Digital Rectal Examination

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A digital rectal examination affords access to several key structures (see the image below) and enables an observant clinician to identify several disease processes pertaining to the rectum, the anus, the prostate, the seminal vesicles, the bladder, and the perineum. In females, it can be performed in conjunction with a pelvic examination. Before the advent of serum prostate-specific antigen (PSA) testing in 1986, the digital rectal examination was the sole method of screening men for prostate cancer.

A digital rectal examination is indicated as part of a full physical examination and is often incorporated in a focused urologic, gynecologic, gastrointestinal, and neurologic examination. Disease processes that may be investigated with a digital rectal examination include, but are not limited to, the following:

Hemorrhoids

Prostatitis

Prostate cancer ^[1]

Benign prostatic hyperplasia ^[2]

Anal and rectal cancers

Anal condyloma

Constipation

Fecal incontinence

Anal fissures

Inflammatory bowel disease, including ulcerative colitis and Crohn disease

Neurologic deficits

An examination may also confirm proper Foley catheter placement and facilitate placement of rectal tubes and suppository medication. According to the American Urological Association (AUA), a digital rectal examination may be indicated for prostate cancer screening.  This is only after discussing and determining the risks and benefits of screening with the patient using the process of shared decision-making.

^[3]

Although there are no circumstances in which a digital rectal examination is overtly contraindicated, caution should be exercised in examining infants and young children, and vigorous manipulation, specifically of the prostate, should be avoided in severely neutropenic patients and patients with prostatic abscesses or prostatitis. The old medical adage often holds true: The only reason not to do a digital rectal examination is if the patient is without a rectum or the clinician is without a finger.

The examination should be performed with the patient in a safe position in case vasovagal syncope should occur (not an uncommon event, particularly in younger males). Ensuring a safe position may include providing a soft surface and limiting the distance the patient falls if syncope occurs.

If the patient has neutropenia or acute prostatitis and there is a need to check for a fluctuant prostate signifying abscess, antibiotic therapy should be started before the examination and after all cultures are obtained. The examination in a patient with prostatic abscess or acute bacterial prostatitis should be gentle and may consist of nothing more than feeling a hot, boggy prostate with a fingertip, then stopping the examination. Prostatic massage is only rarely indicated in patients without suspected chronic bacterial prostatitis.

Roobol MJ, van Vugt HA, Loeb S, Zhu X, Bul M, Bangma CH, et al. Prediction of Prostate Cancer Risk: The Role of Prostate Volume and Digital Rectal Examination in the ERSPC Risk Calculators. Eur Urol. 2012 Mar. 61(3):577-83. [Medline].

Ahmad S, Manecksha RP, Cullen IM, Flynn RJ, McDermott TE, Grainger R, et al. Estimation of clinically significant prostate volumes by digital rectal examination: a comparative prospective study. Can J Urol. 2011 Dec. 18(6):6025-30. [Medline].

[Guideline] Carter, H. Ballentine, et al. AUA Releases Statement Clarifying Prostate Cancer Testing Recommendations. Early Detection of Prostate Cancer. Available at http://www.auanet.org/guidelines/early-detection-of-prostate-cancer-(2013-reviewed-and-validity-confirmed-2015). 2015; Accessed: October 5, 2017.

Gerber GS, Brendler CB. Evaluation of the Urological Patient: History, Physical Exam, and Urinalysis. Campbell-Walsh Urology, 9th ed. Available at http://www.campbellsurology.com. Accessed: April 13, 2011.

Adam Warren Ylitalo, DO, FACOS, FACS Chief of Urology Section, Hillcrest Urology, Baylor Scott and White Health

Adam Warren Ylitalo, DO, FACOS, FACS is a member of the following medical societies: American College of Osteopathic Surgeons, American College of Surgeons, American Osteopathic Association, American Urological Association

Disclosure: Nothing to disclose.

Richard A Santucci, MD, FACS Specialist-in-Chief, Department of Urology, Detroit Medical Center; Chief of Urology, Detroit Receiving Hospital; Director, The Center for Urologic Reconstruction; Clinical Professor of Urology, Michigan State University College of Medicine

Richard A Santucci, MD, FACS is a member of the following medical societies: American College of Surgeons, International Society of Urology, American Urological Association

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgments

The authors wish to thank all of the great physicians who have taught and continue to teach the importance and clinical intricacies of the digital rectal examination.

Medscape Reference also thanks Adam Warren Ylitalo, DO, Resident Physician in Urological Surgery, Detroit Medical Center, Michigan State University College of Osteopathic Medicine, for assistance with the video contribution to this article.

Digital Rectal Examination

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