This article was co-authored by Gary Hoffman, MD. Dr. Gary Hoffman is a board certified Colorectal Surgeon and the Clinical Chief of the Division of Colon and Rectal Surgery at Cedars Sinai Medical Center. With over 35 years of experience, Dr. Hoffman has helped to advance laparoscopic and robotic surgery for the treatment of colon and rectal cancer. Dr. Hoffman holds a BS from the University of California, Irvine, and a Doctor of Medicine (MD) from Vanderbilt University. He completed his surgical internship at Los Angeles County-USC Medical Center and his surgical residency at Louisiana State University-Charity Hospital of New Orleans Medical Center. Dr. Hoffman is an Attending Surgeon in the Division of General Surgery and Colon and Rectal Surgery at Cedars Sinai Medical Center. He is also an Associate Clinical Professor of Surgery at The David Geffen School of Medicine, University of California, Los Angeles. Dr. Hoffman is a member of The American Society of Colon and Rectal Surgeons, The Southern California Society of Colon and Rectal Surgeons, The American College of Surgeons, and The American Medical Association.

There are 27 references cited in this article, which can be found at the bottom of the page.

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A rectal exam is a screening test for both genders that helps to detect abnormalities in the rectum, anus, and prostate gland (men only), such as cancer, infections and various injuries. [1] X Research source These exams should be done fairly regularly (yearly or so) as part of your health physical. Trained medical professionals are the only people who should give rectal exams since untrained individuals can injure the delicate rectal/anal tissues while probing.

The rectal exam is important to make sure causes of rectal bleeding such as hemorrhoids are not missed. Additionally, understanding how to palpate the prostate gland is important for looking for cancer and diagnosis prostatitis.

Introduction to the Rectal Exam

A rectal exam should be performed on most patients with abdominal pain and any concern for blood loss. Here, we review some important steps of a compete rectal exam.

Rectal Exam Technique

There are multiple positions that you can ask your patient to stand or lie. These include:

1. Standing position: patient standing with toes pointing in, then leans over a table
2. Right lateral decubitus (Sims position): patient lies on right side with right hip/leg straight and the left hip/knee is bent
3. Knee to chest: patient with lying on table facing down with knees up to chest bent forward

* (Both the standing and knee to chest positions are optimal for the prostate exam)

Inspection of Anus

Look for external hemorrhoids, fissures (90% of time they are located in midline posteriorly), skin tags, warts or discharge

Palpate Rectum and Prostate

1. Use a small amount of lubricant on the index finger and ask the patient to take a deep breath and insert the finger facing down (6 o’clock position)
2. Appreciate the external sphincter tone then ask the patient to bear down and feel for tightening of the sphincter
3. Palpate the prostate gland. Note the following:
   1. Approximate size of the prostate gland (normally about the size of a walnut, 2-3 cm but wider at the top)
   2. Feel for tenderness (prostatitis)
   3. Feel for nodules or masses
4. Palpate the rectal wall starting from the 6 o’clock position clockwise to the 12 o’clock position. Then return to the 6 o’clock position and palpate the other half of the rectal wall feeling for masses, nodules and tenderness.

Occult Blood Test

Check any fecal material for occult blood with a guaiac kit.

The digital rectal exam (also referred to as the DRE) is used to evaluate the anus, distal rectum, pelvis, and prostate. More specifically, it is used to inspect for anal tumors, obtain fecal samples for a fecal occult blood test, assess the function of the anal sphincters, evaluate for the cause of rectal bleeding (such as hemorrhoids), and evaluate the prostate gland.

Review of anorectal anatomy

To understand how to perform a DRE, a brief review of anorectal anatomy is pertinent. The anus is the most distal portion of the large intestine. The anorectal junction is about 5 cm superior to the anal verge (e.g., the anal orifice). The anal verge is the most distal portion seen externally.

The anal canal is the lumen located between the anal verge and the rectum. The dentate line (e.g., the pectinate line) is about 2 cm superior to the anal verge and is in the transitional zone.

Figure 1. The anal canal is located between the anal verge and anorectal junction, and is divided into two sections by the dentate line.

The dentate line is the division between the ectoderm and endoderm mucosa, which is important because of their embryological origins. Above the dentate line, the mucosa is endoderm, has splanchnic innervation, and is insensitive to pain. Below the dentate line, the mucosa is ectoderm, has somatic innervation through the inferior rectal nerve, and is sensitive to pain.

Figure 2. The dentate line represents the junction between the endoderm and ectoderm portions of the anal canal.

The internal anal sphincter surrounds the upper two-thirds of the anal canal. It is formed from a thickening of the involuntary circular smooth muscle in the bowel wall. The external anal sphincter surrounds the lower two-thirds of the anal canal and is a voluntary muscle.

Figure 3. The internal anal sphincter is a ring of involuntary smooth muscle that surrounds the upper two-thirds of the anal canal, and the external anal sphincter is a ring of voluntary muscle that surrounds the lower two-thirds of the anal canal.

How to perform a digital rectal exam

Start by communicating with the patient about why a DRE is necessary, what is involved, and how the exam will be performed. Prepare the patient for a little bit of discomfort with the exam.

If possible, have the patient lay on their side in the left lateral decubitus position (e.g., with their right side up). A standing rectal exam can also be performed, but it may not be as comfortable for some patients. Usually, a standing exam is only performed for a prostate examination.

To perform a DRE, put on gloves, and perform these five steps:

1. Visually inspect the anus
2. Palpate the anal sphincters
3. Palpate the rectal wall
4. Palpate the prostate (in males)
5. Collect a fecal sample if indicated

Step 1: Visually inspect the anus

First, inspect the anus. Look for any external hemorrhoids, skin tags, anal fissures, discharge, drainage, and any other abnormalities.

Step 2: Palpate the anal sphincters

Use your index finger of your dominant hand and place some lubricant jelly on it. Ask the patient to take a deep breath in, exhale, and relax. Insert your index finger into the anus, with the finger facing anteriorly, which we will refer to as the six o’clock position.

Note the external anal sphincter tone. Ask the patient to bear down and feel for tightening of the sphincter against your finger.

Step 3: Palpate the rectal wall

Palpate the rectal wall for masses, nodules, and tenderness. From the six o’clock position (e.g., the anterior direction), rotate your finger clockwise to the twelve o’clock position (now in a posterior direction), and then return to the six o’clock position.

Step 4: Palpate the prostate

In males, the prostate gland lies anteriorly at the six o’clock position. Palpate the prostate gland and note the approximate size. Feel the prostate gland for tenderness, nodules, or masses.

Step 5: Collect a fecal sample if indicated

If the patient has any signs or symptoms of anemia or unintended weight loss, then a guaiac kit to test fecal matter for occult blood is indicated.

Figure 4. Steps to performing a digital rectal exam include, 1) visually inspecting the anus, 2) palpating the anal sphincters, 3) palpating the rectal wall, 4) palpating the prostate (in males), and 5) collecting a fecal sample if indicated.

That’s it for now. If you want to improve your understanding of key concepts in medicine, and improve your clinical skills, make sure to register for a free trial account, which will give you access to free videos and downloads. We’ll help you make the right decisions for yourself and your patients.

Recommended reading

• de Dombal, FT. 1988. The OMGE acute abdominal pain survey. Progress report, 1986. Scand J Gastroenterol Suppl. 144: 35–42. PMID: 3043646
• Jin, XW, Slomka, J, and Blixen, CE. 2002. Cultural and clinical issues in the care of Asian patients. Cleve Clin J Med. 69: 50, 53–54, 56–58. PMID: 11811720
• Tseng, W-S and Streltzer, J. 2008. “Culture and clinical assessment”. In: Cultural Competence in Health Care. Boston: Springer.
• Wong, C. 2020. Liver fire in traditional Chinese medicine. verywellhealth. https://www.verywellhealth.com

About the Author

Olutayo A. Sogunro, DO

Acute Care and Trauma Surgeon at St. Vincent’s Medical Center and Assistant Professor of Surgery at Netter School of Medicine, Quinnipiac University, USA.

A rectal examination is where a doctor or nurse uses their finger to check for any problems inside your bottom (rectum). It’s usually very quick and you should not feel any pain.

When a rectal examination may be needed

A rectal examination is sometimes needed to investigate:

• bleeding from the bottom
• pain in the bottom
• constipation
• being unable to control when you go to the toilet (incontinence) – including bowel incontinence or urinary incontinence

Men sometimes need a rectal examination to check for problems with the prostate.

What is the prostate?

The prostate is a small gland that only men have. It:

• produces fluid that mixes with sperm to create semen
• often gets larger with age
• may cause problems with how easily you pee and how often you need to go

Before having a rectal examination

Your doctor or nurse should explain what’s going to happen and why you need a rectal examination.

They’ll know that some people can feel embarrassed, but it’s a common procedure.

Let the doctor or nurse know if:

• you’d prefer a man or woman to perform the examination
• you’d like someone else in the room – it could be a friend, family member or another doctor or nurse
• you have severe pain in your bottom – they may be able to use local anaesthetic to numb the area

What happens during a rectal examination

First, you’ll be asked to undress from the waist down. If you’re wearing a loose skirt, you can usually just remove your underwear.

Let the doctor or nurse know if you’d like to get changed behind a curtain or be alone in the room.

The doctor or nurse will:

1. Ask you to lie down on your left side, with your knees lifted up towards your chest. This is the easiest position to examine your rectum.
2. Put on some gloves and look at the outside of your bottom for any problems.
3. Put some lubricating gel on 1 finger and gently slide it into your rectum. This should not be painful, but may be a little bit uncomfortable.
4. Sometimes ask you to squeeze around their finger so they can assess how well the muscles are working.

If you’re a man, the doctor or nurse may press on your prostate. This can make you feel the urge to pee, but it should not hurt.

Once you’re dressed, they’ll discuss the results of the examination with you.

Page last reviewed: 23 December 2020
Next review due: 23 December 2023

A rectal exam, otherwise known as a digital rectal exam or DRE, is an examination of the inside of the rectum and can be one way to detect signs of colon cancer or other indicators that a colonoscopy may be necessary. During the procedure, a physician inserts a gloved, lubricated finger into the rectum to feel for abnormalities. No colon cleansing is necessary. The test happens quickly and usually does not hurt at all. However, the test can only detect problems in the lower rectal area, not the colon. Additional screening tests would need to be performed to find polyps or lesions deeper inside.

Rectal Exam Procedure

During a regular physical exam, after other tests and checks have been administered, a doctor or nurse will ask you to undress completely while he or she leaves the room for a few minutes. A paper hospital gown will be left in the room for minimal coverage.

When the doctor re-enters the room, you will need to position yourself in a way that the anus is accessible to the doctor. This may mean you will need to lie on your side on top of the examination table with your knees pulled toward your chest, to assume a squatting position on the table or to stand flat-footed on the floor while bent over. Some doctor’s offices may be equipped with an apparatus that allows patients to lie comfortably on their backs, at a slight tilt, while their feet rest on stirrups, giving the doctor access to the rectum and anal area between the patients’ legs.

