree DRE done by Mrs. Smith revealed normal anocutaneous reflex,
of perineal descent by the finger in the rectum. Repeat once. increased sphincter tone, and paradoxical anal contraction. Ano-
A normal response consists of abdominal muscle contraction rectal function tests confirmed dyssynergic defecation. The patient
together with the anal sphincter and puborectalis relaxation underwent successful biofeedback therapy with normalization of
and perineal descent. The presence of two or more of the fol- bowel habit.
lowing findings suggests a diagnosis of dyssynergia: (i) the DRE is a useful bedside clinical tool for the evaluation of
inability to contract the abdominal muscles, (ii) inability to anorectal disorders and should be performed in routine prac-
relax the anal sphincter and/or puborectalis, (iii) paradoxical tice. It can reveal significant findings that can guide management
contraction of the anal sphincter or puborectalis (Fig.  2b), or including selection of appropriate tests. A normal examination
(iv) absence of perineal descent. Also, during push, a bulge felt will mostly exclude anorectal dysfunction. Recent studies provide
at the tip of the finger suggests rectal mucosal intussusception credible evidence for its clinical utility when compared to

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

 4 THE Red Section

objective anorectal tests, but emphasize that there is a learning 9. Rao SS.American College of Gastroenterology Practice Parameters
Committee Diagnosis and management of fecal incontinence. American
curve, and that apprenticeship-based training is key for mastering College of Gastroenterology Practice Parameters Committee. Am J Gas-
this technique. troenterol. 2004;99:1585–604.
“If you don’t put your finger, you will put your foot in it”—Bailey 10. Harewood GC, Coulie B, Camilleri M, et al. Descending perineum
How I Approach It

syndrome: audit of clinical and laboratory features and outcome of pelvic

& Love’s textbook of surgery. floor retraining. Am J Gastroenterol. 1999;94:126–30.
11. Hallan RI, Marzouk DE, Waldron DJ, et al. Comparison of digital
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rectal examination prior to manometry - analysis of agreement between
CONFLICT OF INTEREST repeat measurements. Int J Colorectal Dis. 1994;9:207–10.
13. Hill J, Corson RJ, Brandon H, et al. History and examination in the assess-
Guarantor of the article: Satish S.C. Rao, MD, PhD, FRCP(LON), ment of patients with idiopathic fecal incontinence. Dis Colon Rectum.
FACG, AGAF. 1994;37:473–7.
Specific author contributions: SSCR wrote the article. 14. Eckardt VF, Kanzler G. How reliable is digital examination for the evalua-
tion of anal sphincter tone? Int J Colorectal Dis. 1993;8:95–7.
Financial support: This work was supported in part by NIH Grant 15. Soh JS, Lee HJ, Jung KW, et al. The diagnostic value of a digital rectal
R21-DK 104127-02, and U-34, 1434-DK109191-01. examination compared with high-resolution anorectal manometry in
Potential competing interests: None. patients with chronic constipation and fecal incontinence. Am J Gastro-
enterol. 2015;110:1197–204.
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system (DRESS). Dis Colon Rectum. 2010;53:1656–60.
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