PR exam

Original article by Anna Raczkowycz | Last updated on 10/6/2016
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Indications

  • Change of Bowel habitconstipation, diarrhea, tenesmus
  • Rectal bleeding
  • Perianal symptoms e.g. pain/itching/discharge
  • Urinary symptoms in men (for BPH)
  • Assessment of anal tone in neurological exam
                                                                           

Introduction

  • Introduce yourself, check you have the right patient, explain procedure; “will involve examining back passage with a finger”
  • Explain WHY you are doing the procedure!
  • Get verbal consent
  • Alcohol gel hands!
  • Get a chaperone if opposite sex and advised still if same sex.
 

Preparation

  • Get patient to roll onto left hand side with knees up to chest. (Always examine from right hand side!)
  • Collect equipment:
    1. Clean tray
    2. Gel (lubricant)
    3. Gloves
    4. Gauze (for wiping)
 

Inspection

  • Put gloves on
  • Look for…
  • Fissures; normally at 6 o clock or 12 o clock position. Found in Crohn’s or constipation
  • Fistula; consequence of abscess or a complication of Crohn’s.
  • Discharge; mucus, blood, faeces
  • Abscesses; red, painful, swollen
  • Skin tags; can be normal or indicative of Crohn’s or previous hemorrhoids
  • Hemorrhoids; 1st degree- remain in rectum, 2nd degree- prolapse through but spontaneously reduce, 3rd degree- as for 2nd but require digital reduction, 4th degree- remain prolapsed persistently.
  • Prolapse
  • Cancer/polyps; on anal ring
  • Excoriation; sore, red skin from mechanical abrasion (e.g. wiping!), perhaps in diarrhoea.
  • Anal warts; STD
 

Examination

  • Inform patient you are going to examine with your finger now
  • Put blob of lubricant on finger
  • With your left hand, raise up the patient’s right buttock.
  • Insert finger, firstly assessing sphincter tone (hyper/hypotonic). If hypertonic and is difficult to insert finger, patient may be anxious and can ask patient to take a deep breath.
    • Hypertonic – Crohn’s disease, Fissure, stricture, nerves
    • Hypotonic – Old age, nerve damage, Muscle damage
  • Insert whole of finger in. if you are having trouble, then ask the patient to take a deep breath, or to push, as if they are going to the toilet. If the patient lets out a gasp of pain, stop the examination! This is likely to indicate the presence of a fissure.
  • Feel for what is in the rectum/anal canal; is it empty? Full of compact material?
  • Feel posteriorly
  • The feel each side systematically
  • Feeling for any polyps; will feel soft and mobile or cancers; fixed, hard, irregular, lumpy. Describe according to site, size, shape, smoothness, surface, surroundings.
  • To feel anterior part you must bend down! And twist finger round. Can feel prostate in men, cervix in women.
  • Prostate; walnut sized, 2 lobes, separated by sulcus. In prostatic cancer you lose the sulcus.
  • In a woman, you are likely to feel in the region of the cervix when you feel anteriorly.
  • At the end, take out finger, and look at it; check if any blood, faeces, mucus
  • Can take swab if necessary.
  • Wipe the patients or ask them to wipe themselves (use your discretion).
  • Take off glove, thank patient
  • Wipe bottom with swab (if young just hand it to them to do themselves)
  • THANK PATIENT! And WASH HANDS!
 

Likely Findings

  • Faecal loading (lots of faeces in the rectum). This is often found in the elderly. You may experience soft faces, or have difficulty passing your finger through hard faeces. Sometimes, faeces may mimic a rectal tumor, but in the case of faeces, you should be able to separate the lump from the rectal wall.
  • BPH
  • Prostatic cancer
  • Rectal carcinoma – this is normally quite obvious.
 
Don’t forget at the very end to tell the patient what you have found! Also remember to document your findings.
As a practicing doctor you will always have to record whether or not you did a PR on someone with relevant symptoms, and why.