The doctor will then use hands, protected with sterile latex gloves to prevent contamination, to spread the buttocks apart while he or she examines the external area surrounding the anus and perineum. If there are any signs of inflammation or abnormal growths, the doctor will be able to study them at this point of the exam. Common conditions detected on the external part of the colorectal area include rashes and hemorrhoids.

For the second, internal part of the rectal exam, the patient will be asked to relax while the doctor inserts his or her gloved finger into the rectum and through the anus, feeling the patient’s insides for signs of health problems. Most doctors will use a lubricator to allow smoother access. This part of the rectal exam lasts only about a minute.

Patients checking for the following conditions may undergo a digital rectal exam as a preliminary screening test: colorectal cancer, hemorrhoids, prostate cancer in men and ovarian cancer in women.

If your doctor detects cancerous or even non-cancerous tumors during a rectal exam, it is possible that you have one of several health conditions. Patients checking for the following conditions may undergo a digital rectal exam as a preliminary screening test: colorectal cancer, hemorrhoids, prostate cancer in men and ovarian cancer in women. A digital rectal exam is often administered before a regular colonoscopy, as well.

Further Testing After A Rectal Exam

Talk to your GI doctor if you are experiencing constipation—rectal exams can also be used to evaluate the hardness of a patient’s feces. The exam also tests the tonicity of the anal sphincter, for patients who have experienced severe injuries or are having problems controlling their bowel movements. The test is often ordered in conjunction with routine blood tests such as fecal occult blood test (FOBT) or fecal immunochemical test (FIT) for patients who might be bleeding internally.

A digital rectal exam is only a preliminary step in determining whether you have colon cancer. As the test is limited to less than 10 percent of the colon wall, the test is not a keen indicator of colon polyps, colon pouches, or pre-cancerous growths existing deeper inside the GI tract.

Overall, a digital rectal exam is only a preliminary step in determining whether you have colon cancer. As the test is limited to less than 10 percent of the colon wall, the test is not a keen indicator of colon polyps, colon pouches or pre-cancerous growths existing deeper inside the gastrointestinal (GI) tract. Oftentimes, regular screenings with colonoscopy, sigmoidoscopy or certain x-ray procedures may be ordered, even if a rectal exam produces negative results.

Does the thought of examining your patients’ rectums leave your head spinning? I understand: The thought of performing your first anoscopy can be rather intimidating. However, the procedure is actually quite simple, and I’m here to help you through it.

So take a deep breath and gather your supplies. Ahead, you’ll learn what you need for this exam, and I’ll walk you step by step through how to use an anoscope.

Before you know it, you’ll be ready to perform this procedure on your own, and all qualms about conducting anal exams will have faded from memory. But first, read on to become an expert at using an anoscope.

What You Will Need When Using an Anoscope

This is a procedure that is usually performed on an outpatient basis in a doctor’s office or a hospital setting. To perform an exam on a patient, you will need the following supplies:

Anoscope

The primary tool used for this procedure is an anoscope. This two-part device is comprised of a hollow outer sheath and a solid inner obturator. The obturator has a rounded end to ease insertion. This piece is removable after insertion.

Anoscopes can be made of metal or plastic. Typically, metal anoscopes are reusable, but they must be sterilized between uses. Most plastic anoscopes are disposable.

Not only do disposable plastic anoscopes require less preparation and post-procedure cleaning, but they are also advantageous because of their clear construction. You can see through the transparent material to detect fissures or other concerns with the tissue under the scope.

Lubricant

Typically, an anoscope is about 2 inches wide, which is comparable to the width of a normal bowel movement. In other words, the body is used to accommodating an object of that size. Even still, inserting a probe from the opposite end can require some coaxing.

Therefore, it is important to generously coat the instrument with lubricant before attempting insertion. This will ease the effort required of the medical practitioner and will increase comfort for the patient. A water-based, medical-grade lubricant is recommended.

Light

To perform a careful and thorough exam, the rectal area must be fully illuminated. Practitioners have several options for this requirement. Some anoscopes have built-in lights.

Others do not come with attached lights, which gives the doctor the freedom to use the preferred light of his or her choice. A penlight or other handheld device can work well because it allows the practitioner to direct the beam precisely where it is needed. If you do not have a free hand, an assistant can hold the light.

Another option is to use a light that is mounted on your forehead.

Swabs

A rectal exam opens up the anus and the rectum so you have access to the tissue inside. Once access has been granted, you may need swabs with which to clean the passage or to examine the health of the region.

For example, long cotton swabs are useful for wiping away fecal matter or excess lubricant in the examination area. Culture swabs may be necessary if an infection is suspected.

Gloves or Other Protective Garments

The doctor and nurses involved with the procedure should dress in the appropriate protective gear to reduce the transmission of infection and to protect their clothing during the exam.

Rectal (PR) examinations are performed for a number of clinical reasons, such as altered bowel habit, rectal bleeding, or urinary symptoms. It is a skill surgeons perform on all patients and as such it is commonly examined as it is an important skill to know.

For the purpose of examinations you will be provided with a mannequin, however you should pretend it is a real patient and talk to it as such as this forms part of the marking scheme.

Procedure Steps

Step 01

Wash your hands, introduce yourself to the patient and clarify their identity. Explain what you would like to do and obtain consent. This is a slightly uncomfortable procedure so you should warn the patient of this.

A chaperone is required for this examination.

Step 02

Ensure you have all of the necessary equipment for the station:

• Gloves.
• Lubricant.
• Tissues.

Step 03

Positioning of the patient in this procedure is very important. Ask them to lie on their left hand side with their knees drawn up towards their chest, their feet pushed forward and their anus exposed.

Step 04

Having washed your hands and put on your gloves, separate the buttocks and inspect the area around the anus. Look for any abnormalities including skin tags, haemorrhoids and fissures.

Step 05

After inspecting, lubricate your right index finger.

Step 06

Tell the patient you are about to start the procedure. Place your finger on the anus so that it points anteriorly and apply pressure to the midline of the anus.

Step 07

Maintain the pressure so that your finger enters the rectum. Initially you need to assess anal tone by asking the patient to squeeze your finger.

Step 08

Systematically examine each part of the rectum by sweeping the finger both clockwise and anti-clockwise around the entire circumference. You should be feeling for any abnormalities such as impacted faeces, masses or ulcers.

Step 09

One of the main reasons for performing a rectal examination in males is to assess the prostate gland. This lies anteriorly and should always be felt. You should check the size, consistency and presence of the midline groove.

Step 10

Remove your finger and examine the glove for the colour of any faeces as well as the presence of any mucus or blood.

Step 11

Clean off any lubricant left around the anus and remove and dispose of your gloves in the clinical waste bin.

Step 12

Allow the patient to dress and thank them. Wash your hands and report your findings to the examiner.

Assessing the Benefits and Limitations of the Procedure

Monique Rainford, MD, is board-certified in obstetrics-gynecology, and currently serves as an Assistant Clinical Professor at Yale Medicine. She is the former chief of obstetrics-gynecology at Yale Health.

A rectovaginal examination is a manual physical examination of the rectum and the vagina, It is not a standard part of a medical or gynecological evaluation, but you might need it if there is a concern about issues such as rectal involvement of endometriosis, a rectovaginal fistula (an abnormal connection between the rectum and vagina), or rectal or vaginal cancer.

A pelvic exam is typically recommended for females for the purpose of evaluating symptoms such as irregular bleeding or discharge, and for screening for malignancy (cancer). Components of a pelvic exam can include a speculum exam, bimanual exam, and rectovaginal exam.

Purpose of a Rectovaginal Exam

A rectovaginal exam can allow your healthcare provider to examine and identify abnormalities in your pelvic area, including the cervix, uterus, ovaries, fallopian tubes, anus, and rectum.

The recto-vaginal exam is not a particularly accurate screening exam and is usually reserved for people who either have rectal or pelvic pain or are experiencing symptoms related to the genitourinary tract (such as pain, urinary urgency, or abnormal bleeding).

Other reasons for the exam can include:

• Identifying scarring or a mass that could indicate cancer or another disease
• Obtaining a fecal blood sample (blood in the stool)
• Diagnosing a tilted pelvis

Although a pelvic exam is considered important for identifying and treating cancer, sexually transmitted infections (STIs), and other genitourinary tract disorders, a rectovaginal exam offers uncertain benefits.

According to a 2016 review of studies in the Journal of the American Association of Nurse Practitioners, a rectovaginal exam has a low sensitivity in detecting uterosacral nodules, rectal compression, cervical involvement of endometrial cancer, and colorectal cancer. This means it misses many of these problems.

How a Rectovaginal Exam Is Performed

Normally, there is no special preparation needed before having a rectovaginal exam. As with any pelvic exam, you should not engage in sexual intercourse (including anal sex) for 24 hours prior to your appointment. In some cases, your healthcare provider may want you to take a laxative and will advise you about this beforehand.

A rectovaginal exam typically lasts for less than a minute, but it may last longer if your medical professional finds something concerning. It can be a little uncomfortable, but should not produce any real pain. Deep breathing and relaxing your pelvic muscles can help. If you feel any pain, let your healthcare provider know.

There are no risks involved with the procedure.

To do your rectovaginal exam, your practitioner will:

• Insert a gloved, lubricated finger into your vagina
• Insert another finger from the same hand into your rectum
• Palpate (examine by feeling) your abdomen with the other hand

During this procedure, your healthcare provider will evaluate the tissues in your rectum and vagina, the tone and alignment of your pelvic organs, including the ovaries and fallopian tubes, and the ligaments that hold the uterus in place.

When a Rectovaginal Exam Is Indicated

Your healthcare provider might consider doing a rectovaginal exam if you have pain, discomfort, or pressure that seems like it is coming from the anal or rectal area. They might also do this exam if they detect a possible growth or abnormality in or near your rectum while they are doing other parts of your pelvic exam.

In general, a rectovaginal exam is considered when symptoms or other examination findings raise the possibility of a problem involving both the rectum and the vagina. You and your medical professional will discuss this part of the exam and why it is being done.

Even if you have a rectovaginal exam, there is a high chance that your symptoms are not caused by a serious problem and that your symptoms can be effectively treated.

Other Female Rectal Exams

Besides a rectovaginal exam, there are other types of rectal exams, typically for evaluation of gastrointestinal problems.

• Stool sample: Generally, one of the most common reasons for a rectal exam is testing for blood in the stool. This could be a concern if you have obvious blood streaks in the toilet, blood on the toilet paper, black tarry stools, unexplained weight loss, vomiting blood, or diarrhea.
• Anal sphincter tone: Additionally, you might have a rectal exam if you have experienced stool incontinence or if you are unable to control your stool. In this case, your healthcare provider would do a rectal exam to check your anal sphincter tone, which can affect your control over your stool.

Pelvic Exam Recommendations

The American Congress of Obstetricians and Gynecologists (ACOG) guidelines include the following recommendations:

• The decision to have a pelvic exam should involve shared decision making between the patient and practitioner.
• A pelvic exam is recommended for people who have symptoms of an STI or other pelvic conditions.
• For people who do not have symptoms of illness, a pelvic exam is necessary before placement of an intrauterine device (IUD) but is not necessary before prescription of other forms of birth control.

Frequently Asked Questions (FAQs)

When is a rectovaginal exam indicated?

You may need to have a rectovaginal exam if you have an abnormal appearance, sensation, or control of your rectal and vaginal areas.

What is a healthcare provider checking for during a rectovaginal exam?

During this exam, your healthcare provider is checking for tenderness, structural irregularities, discharge, blood, and altered muscle tone.

Do I have to let my gynecologist perform a rectovaginal examination?

You do not have to agree to any exam you don’t want. Discuss alternate approaches that might help in diagnosing your problem.

Does a recotovaginal exam hurt?

It shouldn’t hurt, but it can be uncomfortable or even painful if you have a medical problem affecting your rectum or vagina.

A Word From Verywell

Gynecological examinations are often needed for screening or to evaluate symptoms. These physical examination techniques can help your healthcare provider decide about the next steps in your diagnostic evaluation or treatment plan.

If you have any questions or if you are hesitant about any part of your exam, be sure to talk about it either with your practitioner or with someone else on your medical team until you feel that your concerns and questions have been addressed to your satisfaction.

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What is a prostate/rectal ultrasound?

A prostate or rectal ultrasound is an imaging test that uses sound waves to look at your prostate or your rectum.

The healthcare provider uses a small probe called a transducer to make the images of your prostate or rectum. The transducer is about the size of a finger. It is gently placed into your rectum, where it sends out sound waves that bounce off your organs and other structures. The sound waves are too high-pitched for you to hear. The transducer then picks up the bounced sound waves. These are made into pictures of your organs.

Your provider can add another device called a Doppler probe to the transducer. This probe lets your provider hear the sound waves the transducer sends out. He or she can hear how fast blood is flowing through a blood vessel and in which direction it is flowing. No sound or a faint sound may mean that you have a blockage in the flow.

Why might I need a prostate/rectal ultrasound?

A prostate/rectal ultrasound may be used to check the size, location, and shape of the prostate gland and nearby structures. It may be used to look at the prostate gland for signs of cancer or other conditions. It’s often the next step after a finding of raised (elevated) prostate-specific antigen (PSA) during a blood test. Prostate/rectal ultrasound may be used to stage and watch treatment of rectal cancer. It is also used to look at the rectum for other problems.

Your healthcare provider may also use a prostate/rectal ultrasound to help place a needle to take a tissue sample (biopsy) . Or he or she may use it to help place radiation seeds used to treat prostate cancer.

Your provider may also use the test to see how well blood is flowing to the prostate or find masses.

Your provider may have other reasons to recommend a prostate/rectal ultrasound.

What are the risks of a prostate/rectal ultrasound?

An ultrasound has no risk from radiation. Most people have mild discomfort from the transducer being placed in the rectum.

Tell your healthcare provider if you are allergic to latex. The probe is placed in a latex covering before it is put into the rectum.

You may have risks depending on your specific health condition. Be certain your healthcare provider knows about all of your health conditions before the procedure.

Too much stool in the rectum may make the test less accurate.

How do I get ready for a prostate/rectal ultrasound?

Your healthcare provider will explain the procedure and you can ask questions. Make a list of questions and any concerns with your healthcare provider before the procedure. Consider bringing a family member or trusted friend to the medical appointment to help you remember your questions and concerns.

You may be asked to sign a consent form that gives your permission to do the procedure. Read the form carefully and ask questions if something is not clear.

You may be asked to stop taking blood-thinning medicines, such as aspirin, for a week or so before the test if it is being done as part of a biopsy.

You usually do not need to stop eating or drinking before the test. You also usually will not need medicine to help you relax (sedation).

You may be given a small enema before the test.

Follow any other instructions your provider gives you to get ready.

What happens during a prostate/rectal ultrasound?

You may have a prostate/rectal ultrasound done as an outpatient or during a hospital stay. The way the test is done may vary depending on your condition and your healthcare provider’s practices.

Generally, a prostate/rectal ultrasound follows this process:

You will need to remove any clothing, jewelry, or other objects that may get in the way of the procedure.

If asked to remove clothing, you will be given a gown to wear.

You will lie on an exam table on your left side with your knees bent up to your chest.

The healthcare provider may do a digital rectal exam before the ultrasound.

The provider puts a clear gel on the transducer and puts the probe into the rectum. You may feel a fullness of the rectum at this time.

The provider will turn the transducer slightly several times to see different parts of the prostate gland and other structures.

If blood flow is being looked at, you may hear a whoosh, whoosh sound when the Doppler probe is used.

Once the test is done, the provider will wipe off the gel.

A prostate/rectal ultrasound may be uncomfortable and you will need to remain still during the test. The gel will also feel cool and wet. The technologist will use all possible comfort measures and do the scan as quickly as possible to minimize any discomfort.

What happens after a prostate/rectal ultrasound?

You don’t need any special care after a prostate/rectal ultrasound. You may go back to your usual diet and activities unless your healthcare provider tells you otherwise.

Affiliations

• 1 University of Pittsburgh School of Medicine, 303 Church Ln, Pittsburgh, PA, 15238-1063, USA. [email protected]
• 2 Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Centennial Building, 1685 Highland Ave, Madison, WI, 53705-2281, USA. [email protected]

• PMID: 26739462
• DOI: 10.1007/s11894-015-0478-5

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• Search in NLM Catalog
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Authors

Affiliations

• 1 University of Pittsburgh School of Medicine, 303 Church Ln, Pittsburgh, PA, 15238-1063, USA. [email protected]
• 2 Division of Gastroenterology & Hepatology, University of Wisconsin School of Medicine & Public Health, Centennial Building, 1685 Highland Ave, Madison, WI, 53705-2281, USA. [email protected]

• PMID: 26739462
• DOI: 10.1007/s11894-015-0478-5

Abstract

The digital rectal examination (DRE) is performed in children less often than is indicated. Indications for the pediatric DRE include diarrhea, constipation, fecal incontinence, abdominal pain, gastrointestinal bleeding, and anemia. Less well-recognized indications may include abdominal mass, urinary symptoms, neurologic symptoms, urogenital or gynecologic symptoms, and anemia. Indeed, we believe that it should be considered part of a complete physical examination in children presenting with many different complaints. Physicians avoid this part of the physical examination in both children and adults for a number of reasons: discomfort on the part of the health care provider; belief that no useful information will be provided; lack of adequate training and experience in the performance of the DRE; conviction that planned “orders” or testing can obviate the need for the DRE; worry about “assaulting” a patient, particularly one who is small, young, and subordinate; anticipation that the exam will be refused by patient or parent; and concern regarding the time involved in the exam. The rationale and clinical utility of the DRE will be summarized in this article. In addition, the components of a complete pediatric DRE, along with suggestions for efficiently obtaining the child’s consent and cooperation, will be presented.

Keywords: Anus; Child; Digital rectal exam; Pediatric; Pediatric rectal exam; Rectal exam.

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It was quite an experience, once that is fresh in my mind 35 years later, probabliy becuase at the time my father was coming in for my physical exams so I had my first prostate exam right in front of him. Rather than being embarrassing, to me it was sort of a rite of passage and I was glad that my father was there to see it.

However, I must admit it was rather interesting seeing all the other candidates getting their examinations, as well. I really felt no embarrassment and wasn�t paying too much attention as to whether any of the other guys were embarrassed. Nobody complained, but that wouldn�t have exactly been acceptable behavior for military service.

I had my first rectal exam when I was 9. I was sick and my mother took me to the doctor. After taking my rectal temperature, the doctor put on a glove and slipped his finger in my bottom. I was very surprised and clearly remember wondering why he was doing this.

I was lying on the examination table, almost entirely naked, my underwear down to my ankles.

It lasted several minutes. I didn’t hurt at all, but I felt terribly embarrassed because my mother watched everything. It’s been a long time since I had my underwear pulled down at the doctor’s.

I never knew why I had a rectal exam on that day. I was too embarrassed to ask my mother about it.

Horses with signs of colic can be grouped into one of three categories:

horses which are resolved after medical management at the farm;

horses which are resolved after more intensive medical management at a referral

Horses with signs of colic can be grouped into one of three categories:

1. horses which are resolved after medical management at the farm;
2. horses which are resolved after more intensive medical management at a referral facility; and,
3. horses which are resolved after performing emergency abdominal surgery.

In a study of 1,929 equine ambulatory calls made during two years, 7.6% (147 out of 1,929) of these calls were to treat horses with signs of colic, and only one horse required emergency abdominal surgery, suggesting that the great majority of colicky horses resolve with medical management.

Veterinarians assign horses into one of these three categories after reviewing the pertinent aspects: a thorough history, a complete physical examination, and any laboratory data deemed significant. A complete physical examination includes evaluation of the horse’s clinical signs (e.g., depression, abdominal distension, sweating), the cardiovascular system (e.g., heart rate, mucous membrane color, capillary refill time), reflux from the stomach after passing the nasogastric tube (e.g., fluid volume, color, smell), the quality and duration of pain relief by analgesics (e.g., flunixin meglumine, butorphanol), and findings of examination per rectum. Although it is not necessary to perform all of the items listed when evaluating horses, veterinarians gather information from these areas to formulate a diagnosis.

Findings of examination per rectum have been suggested to be the most important aspect of the physical examination in a horse with signs of colic, therefore evaluation of the gastrointestinal tract per rectum is usually performed on all horses with signs of colic. Performing an examination per rectum is not without risk, and should only be performed by an equine veterinarian. Rupture of the equine rectum is a life-threatening complication, and a high percentage of horses wi

• 
• 
• 

What is a rectal examination?

It is an examination where the doctor puts a finger inside the rectum to feel if there is any abnormality. The Latin word for finger is digitus, so it is also called a digital rectal examination or DRE.

The rectum is the last (or distal) part of the large bowel (colon) through which solid waste (stools or faeces) pass to the outside of the body. The distal colon has an S-shaped part (the sigmoid, from the Greek word for the letter S) which passes on to the rectum (from the Latin word rectus, straight). The opening of the rectum on the outside is called the anus. This is surrounded by a ring of smooth muscle (the anal sphincter) which keeps it closed. When the rectum becomes filled with faeces, the person can choose to relax the anal sphincter, then the smooth muscles of the rectum contract automatically, forcing the stools to the outside (defecation).

Why is rectal examination performed?

Rectal examination involves looking at the area around the anus to see if there are any abnormalities, for example haemorrhoids, which are enlarged or dilated veins (varicose veins) of the lower rectum. With the finger placed through the anus the doctor feels if there is any abnormality inside the rectum or in the prostate gland, which is located below the bladder neck just in front of the rectum.

There are mainly three reasons for performing a DRE:

• Complaints (symptoms) that raise suspicion of a bowel problem.
• Symptoms suggesting a prostate problem.
• In men over the age of 50, without any symptoms, to feel if there is cancer in the prostate.

Complaints suggesting a bowel problem include

• passing blood from the rectum (haematochezia),
• pain on defecation,
• infrequent and difficult passing of stools (constipation),
• frequently passing loose or watery stools (diarrhoea),
• pain in the stomach,
• not wanting to eat (anorexia),
• nausea, vomiting and loss of weight.

Symptoms suggesting a prostate problem include

• passing urine very often during the day (frequency) and night (nocturia),
• feeling a great urge to pass urine immediately when the bladder is full (urgency),
• having to wait long before the urine stream starts (hesitancy),
• pushing or straining to pass urine,
• a weak urinary stream (stranguria),
• stopping and starting of the stream (intermittency),
• a feeling that the bladder is not empty after urination,
• involuntary passing of urine (incontinence),
• pain during urination (dysuria) and
• blood in the urine (haematuria).

Prostate cancer is one of the most common types of cancer in men over the age of 50, and the risk of developing prostate cancer increases rapidly with age. Early stage prostate cancer does not cause any symptoms, and the easiest way to detect it is with DRE.

How is a rectal examination performed?

The doctor should tell you if a rectal examination is necessary, using words such as “I have to examine your back passage” or “I have to feel your prostate”. The doctor will usually ask you to turn over on your left or right side, rest your head on a pillow, bend your hips and draw your knees up against your belly, so that you are lying in a curled-up position.

DRE can also be performed in other positions, depending on the doctor’s preference. You may be asked to lie on your back, draw your knees up and open your thighs, or you may be asked to turn over on your knees and elbows on the examining table, or you may be asked to stand up and bend forwards over the table, resting on your elbows.

The doctor may touch your buttocks to open them in order to inspect the area around the anus. The doctor puts a glove on and smears lubricating jelly on the index finger, which is then inserted through the anus into the rectum. You may be asked to relax completely, to breathe in and out deeply, or to push down like when you are passing a stool. Usually the doctor will insert the finger quite slowly, giving the anal sphincter time to relax.

After feeling the prostate and the inside of the rectum, the doctor removes the finger and looks to see if there is any blood on the glove. He may also test the faeces sticking to the gloved finger with a test strip to see if it contains blood which is not visible (occult blood). The doctor will then usually wipe the anal opening with a piece of paper, or give you some paper and ask you to wipe yourself.

How should I prepare?

Many patients are embarrassed about undergoing a rectal examination, or are afraid that it will be painful. It is important to realize that your doctor has performed this examination many times before, and it is not really different from examining any other part of your body or looking into your mouth or ears. It is also important to realize that when passing a stool, the anal sphincter is able to relax and pass a solid body which is considerably thicker than the doctor’s index finger.

It is not necessary to take a laxative or have an enema before a DRE. It is important to relax completely during the examination, and especially to relax the muscles of your buttocks and anal sphincter. When you feel the finger touching your anus, it helps to push down slightly, like when you are passing a stool. Although DRE may be slightly uncomfortable, it should be no more so than passing a stool. It should not be painful, unless there is a problem such as a raw area (fissure) in the anal canal, haemorrhoids which have thrombosed (become clotted) or acute infection of the prostate.

What are the risks?

Apart from embarrassment and slight discomfort, DRE is completely safe and risk-free.

What are the limitations of the procedure?

DRE is not very reliable in detecting early stage prostate cancer, therefore it is necessary to also do a blood test, prostate specific antigen (PSA), which becomes elevated if there is prostate cancer. However, some men have prostate cancer with a low PSA, and in such cases DRE is the only way to find out if they have cancer.

In patients with bowel symptoms, DRE often does not make a definitive diagnosis, but it can rule out conditions such as cancer of the anus or rectum, or detect the presence of occult blood in the stool, which may indicate cancer of the colon. If the diagnosis is still unsure after DRE, further investigations may be necessary.

Articles On Colon Cancer Screening Tests

• Digital Rectal Exam
• Flexible Sigmoidoscopy
• At-Home Screening
• Barium Enema
• Virtual Colonoscopy
• Proctoscopy

Your doctor may recommend a digital rectal examВ (DRE) for these reasons:

• Help evaluate growths or enlargement of the prostate gland in men
• Look for the cause of symptoms such as rectal bleeding (blood in the stool), abdominal or pelvic pain, or a change in bowel habits
• Check on some problems in a woman’s reproductive system (such as the uterus or ovaries)
• Collect a sample of stool to test for blood
• Check for hemorrhoids or other growths in the rectum

Who Should Get a Digital Rectal Exam?

You may need a digital rectal examВ if you have rectal bleeding, abdominal or pelvic pain or a change in bowel habits.

But studies have shown there is little evidence that DREs are effective in screening for cancers such as colon, rectal or prostate. For that reason it is not part of the routine physical examination.

However, a DREВ might be included as a part of prostate cancer screening. This will depend on your age, risk factors and symptoms.

What Happens During a Digital Rectal Exam?

You’ll get this test in your doctor’s office. It only takes a few minutes.

First, you’ll undress below the waist and drape a paper or cloth covering over your waist. Men are often examined while standing, bending forward at the waist, or lying on their side with knees bent. Women usually get this test during a pelvic exam, with their feet raised and supported by stirrups.

The doctor will insert a lubricated, gloved finger into the rectum and feel for tenderness or other abnormalities. They’ll probably press the abdomen with their other hand to help them feel any abnormalities.

You may feel slight, momentary discomfort during the test. But it shouldn’t hurt.

What Happens After the Digital Rectal Exam?

Your doctor will discuss the test results with you. This is what they may find:

• Nothing, a normal exam
• Abnormal growths or enlargement of an organ (such as the prostate, cervix, uterus, ovaries, rectum, or bladder)
• Hemorrhoids, abscesses, or anal fissures (breaks in the skin around the anus)
• Polyps, or tissue growths in the rectum
• Blood in the stool

Show Sources

American Cancer Society.

NIH: ” Prostate-Specific Antigen (PSA) Test.”

A complete physical examination includes a digital rectal examination. If the digital rectal examination is inconclusive, then anoscopy can be used to further examine the anal canal. This video demonstrates both the digital rectal examination and anoscopy.

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Funding and Disclosures

Disclosure forms provided by the authors are available at NEJM.org.

No potential conflict of interest relevant to this video was reported.

Author Affiliations

From Brigham and Women’s Hospital, Harvard Medical School (T.K.R., A.V.K.), and Massachusetts General Hospital (L.G.B.) — both in Boston; the University of Tübingen, Tübingen, Germany (H.R.); and Changzheng Hospital, Second Military Medical University, Shanghai, China (H.Z.).

Address reprint requests to Dr. Zhou at Shanghai Changzheng Hospital, No. 415 Fengyang Rd., Shanghai, 200003, China, or at [email protected] .

Colorectal Exam

A colorectal exam, or digital rectal exam (DRE), is a physical exam of your rectum. Your gynecologist or primary care doctor may perform this as part of a pelvic exam. It involves inserting a lubricated, gloved finger into your rectum to feel for abnormalities. While the procedure can be uncomfortable, it should not be painful.

Contact Southcoast Health or find a doctor near you to set up a colorectal exam in southeastern Massachusetts or Rhode Island.

Reasons for a Colorectal Exam

Your doctor at Southcoast may perform a colorectal exam for the following reasons:

• To screen for rectal, ovarian or uterine cancer
• As part of a routine exam, but not all doctors include a colorectal exam
• To evaluate pelvic support problems, such as pelvic organ prolapse
• To evaluate symptoms, such as changes in bowel habits, pelvic pain and rectal bleeding

After the exam, you may experience slight rectal bleeding. This is especially true if you suffer from hemorrhoids or anal fissures. Tell your doctor if the bleeding is heavy or doesn’t stop.

What to Expect

If your doctor includes a colorectal exam it will only take only a few minutes. If you’re a woman and your doctor includes a colorectal exam during a pelvic exam, it will likely take place after your vaginal exam. Your doctor will ask you to breathe deeply and relax. After your doctor inserts a finger, he or she may press on your lower belly or a woman’s pelvic area. This can help your doctor better feel the organs in your pelvis. Your doctor will tell you what is happening at each step, so you know what to expect. They may also use a sigmoidoscopy to examine the rectum and colon more closely.

Schedule Your Annual Exam at Southcoast Health

Easily make an appointment for your annual colorectal or gynecological exam at a Southcoast Health location near you today.

Southcoast Health provides colorectal exams for patients across southeastern Massachusetts and parts of Rhode Island.

A digital rectal exam (DRE) is an exam in which a healthcare professional puts a finger into the rectum to check for problems or abnormalities in the lower abdomen and pelvis.

Why a DRE is done

A DRE is most often done as part of a routine physical exam in adults. It is done:

• to check the prostate gland for enlargement or growths in men
• as part of a pelvic exam to check the uterus and ovaries in women
• to check for problems with structures or other organs in the pelvis, such as the bladder
• to help find the cause of symptoms, such as blood in the stool (poop), rectal bleeding, changes in bowel or bladder habits, lower abdominal pain or pelvic pain
• to check for hemorrhoids (swollen blood vessels near the anus or rectum) and growths in the rectum

How a DRE is done

There is no special preparation for a DRE.

• Men are often examined while lying on their side with their knees bent toward the chest. They may also be examined while standing and bending forward at the waist.
• Women are examined while lying on their back with their knees bent and spread apart or with their feet raised in stirrups.
• The outside of the anus is checked for hemorrhoids, small cracks or tears in the skin (fissures) around the anus and other abnormalities.
• The healthcare professional gently inserts a lubricated, gloved finger of one hand into the rectum. The other hand may be used to press on the lower abdomen or pelvic area to feel for tenderness, hardness or growths.

You may feel some mild discomfort or pressure during the test.

What the results mean

A DRE is usually done with other tests to check for abnormalities. Even if DRE results are normal, further tests may be suggested.

Abnormal findings may include:

• enlargement of the prostate gland or growths or tumours in the prostate gland in men
• growths or tumours of the cervix, uterus or ovaries in women
• hemorrhoids, polyps or fissures in the rectum
• growths or tumours, such as cancer in the rectum

What happens if the results are abnormal

Your doctor may recommend more tests, procedures, follow-up care or treatment.

Rectal exam under anesthesia is performed to examine your rectum for any abnormalities or problems. Dr. Madhu Prasad, a trusted general surgeon in Anchorage, AK, has years of experience in conducting rectal exam under anesthesia with successful results.

When Do You Need a Rectal Examination?

A rectal examination is needed for the following reasons:

• A change in your bowel habits
• Signs of rectal bleeding, abdominal or pelvic pain
• Hemorrhoids or other problems in the rectum
• Growth of the prostate gland in men
• Problems in a woman’s reproductive system

Why Is Rectal Exam Performed Under Anesthesia?

The doctor uses a lubricated, gloved finger to check any abnormalities in your rectum. Anesthesia is used to make you feel comfortable during the examination. It helps in relaxing the muscles around the anus and makes the examination procedure easier.

How Is Rectal Exam Under Anesthesia Performed?

A rectal examination is quick and little to no pain is felt during the procedure. A rigid sigmoidoscopy and a proctoscopy are used in the rectal exam. In rigid sigmoidoscopy, a small telescope is inserted into your rectum to make it easy for your doctor to examine your rectum and lower colon. A proctoscopy is used to examine the rectum, anal cavity, or sigmoid colon for diagnosing conditions such as anal fissures, hemorrhoids, and anal fistulae.

How Long Do You Have to Stay in the Hospital After a Rectal Examination?

You may go home the same day or the next day depending on the type of anesthesia you are given.

What Is the Recovery Time for Rectal Exam Under Anesthesia?

You can get back to your work and normal activities within a few days.

Why Choose Us for Rectal Exam Under Anesthesia?

At Far North Surgery, we use the best and latest surgical tools and techniques to conduct rectal exam under anesthesia. Our team is committed to providing high-quality medical care and speedy recovery to our patients.

Call us at 907-276-3676 to get more information about rectal exam under anesthesia or if you have any questions.

Dr. Madhu Prasad, M.D., FACS

Dr. Madhu Prasad has over 30+ years of experience working as a general surgeon and surgical oncologist and providing the highest level of care in Anchorage, Alaska. He believes in providing quality care to patients and their families. Inspired by compassion and humanism, Dr. Prasad and his team work for the well-being of their patients.

Abstract

Patients with pathologically low neutrophil counts, or neutropenia, can present a diagnostic and management challenge in the emergency department (ED). One diagnostic tool, the digital rectal exam (DRE), has historically been discouraged in neutropenic patients due to the concern that it may lead to bacterial translocation and subsequent bacteremia; however, evidence to support this position is lacking. Certain circumstances may justify its use if other lower-risk testing modalities are not readily available.

Keywords

• Neutropenia
• Neutropenic fever
• Rectal exam
• Anorectal

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References

Hsieh MM, Everhart JE, Byrd-Holt DD, Tisdale JF, Rodgers GP. Prevalence of neutropenia in the U.S. population: age, sex, smoking status, and ethnic differences. Ann Intern Med. 2007;146:486–92.

Schouten HC. Neutropenia management. Ann Oncol. 2006;17(Suppl 10):x85–9.

Dale D, Welte K. Neutropenia and neutrophilia. In: Kaushansky K, Lichtman M, Prchal J, Levi M, Press O, Burns L, et al., editors. Williams hematology. 9th ed. New York: McGraw-Hill; 2016. p. 991–1004.

Tomblyn M, Chiller T, Einsele H, Gress R, Sepkowitz K, Storek J, et al. Guidelines for preventing infectious complications among hematopoietic cell transplantation recipients: a global perspective. Biol Blood Marrow Transplant. 2009;15:1143–238.

Freifeld AG, Bow EJ, Sepkowitz KA, Boeckh MJ, Ito JI, Mullen CA, et al. Clinical practice guideline for the use of antimicrobial agents in neutropenic patients with cancer: 2010 update by the Infectious Diseases Society of America. Clin Infect Dis. 2011;52:e56–93.

Grewal H, Guillem JG, Quan SH, Enker WE, Cohen AM. Anorectal disease in neutropenic leukemic patients. Operative vs. nonoperative management. Dis Colon Rectum. 1994;37:1095–9.

Boddie AW, Bines SD. Management of acute rectal problems in leukemic patients. J Surg Oncol. 1986;33:53–6.

ASGE Standards of Practice Committee, Khashab MA, Chithadi KV, Acosta RD, Bruining DH, Chandrasekhara V, et al. Antibiotic prophylaxis for GI endoscopy. Gastrointest Endosc. 2015;81:81–9.

Smiley S, Almyroudis N, Segal B. Epidemiology and management of opportunistic infections in immunocompromised patients with cancer. Abstr Hematol Oncol. 2005;8:20–30.

Perazzoli C, Feitosa MR, de Figueiredo-Pontes LL, da Rocha JJR, Simões BP, Féres O. Management of acute colorectal diseases in febrile neutropenic patients. J Coloproctology. 2014;34:189–92.

Author information

Authors and Affiliations

Virginia Tech Carilion School of Medicine, Department of Emergency Medicine, Roanoke, VA, USA

Chad Mosby & Matthew P. Borloz

You can also search for this author in PubMed Google Scholar

You can also search for this author in PubMed Google Scholar

One of the advantages of starting and ending at the tail is that the more dirty procedures can be left until last! It is also the most likely site for taking diagnostic samples if a clinical diagnosis has not yet been reached.

Rectal Examination

A rectal examination is an essential part of a thorough clinical examination, and is often performed at the end of the clinical exam. Before entering the rectum, is common practice to perform a brief vaginal examination with a gloved hand to look for signs of ‘whites’ – this may either be an abnormal smell, consistency or colour of the mucous. The rectal examination can safely be done using a glove previously used for a vaginal examination, but never the other way around as this is highly likely to introduce bacteria into the reproductive tract.

The most obvious requirement for a rectal examination in an adult cow is for pregnancy diagnosis, but a rectal examination is also an integral part of a thorough clinical examination. The left kidney is situated in the midline almost directly above the rectum and should be easily palpable – check that the lobules are distinct and that the kidney is of a normal size. The right kidney is situated more cranially, but should be palpable in a shorter cow (or for those with long arms) – the caudal edge of the liver may also be within reach. Gently palpate downwards across the digestive tract – individual lymph nodes may be palpably enlarged. If the vaginal examination indicated a potential metritis, then also palpate the uterus for size and tone. If you have a scanner, then use it to assess the amount of purulent material in the uterus, and check for a CL on either ovary. Before performing a rectal examination, ensure that you have used a sufficient amount of lubrication. Thoroughly applying lubrication to the anus will make the rectal examination much easier and more comfortable for both you and the animal![watch video]

Diagnostic Tests

If a clinical diagnosis can not be conclusively reached from the full clinical exam, it may be necessary to take a blood sample, faecal sample or urine sample to aid with diagnosis. It is advisable to collect urine at the start of the clinical examination, but a faecal sample is easiest to collect immediately after the rectal examination. A blood sample is usually taken from the tail vein and can be left until the clinical examination is complete; but remember to remove any faeces from the underside of the tail before sampling (especially if a rectal examination has been performed).

More Gay/Bi students have come forward to sue the USC doctor who gave them unwanted prostate exams.

Apparently, Dr. Dennis Kelly, who was the only physician available to men at the college, would subject any boy who expressed being LGBTQ to a prostate exam and invasive questions about their sex life. Many of the men were just seeing a doctor by themselves for the first time and didn’t understand that this practice was unusual until several accounts of Dr. Kelly’s acts became public knowledge.

Then in February, six plaintiffs came forward to sue Dr. Kelly (and USC for their neglect over the situation). 15 men later joined the lawsuit.

Dr. Kelly did not treat heterosexual men in a similar manner and did not … perform rectal examinations on heterosexual men who had similar sexual practices,” said the updated suit.

“Despite receiving repeated complaints regarding Dr. Kelly’s misconduct, USC actively and deliberately failed to investigate, discipline, or address Dr. Kelly’s sexually abusive and discriminatory behavior and instead, continued to employ Dr. Kelly for years, allowing him unencumbered access to sexually abuse, harass, and discriminate against Plaintiffs and other male gay and bisexual USC students in his care,” the suit added.

Now, 18 additional men have come forward to join the lawsuit against Dr. Kelly, according to local news source KTLA5. In addition, two victims publicly discussed their experiences for the first time during a press conference on Thursday.

According to student reports, Dr. Kelly would ask the boys if they used sex toys and what kind. He asked one patient if he was into older men or “twinks” and how often he topped or bottomed.

One plaintiff says that Kelly, while inserting a medical device into his rectum, asked him, “How often do you let your partners come in you?”

One patient who was the victim of sexual assault went to Kelly for medical help after suffering from rectal pain and bleeding. He was then forced to go through a rectal exam and asked to recount the event despite asking not to. Kelly then allegedly told the patient that his experience was “normal sexual activity” and something “people do for pleasure.” He then asked the patient if he welcomed or enjoyed forcible penetration.

Student Jalal-Kamali said that Kelly made him uncomfortable with inappropriate questions and “the creepy smile that he had on his face throughout the conversation.”

Kelly allegedly mocked and shamed Jalal-Kamali “for anything and everything he felt like he could, based on information he forced out of me, as if it brought him some sick joy or satisfaction,” according to the student. said. “He went on to objectify my partner at the time based on my partner’s racial stereotypes, reducing his humanity to the potential size of his genitals.”

Jalal-Kamali stated that he had to return to the doctor in hopes of receiving PrEP medication.

“The process continued as I had more and more visits because he demanded it, and because he forced me to come again and again without providing PrEP medicine,” Jalal-Kamali said. “I felt so uncomfortable that I finally decided not to pursue getting PrEP medication anymore while I got into a monogamous relationship, and because Kelly made it so difficult for me to get it.”

Eventually, Jalal-Kamali went to a different medical facility to get the medication he was looking for.

Photo by Eliott Reyna on Unsplash

32-year-old John Keyes, who attended USC in 2006, also says that he was bothered by Kelly while attending the school.

“Dr. Kelly’s bedside manner was immediately off-putting,” Keyes said. “I remember him focusing on specific details, such as where I met my sexual partners, whether I frequented sex clubs or participated in online sex chats.

Kelly apparently made several offensive terms that implied Keyes was sexually promiscuous.

“I didn’t know why Dr. Kelly was making these comments, or how I was supposed to interpret them,” he recounted.

Keyes says when he went back to Dr. Kelly a year later, and the experience was more of the same.

“Like clockwork, he insisted on performing another rectal exam,” Keyes said. “More than just the crass and unprofessional language, it was Dr. Kelly’s insistence on the rectal exam — knowing how he would perform it — that made me fearful all over again. The knot I felt in the pit of my stomach was how no patient should feel with their doctor.”

USC released a statement to say to that its aware of the lawsuit and finds the allegations concerning.

“We’re working to understand the facts of this matter,” the statement reads. “We care deeply about our entire Trojan family, including our LGBTQ+ community, and take this matter very seriously.”

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Patient Preparation

Anesthesia

No anesthesia is needed, although in some patients, it may be easier to perform digital rectal examination concomitantly with other procedures that require general or intravenous sedation. Empirically, patients seem to tolerate procedures without anesthesia best when they are fully informed about expectations and are aware of exactly what is being done and when.

Positioning

Multiple positions may be used to accomplish a digital rectal examination. The easiest for the examiner is to have the patient tuck the knees up to the chest, either in the dorsal lithotomy position or the lateral recumbent position.

However, the traditional practice in the office-visit setting is to have the patient bend over a table at the waist with the knees slightly flexed, the feet shoulder-width apart, the toes pointed inward, the waist within inches of the table edge, and the forearms resting on the table. The patient should be made to feel as comfortable as possible; to this end, he or she should be afforded privacy and security in a relaxed environment.

References

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. [QxMD MEDLINE Link].

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. [QxMD MEDLINE Link].

In recent years, colorectal cancers have begun getting the attention they deserve. Cancer is the second leading cause of death (behind heart disease) in the United States. Another runner up, colorectal cancer is the second most fatal cancer (behind lung and bronchial cancer). With smoking rates dropping and no recent change in rectal health discussions, many are fearful that these two will one-day swap positions on the top of the “deadliest cancers” list. Colorectal cancer and other disorders are frequently ignored until it is much too late. Generally speaking, the normal population is not comfortable talking about their gut or butt health or discussing changes and concerns with anyone. In today’s post, we want to help shed some insight on how you can better care for your rectum and help prevent or identify problems before they become fatal.

At HR Pharmaceuticals, we create medical lubricants that make rectal exams more comfortable and limit the effects on cytology specimens. Making rectal exams more comfortable enhances the chances that patients will participate in them regularly and can decrease the incidence of stage 3 or 4 cancers. Our HR Lubricating Jelly is water-soluble so it won’t leave unsightly stains, nor will it interfere with natural gut flora.

Tips For Taking Care of Your Rectum

Maintain Proper Nutrition

What goes in, must come out. With this in mind, it should come as no surprise that the high-fat content of the typical American diet is linked to higher rates of colorectal cancer. Trans fats, grease, salts, and nitrates have all been linked to causes of colorectal cancer. Processed or preserved foods also serve to preserve your intestines, causing damage to your gut lining. Fiber plays a big role in colon health and should be consumed liberally. Eat plenty of vegetables and whole grains. Reduce the amount of processed and preserved foods. Maintain optimal hydration to keep cells happy and waste moving.

Be Mindful of What Goes In

Regardless of the route, you should be mindful of what is going into your body. In regards to the rectal cavity, there are additional considerations that should be taken before inserting anything. The anus, unlike any other cavity, is incredibly sensitive and full of natural flora and bacteria. The nature of rectal tissues is meant to keep feces from coming out until you are ready. For this reason, the sphincters are very tight and the walls are not smooth like other cavities. When anything is to be inserted into the anus, there are a few steps that should be taken.

Ensure cleanliness

If you are considering keistering your life savings, don’t. Money and other publically handled items are incredibly dirty and will introduce unwelcome bacteria into your digestive system. For suppositories or medication, ensure the medication comes directly from packaging into the anus. If you participate in anal sex, ensure that your partner showers beforehand (and afterward) or ensure that any adult toys are thoroughly cleaned after every use and again directly before being used again. This prevents any bacteria that may have grown on the toys from entering your body.

Lubricate liberally

Don’t skimp on the lube! The only time you may want to take it easy on lubricating anything being inserted into the rectal cavity is when you are placing tablets and this is to ensure maximum absorption. Anything else — fingers, scopes, speculums, rectal tubes, phallus, or adult toys — should be lubricated well with water-based lubricating jelly. Not only will proper lubrication make insertion more comfortable, but it will reduce tissue damage and tearing. Shearing of the rectal cavity can cause a variety of infections. Additionally, tears will cause scar tissue to build up, making your sphincters less effective and peristalsis slower. The takeaway? Lube liberally.

Modify Your Habits

There are many day to day habits that can influence your rectal health in different ways. While doing any of these things every once in a while may not cause problems, developing poor habits can cause major issues in the long run.

Don’t wax or bleach

Waxing and bleaching your anus causes damage to the tissues. Leaving your rectum in its natural state is your best bet to avoid problems. And, if you insist on engaging in these beauty procedures, use them sparingly.

Don’t rest on the toilet

The toilet should not be a place to read the news or scroll through your phone. Take only as long as it takes to complete your business and then get up. The toilet bowl works like a gravity sink. Combined with the relaxation of your sphincter or pressure from straining can cause hemorrhoids.

Wash with water and soap

There is no need to use any special products to clean your rectum, or any cavity for that matter. Use warm water and soap only. Avoid using antimicrobial or scented soaps and definitely no scrubbing!

Avoid straining

Sometimes straining is unavoidable. However, when you have a normal bowel movement, you should be able to simply relax and allow gravity to assist. Straining can cause hemorrhoids to develop and break blood vessels in your colon.

Get Routine Screenings

Don’t skip on routine screenings because you are embarrassed or are concerned it will be uncomfortable. Techniques have advanced to improve patient comfort and providers are well aware of the discomfort that rectal exams and colonoscopies cause and do everything they can to reduce discomfort and protect your dignity.

The type of routine screening you get will vary depending on your risk of colorectal cancer, including inherited and lifestyle risks. Generally, everyone should begin colorectal cancer screening at age 50 and those at an increased risk should begin screening by age 45 or the age an immediate family member was diagnosed, whichever is earlier. Testing may consist of a simple fecal test every year at your physical or may include rectal exams. Rectal exams to test for rectal disorders and cancer include flexible sigmoidoscopy, CT colonography, or a colonoscopy. You can discuss the options and which is suggested for you with your provider.

When It’s Time to Investigate Your Symptoms

Colorectal cancers are somewhat preventable and are relatively easy to treat if caught early. Don’t ignore changes in bowel habits and speak honestly with your provider.

Abnormal symptoms that should be investigated:

There are several symptoms that may indicate gut or rectal disorders or colorectal cancers. If you experience any of these symptoms, don’t ignore them. Contact your provider to have them checked out right away. When caught early, benign or malignant polyps can be removed fairly easily. If left untreated, colorectal cancers can quickly metastasize to other areas and organs. Symptoms you should seek medical attention for include:

• Unexplained changes in bowel habits.
• Unexplained or reoccurring diarrhea or constipation.
• Feeling that you have not completely emptied your colon after having a bowel movement.
• Black, tarry, or coffee-ground bowel-movements.
• Bleeding from the rectum.
• A constant feeling of “fullness” despite eating or bowel habits.
• Sudden change in energy levels.
• Unexplained weight loss.
• Unexplained abdominal pain or bloating.

At HR Pharmaceuticals, we are determined to help improve patient comfort and increase screenings to promote the health and safety of all people. For all of your anal lubricant needs, trust the industry’s most trusted medical lubricant — HR Lubricating Jelly. Our formula is water-based and bacteriostatic for optimal viscosity and safety. Browse our entire product line online today.

SAN DIEGO — By skipping rectal examinations as part of their workup, physicians may be missing the cause of constipation for some, a new study suggests.

Constipation is one of the most common reasons that patients present to a gastroenterologist or primary care clinic, and digital rectal exams are recommended for constipation workups by the American Gastroenterological Association (Gastroenterology. 2013;144:211–217).

Digital rectal examinations can determine whether the patient has dyssynergic defecation, which causes between 20% and 80% of chronic constipation, Shalaka Akolkar, DO, told Medscape Medical News.

“It can curb healthcare costs and improve patients’ lives because they don’t have to go through multiple imaging and testing before having a diagnosis,” she explained.

But in a retrospective review of constipation workups at two community hospitals, Akolkar and her colleagues found that only 7% included digital rectal exams. Akolkar, from Ascension Providence Hospital in Southfield, Michigan, presented the finding here at Digestive Disease Week (DDW).

The researchers identified 184 patients who made 345 office visits, receiving a total of 24 digital rectal exams. They couldn’t find comments in any of the records on maneuvers testing for dyssynergia.

On average, the digital rectal exam was not performed until the third visit. Before any digital rectal exam, 50% of the patients underwent imaging. Thirty-two percent had x-rays, 18% had computed tomography (CT) scans, and 36% had colonoscopies. The patients received an average of 1.8 laxatives before getting a digital rectal exam.

Both physicians and patients may feel some discomfort with digital rectal examinations, said Akolkar. Some male physicians won’t perform one on a female patient unless a chaperone is present, making it more difficult to arrange, she said. “I think a big factor is time,” she said. “It’s easier to order an x-ray.”

But she speculated that many physicians are not performing the procedure because they are not aware of its importance in a constipation workup. “Before I did this study, I was unaware of it,” said Akolkar, who is a resident.

Patients who made more office visits were more likely to get digital rectal exams (odds ratio [OR], 1.4) and so were those who had more tests overall (OR, 3.9).

All of this testing and laxative prescribing could be avoided for many patients whose actual problem is dyssynergic defecation, said Akolkar. “They’re contracting their sphincter when they should be relaxing it. You can train the patients to realize that they’re doing this and help the constipation to kind of relieve itself.” Biofeedback methods can be used for this kind of training, she said.

To test if a patient suffers from this problem, physicians should ask the patient to contract and bear down, then relax, as if having a bowl movement, she explained. The physician should feel more contraction higher up and less lower down; if the sphincter is contracted everywhere, that is a sign of dyssynergic defecation, she said. “The anal vault should not be tight around the finger.”

Her poster presentation raised the awareness of at least one clinician. “I see a lot of patients with constipation,” said Richard Woller, PA, from Bay State Medical Center in Springfield, Massachusetts. “And a digital rectal exam in general is not the first thing I do.”

After talking to Akolkar, he planned to try the exam to see if he found any cases of dyssynergic defecation.

“Most of the time I ask them about diet and lifestyle,” he said. “They change them and when they come back they are doing fine.”

Woller has done a lot of digital rectal exams, however, especially when patients are bleeding. Often patients express discomfort with having a digital rectal exam, and some have even refused. But he is often able to gain their cooperation by carefully explaining each step of the procedure, both before and during it, he said.

Akolkar and Woller report no relevant financial relationships.

Digestive Disease Week (DDW) 2019: Abstract Sa1086. Presented May 18, 2019.

Follow Medscape on Twitter @Medscape and Laird Harrison @LairdH

Medscape Medical News © 2019 WebMD, LLC

Send comments and news tips to [email protected]

Cite this: Rectal Exam Needed to Determine Cause of Constipation – Medscape – May 18, 2019.

To do a digital rectal examination (DRE), the urologist places a finger into your rectum to feel the back of the prostate. They’ll wear gloves and put gel on their finger to make the examination more comfortable.

You may have further tests if the specialist feels a hardened area or an odd shape. These changes do not always mean you have prostate cancer. Having a normal DRE also does not rule out prostate cancer, as the finger can’t reach all of the prostate and the examination is unlikely to pick up a small cancer.

A DRE is no longer recommended as a routine test for GPs to do, but a urologist will use it to help assess the prostate and decide if you need further tests.

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A/Prof Ian Vela, Urologic Oncologist, Princess Alexandra Hospital, Queensland University of Technology, and Urocology, QLD; A/Prof Arun Azad, Medical Oncologist, Urological Cancers, Peter MacCallum Cancer Centre, VIC; A/Prof Nicholas Brook, Consultant Urological Surgeon, Royal Adelaide Hospital and A/Prof Surgery, The University of Adelaide, SA; Peter Greaves, Consumer; Graham Henry, Consumer; Clin Prof Nat Lenzo, Nuclear Physician and Specialist in Internal Medicine, Group Clinical Director, GenesisCare Theranostics, and Notre Dame University Australia, WA; Henry McGregor, Men’s Health Physiotherapist, Adelaide Men’s Health Physio, SA; Jessica Medd, Senior Clinical Psychologist, Department of Urology, Concord Repatriation General Hospital, NSW; Dr Tom Shakespeare, Director, Radiation Oncology, Coffs Harbour, Port Macquarie and Lismore Public Hospitals, NSW; A/Prof David Smith, Senior Research Fellow, Daffodil Centre, Cancer Council NSW; Allison Turner, Prostate Cancer Specialist Nurse (PCFA), Canberra Region Cancer Centre, Canberra Hospital, ACT; Maria Veale, 13 11 20 Consultant, Cancer Council QLD; Michael Walkden, Consumer; Prof Scott Williams, Radiation Oncology Lead, Urology Tumour Stream, Peter MacCallum Cancer Centre, and Professor of Oncology, Sir Peter MacCallum Department of Oncology, The University of Melbourne, VIC.

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Time to double glove!

Breast, genital, and rectal exams… how do I even begin?

Well, I can begin by saying that I was nervous about this week for a long time. Ever since second semester, we’ve learned how to perform physical exams on most of the body, from palpating for tactile fremitus on the lungs to testing deep tendon reflexes with a reflex hammer. Most everything is more or less straightforward and easy to practice with a fellow classmate. However, in fifth semester, we complete our physical exam training by learning how to perform male and female breast, axillary, genital, and rectal exams, which include hernia exams for males and pap smear, bi-manual, and rectovaginal exams for females. Obviously, we can’t perform these exams on each other, and so the school, like all other medical education programs in the US, bring in professional patients to let us practice these necessary skills.

It all started last week, after a relatively unorthodox, but helpful lecture by Dr. V that started with a reenactment from the off-Broadway theatrical play “The Vagina Monologues.” Dr. V is an awesome professor with many decades of practicing experience who always has his own way of making lectures both educational and fun, two qualities that you often don’t expect to go together in school. Afterwards we learned to perform the exams on plastic models. The plastic models were pretty cool because they had modules that you could switch out that simulated pathological body parts with tumors as well as body parts that felt normal. After a week of practicing on these plastic dummies, we were finally ready to experience the real deal on real people.

This week, two male and two female trained professional patients flew down from the states to AUC to help us in this part of our training. The professional patients were exactly that… professional patients. They weren’t just people who were there to expose their bodies for students to practice on. They were trained instructors who travel to different med schools and PA schools to teach students not only how to perform the exams correctly on their bodies, but also what to say to make patients feel comfortable and safe, and how to teach patients to do self exams. For most of us, this was our first time ever doing these exams, and many of us felt a little nervous and awkward. I certainly was, as I was afraid of hurting the patients. However, the professional patients had a lot of patience in walking us through the steps in every detail, guiding our hands to the right places, and letting us feel what we were supposed to feel, like checking the inguinal ring for hernias, or palpating for the two sides of the prostate. They knew what they were talking about and guided us well.

We learned to perform the male exams in groups of six students to one patient while we learned to perform the female exams in groups of three students to one patient. Our male patient was especially helpful and we learned a lot from him. He also had a really great sense of humor, which certainly helped in making what is normally a very awkward experience into something that’s not that bad anymore. Our female patient was also very helpful and nice. I felt a lot more comfortable and less nervous and more receptive to learning because of our professional patients’ attitude and guidance. The professional patients were also the ones that evaluated us as students.

Part of learning how to perform breast and genital exams on others is also how to perform these exams on ourselves. During our male exam, our professional patient asked the male students in our group if any of us performed self exams. None of us raised our hands. He then reminded us that most of us are in the 20-30 age range, the peak range for testicular cancer, which we had all learned about in Pathology not too long ago. All of us were pursuing the medical field yet none of us cared enough about our own bodies to regularly screen ourselves with a simple exam for a disease that could potentially kill us. It made me realize the importance of self exams, especially as aspiring physicians, and the importance of being a role model for health in the society we want to help.

So in conclusion, it turns out that an experience that I wasn’t really looking forward to actually became a really awesome experience that I learned a lot from and am so happy I did. I have to really applaud and thank the professional patients. It’s not easy doing what they do (especially with so many students and so many fingers) and they did a great job. My comfort level has been pushed up to the next level, which is what med school is all about.

**UPDATE 5/2012**
Now that I am in clinicals, I have to say that I think it is so awesome that our school provided live people to teach us and let us practice breast, genital, and rectal exams before we even started clinicals. Today my attending asked me to do a breast exam on a patient, and I was able to say that I’ve done one before and feel comfortable doing it. Students from other schools may not necessarily feel as comfortable as I did today.

Under what circumstances can a patient in an emergency room be forced to submit to a procedure that doctors deem to be medically necessary? That question — and the notion of informed consent — is at the heart of a civil case that is about to go to trial in March in State Supreme Court in Manhattan.

Brian Persaud, a 38-year-old construction worker who lives in Brooklyn, asserts that he was forced to undergo a rectal examination after sustaining a head injury in an on-the-job accident at a Midtown construction site on May 20, 2003. Mr. Persaud was taken to the emergency room at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, where he received eight stitches to his head.

According to a lawsuit he later filed, Mr. Persaud was then told that he needed an immediate rectal examination to determine whether he had a spinal-cord injury. He adamantly objected to the procedure, he said, but was held down as he begged, “Please don’t do that.” As Mr. Persaud resisted, he freed one of his hands and struck a doctor, according to the suit. Then he was sedated, the suit says, with a breathing tube inserted through his mouth.

After Mr. Persaud regained consciousness, he was arrested, then taken — still in his hospital gown — to be booked on a misdemeanor assault charge. Gerard M. Marrone, who was Mr. Persaud’s lawyer, got the criminal charges dropped, then helped Mr. Persaud file a civil lawsuit against the hospital.

“Psychologically, it changed his life completely,” Mr. Marrone said of the episode. “He hasn’t been able to work. He has absolutely no trust in the system at all: doctors or the police. He has post-traumatic stress syndrome.” Mr. Persaud has been under the care of a psychiatrist who made the diagnosis, Mr. Marrone said.

After several years of legal wrangling, discovery and dueling motions, a State Supreme Court justice, Alice Schlesinger, this week refused to grant the hospital’s petition to dismiss the lawsuit.

The hospital is contesting the lawsuit. “While it would be inappropriate for us to comment on the specifics of the case, we believe it is completely without merit and intend to vigorously contest it,” said a hospital spokesman, Bryan Dotson.

In an interview today, Nancy Berlinger, deputy director at the Hastings Center, a bioethics research institute based in Garrison, N.Y., emphasized that she was not familiar with the specifics of the case but said it appeared to raise important questions about the doctrine of informed consent.

In general, patients may decline medical treatment if they are informed of the consequences of doing so and capable of making such a decision.

“There are special considerations in emergency medicine because of the need to make rapid assessments,” Ms. Berlinger said. “You could have an evident life-threatening injury — someone bleeding out of a carotid artery — or the potential for a life-threatening injury that you can’t see, such as a stroke or spinal-cord injury. It is not always clear what is the patient’s capacity to make decisions, especially if the doctor suspects a head injury.”

A jury or judge evaluating the case, Ms. Berlinger said, might have to answer these questions about the procedure: “Was it medically necessary? Was the patient capable of understanding what was going on and making a decision about it and understanding the consequences of refusal?”

To successfully demonstrate that the hospital was negligent, Ms. Berlinger said, the plaintiff would have to show that the treatment involved a departure from the “standard of care,” that the patient was harmed and that the harm resulted from the departure from the standard.

Lawyers for both sides — the hospital and Mr. Persaud — have lined up doctors to testify. In an Aug. 9, 2007, seven-page medical evaluation, Dr. Irving Friedman, a neurologist and psychiatrist hired by Mr. Persaud’s lawyers, wrote:

Although a rectal exam is part of the routine E.R. evaluation, this patient clearly refused. His life was not in danger. He did not have any signs of abdominal trauma. He had full range of motion and movement of all four extremities. A reasonable analysis of his situation could have been obtained without checking for “rectal tone.”

Dr. Friedman concluded that Mr. Persaud “has been left with extreme anxiety, agitation and depression due to the events at the emergency room.”

But there are complicating factors. Mr. Persaud was evidently driven to the hospital; doctors might have suspected he had injuries despite his ability to walk. He did not have family members present who could have helped him to articulate his medical preferences. Finally, the head injury — requiring stitches — might have led doctors to question Mr. Persaud’s capacity for making an informed decision.

Now the case goes to court. The judge set a trial date of March 31.

the online peer-reviewed publication for medical students

“The patient, today, is Stephen,” revealed Mister the patient, his lips curled up in a mischievous smile. He was already wearing a hospital gown when I entered the physical exam room with two of my classmates.

“But it’s not the name that’s written on the schedule. I’ve got Luke here,” my classmate noticed.

When I heard Mister laughing that cheerfully, I knew that this clinical skills session would be different. Really different. It was not the posters of a male genital anatomy on the wall, the famous blue latex gloves on the table or even the patient’s buttocks that the gown left bare which gave me a clue, but rather his cheeky sense of humor.

“It’s going to be Stephen for today. You’ll understand, if you know a little about Canadian politics,” promised Mister.

“So put your gloves on, and don’t forget the lube. There are no budget cuts in that department yet,” Mister joked once again, strangely more at ease than us. As medical students, we thought that we had seen it all even before working at the hospital.

Usually, instead of examining prostates, college students sleep in on Friday mornings, especially when there are no scheduled lectures. But in medicine, we tend to do things a little differently.

“Do we have a volunteer?”

So I washed my hands and put on some gloves in the blink of an eye, a little too enthusiastic. However, as soon as I stood in front of the examination table, my heart started pounding hard, betraying my novice status.

Mister took the bed sheet off the plastic mannequin, and then told me, with a swift movement of the hand, that the ball was now in my court after explaining the maneuver. Not all patients are equal, and Mister, one of those teaching patients, is responsible for teaching us the needed clinical skills. For once, a patient would teach a medical student, and not the other way around.

“Don’t forget: Stephen really, really loves guns.”

The gun that Mister was talking about is the position of the hand most appropriate for a digital rectal exam. Sometimes small details matter, and turning our hand into a one-finger revolver would make the exam less uncomfortable for the patient. As a medical student who is more anxious about getting the technique right, I sometimes forget that patient’s comfort should be put first.

But it was not the end. The hardest was yet to come.

“Stephen, it’s also me for today. It’s your turn now!”

If I were Mister, I would really be worried: how could he trust a second-year medical student to do a digital rectal exam on his own body? Yes, I have practiced the technique on Stephen, the mannequin, but that does not make me an expert. I realized that it was my low level of competency that made me uncomfortable, not the intimate nature of the exam or even the patient’s nudity.

Gun, Nina, gun. Don’t forget. The gun can shoot cancer.

It was my time to learn.

Conclusion: Stephen the patient had a symmetrical prostate, as big as a walnut. No prostate cancer. I was listing the findings while I was taking my gloves off, proud to have accomplished my first digital rectal exam.

When we know that half of the patients with an abnormal digital rectal exam result will be diagnosed with prostate cancer, it is mandatory that tomorrow’s physicians learn how to do this procedure appropriately. Without Stephen and his guns, I would have never learned. I would have stayed a novice all my life.

Saving a life with an exam that does not even take a minute? Mission accomplished.

Thanks, Stephen. I do not approve your love for guns but, at least, you will have taught me how to save lives when I’ll finally enter the wards.

Former Managing Editor

University of Sherbrooke Faculty of Medicine

Nina Nguyen is a Class of 2016 student at the University of Sherbrooke Faculty of Medicine in Sherbrooke, Canada. Currently a blogger for her institution and a content editor of the Publications Support Division of the International Federation of Medical Students’ Association, she has a strong interest in medical journalism and in medical humanities. As an aspiring physician-writer who wishes to commit to the field of public health, she enjoys advocating for reproductive health and rights and understanding the power of media in the doctor-patient relationship. Find her on Twitter at @meimeian, where she can tweet in 5, maybe 6, languages.

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Nina Nguyen

Former Managing Editor

University of Sherbrooke Faculty of Medicine

Nina Nguyen is a Class of 2016 student at the University of Sherbrooke Faculty of Medicine in Sherbrooke, Canada. Currently a blogger for her institution and a content editor of the Publications Support Division of the International Federation of Medical Students’ Association, she has a strong interest in medical journalism and in medical humanities. As an aspiring physician-writer who wishes to commit to the field of public health, she enjoys advocating for reproductive health and rights and understanding the power of media in the doctor-patient relationship. Find her on Twitter at @meimeian, where she can tweet in 5, maybe 6, languages.

As a medical student, I found it surprisingly comfortable, because my “patient” was also my very patient instructor

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The first time I did a pelvic exam on a real patient, that patient was also my instructor. In the exam room, a bathroom and hospital gown draped the upright exam chair; and staring straight at me hung a laminated photo of the external female anatomy. The paper towel, speculum and two bottles of lubricant had been arranged perfectly on the counter. Another medical student and I had three hours to spend with our educator, someone who was not an M.D. or a med school professor, but rather a professional who has been trained in how to teach about her own body.

“Hi, my name is Liz and I am your educator today. I’m going to walk you through how to do a pelvic exam, which you will do on my body. I’ll guide you through the entire process.” At this point, I felt nervous in my chest. I had read the curriculum pre-notes before the session but had no idea what I was supposed to do once my hand was in the vagina.

After Liz gave us a quick overview, we entered into the portion of physically conducting the exam. “First, you’re going to inspect my external genitalia. Tell me what you see.” She instructs me to cinch the center of the white cloth draped over the lower half of her body and hand her the bunched-up cloth. Here I am, eye-level with her vagina, the educator slightly elevated on the examination table such that she can follow my actions.

Awkwardly, I began to describe the anatomical features, the distribution of hair, any signs of a rash or redness. I felt self-conscious that my patient could hear my observations of her own anatomy described in highly medical terms. She seemed unfazed, though, and expanded on my words.

“In fact, if you look here, this patient had a Brazilian wax and what might be mistaken for an ingrown hair or a cyst. If you see this, palpate the area and ask the patient about any recent changes to their body.”

Liz described herself as “this patient,” which at first made me feel confused. Why didn’t she just use first person pronouns? As the encounter continued, I began to see why. The language allowed herself to separate the two roles of educator and patient. She, the educator, could tell me from a professional standpoint how to accurately and effectively examine the anatomy. She, the patient, could also give me real-time feedback on how to make her more comfortable and what hurt and didn’t hurt.

“Now you’ll go ahead and palpate, making concentric circles to feel for any masses. Then you’ll trace down the labia majora and the labia minora until you reach the introitus, making a piano key–like motion.”

As I placed my hands on the educator for the first time, I realized how this was the first time I had encountered female anatomy from a purely educational standpoint. The interaction was clearly not sexual. It was not personal. I only felt extreme gratitude she would allow medical students to learn from her body.

“Should I take my hand out while you’re answering my questions?” I asked. I felt strangely uncomfortable talking to her with my hand inside.

“No,” she stated, “it’s totally fine.” My fingers sat in her vaginal canal while she gave extensive answers and feedback, often for five to 10 minutes at a time.

As we moved on the speculum portion of the exam, my fear of causing her any discomfort was quelled by her calming tone. She knew her anatomy. She knew how to guide students to find different anatomical landmarks. The death trap of a speculum somehow made it to its place, but I still couldn’t locate the cervix. I tilted the speculum 10 degrees to the right, still trying to visualize the cervix, when Liz declared, “One thing to note is not to move around in there like the speculum is a telescope.”

“Ah, I’m sorry if that hurt.” Liz shook her head denoting that it was okay. “On the flip side, I did find your cervix!”

She immediately broke character. “WHAT? No way. Wait, let me see!” She pulled up a mirror to look at her own cervix. “Students often have a really hard time seeing my cervix, so I never get to see it. Good job, you go girl!” She quickly remembered how she had to be in professional character, and gently switched back to a confident, but beaming, tone. We both smiled.

And that was the moment.

Up to that point, medical school had been: Physician dumps information on students. Physician brings in a patient. Patient gets stereotyped as “the one with this certain disease.” Rinse-Lather-Repeat. The patient and the teacher were roles held by different people. Yet this was the first time I had seen how merging the roles of patient and teacher into one could equalize the playing field, opening the door for a more meaningful doctor-patient relationship. It requires a trust for the patient, trusting that patients know their body best—something not always acknowledged in the practice of medicine today. The opportunity to build that trust happens every time a patient walks into an exam room and the doctor is willing to listen. And from what I’ve learned administering my first pelvic exam with Liz, that can make all the difference.

The views expressed are those of the author(s) and are not necessarily those of Scientific American.

Author

Senior Lecturer in General Practice, The University of Western Australia

Disclosure statement

Brett Montgomery is a fellow of the Royal Australian College of General Practitioners, whose guidelines he discusses in this article. He was not involved in the writing of these guidelines. Ceasing routine rectal examinations during prostate cancer screening may make his clinical work a little bit easier. Some of his patients and family members have been affected by prostate cancer.

Partners

University of Western Australia provides funding as a founding partner of The Conversation AU.

Three prime ministers and nearly three years ago, “first bloke” Tim Mathieson caused a brouhaha with his advice on prostate cancer screening:

We can get a blood test for it, but the digital examination is the only true way to get a correct reading on your prostate, so make sure you go and do that, and perhaps look for a small Asian female doctor is probably the best way.

It was the “small Asian female” part of this statement that attracted criticism, but what of the rest of his advice?

It correctly identifies the two common ways GPs screen for prostate cancer: a blood test (for a protein called prostate-specific antigen, or PSA) and the digital rectal examination, in which a doctor feels the prostate gland by inserting a gloved finger (“digit”) into a man’s rectum.

But rectal examination is less accurate than the PSA blood test, missing more cancer and causing more false alarm.

Until recently, the combination of PSA and rectal examination was recommended. If the PSA level is too high, or the prostate feels suspiciously abnormal, men usually go to get a biopsy to see if there is truly cancer in the prostate.

In news that may come as a relief to apprehensive men and short-fingered doctors alike, guidelines are changing. Both the Cancer Council and the Royal Australian College of General Practitioners have recently recommended doctors dispense with the rectal examination when screening for prostate cancer.

What is prostate cancer screening?

The prostate is a gland at the base of the male bladder which wraps itself around the beginning of the urethra (the urine outflow tube). Though small, it can cause big problems for men’s well-being. Prostate cancer is the fourth leading cause of death in Australian men, after heart attacks, lung cancer and stroke.

By “screening”, we mean doing tests that look for prostate cancer in men who are at low risk – those with no family history of prostate cancer. (The situation is more complicated for men with such family history; I won’t discuss this here.) This screening is most often considered for men aged 50-69.

The hope with cancer screening is that, by picking up cancer early, we may forestall death and avoid suffering. But for prostate cancer, our screening tests (PSA and rectal examination) have significant limitations.

Should you choose to be screened for prostate cancer at all?

Prostate cancer is a disease that many men die with rather than of – that is, despite aggressive prostate cancer killing some men, many more men would peacefully co-exist with their mild prostate cancers if they were left undiscovered.

Detecting prostate cancer might do good if it allows timely treatment to save men’s lives, but can do harm via treatment side-effects: impotence, incontinence, the anxiety of false alarms or of discovering cancer, and so on.

Whether prostate screening saves lives at all is still debated. Several trials have found no preventive effect. The best-conducted trial (probably our most reliable) showed that screening could prevent about one in five deaths from prostate cancer. However, this protection doesn’t happen very often.

For a useful illustration, see the second page of this information sheet. This shows that over 11 years, about 1,000 men must be screened (with PSA with or without rectal examinations) to save one life. In saving this one life, the trade-offs include:

• scores of men will have to undergo a prostate biopsy (passing a needle into the prostate several times via the rectum, and getting samples to be examined under a microscope)
• several will have complications of this biopsy
• about 37 extra men will find out they have prostate cancer (many of whom would not have suffered if the cancer was undetected)
• several will suffer cancer treatment side effects such as impotence or incontinence.

How should we weigh up these pros and cons?

For some men, the small chance of benefit and the larger risk of harm leads them to decide not to proceed with testing. For others, the possibility of averting a cancer death, though small and uncertain, is worth the risks.

There’s no right or wrong answer about whether to screen – it’s a value judgement. Doctors should share good information with their patients and help men make a decision in keeping with their own preferences.

If you do choose screening, should you have a rectal examination?

Doctors have a hackneyed saying about rectal examinations: “if you don’t put your finger in it, you’ll put your foot in it”.

The point is that we can miss important things by not doing a rectal examination. This can be true for some people with symptoms, such as rectal bleeding. But on balance, it seems it’s not the case for prostate cancer screening.

We need to decide where to set the threshold for what is considered normal for diagnostic tests. This is the case for the PSA blood test, where traditionally we use a cut-off of four nanograms per millilitre (4ng/ml) as dividing normal from abnormal (though some studies used a cut-off of 3ng/ml).

Set the cut-off too low, close to zero, and we’ll send nearly all men for biopsies that are largely unnecessary. Set the cut-off too high and we’ll miss many prostate cancers. Unfortunately, there’s no magic threshold that perfectly divides the men with the cancers we want to catch from the men we needn’t trouble.

Does the digital rectal examination improve matters when added to the PSA test? Not really. The rectal examination does pick up slightly more cancers, but these seem to be mostly the less aggressive cancers, less likely to be the ones we need worry about. In doing so, it causes more false alarms, by creating two or more false positive results for every cancer found.

The right balance between detection and false alarm is again a value judgement. But, critically, we can achieve the same sort of pick-up of cancers that we get from adding a rectal examination just by changing our PSA threshold from 4ng/ml to 3ng/ml.

Why would we want to perform an examination that many men find unpleasant when we could instead simply interpret the blood test a little differently?

As a GP, I’m following the new guidelines and not routinely performing screening rectal examinations any more.

No doubt some men will expect an examination, perhaps due to tradition, or fear of missing things. If so, I will go ahead with the examination if they prefer. But first I’ll make sure I discuss all the pros and cons – first of screening at all, and then of the limited additional value of the rectal examination.

It’ll be good to be able to reassure many men that screening rectal examinations are no longer the norm.

Subject: Rectal exams