PR (Per Rectal Examination)
It is a misnomer. It should be per anal examination. You enter through
anus, into the rectum. The average finger is 4 inches. The anal canal
is about 1 ½ inches, hence about 50% of the examination is
of the anal canal. The other factors apart from short finger are how
fat the patient is, and how co operative he is. That further limits
the entry into rectum. The rectum is about 10 inches and one barely
touches the level of peritoneal reflection. Hence it is always a partial
rectal examination. There is a popular saying If you forget
to put your finger in the rectum, you will put your foot in.
If this really becomes possible, then only it will become a Per rectal
examination in toto.
Abdomen can be considered as a box, with six surfaces. Top, the diaphragm;
sides, the flanks; Anterior, ant abdominal wall, which we usually
examine in detail. Post, spine and back, usually ignored and bottom,
genitals, per rectal and per vaginal examination.
It gives and idea of pelvic collections and masses, apart from local
pathology of the ano rectum.
Of Instruments / Of the patient
It is a very embarrassing examination. Just to avoid that, patient
reports very late.
He feels shy of faecal contamination and is tense with anticipation
of the pain.
Explanation of the procedure and obtaining consent becomes easy if
you tell the patient about the important and need to do it. They usually
visit a surgeon after having tried all sorts of home and alternative
therapies. They come to you mentally prepared for surgery. You can
give a temptation that surgery can be avoided after making a proper
diagnosis with thorough examination. A detailed history taking is
not necessary most of the times, but spending the time with patient
is valuable to build the rapport. Most of the time patients themselves
come out saying Doctor why dont you see me properly if
it can change the decision for surgery.
Of the instruments
It includes proper table height, illumination ( a flexible wall hung
Variety of proctoscopes; Hand gloves, finger stall; Torch; Water
soluble lubricant (KY Jelly); Tissue paper; A long non tooth forceps;
Exposure should be with dignity. Room should be well lit. There should
be total privacy. A sister should be standing in front if the patient
is female, and should not be there if the patient is male.
Protection of the finger is better offered by the gloves and not
finger stall. The commonest and cheapest finger stall used is condom.
But has two problems, one it limits the access by at least two inches
as you hesitate to push in your finger in the natal cleft for the
fear of soiling of webs with faecal matter, and another funny problem
it is very much embarrassing if you put on condom on your finger
in front of any female patient. One of the patients of my colleague
literally sprang out of the examination table never to come back.
It is very simple to show the picture to your patient about how to
take the position, as compared to giving lot of instructions to make
him as you want.
A thorough external examination gives lot of information and gives
valuable time for the patient to become mentally prepared for the
internal examination. In certain painful conditions like an abscess
or a fissure in ano, you may even drop the idea of internal examination.
Lubrication is a must and it should preferably be water soluble like
KY jelly. Vaseline should be avoided. It is a bad temptation for the
surgeon to keep a jar full of Vaseline on the side of examination
table, dip the instrument or finger into that jar and thrust it into
the patients anus. It is an unhygienic practice. It also stains
the undergarments, because nobody shows courtesy to gently wipe off
patients anus after rectal examination.
The patient should be warned and assured just before you put in the
finger. Your left hand should separate the natal cleft; ask him to
take few deep breaths before you place your right index finger flat
on the perineum. A word of caution in female patients, finger should
not slip in the vagina. It happens very easily because an anxious
patient has a tight anus but lax vagina. Patient may not excuse you
for this mistake. A less confident junior may put his finger on the
coccyx to avoid this complication.
Ask the patient to strain. Your finger will slip in without pain,
because the sphincter relaxes on straining. Patient may again tighten
the sphincter after entry, dont be harsh. Ask him to relax while
your finger is still in. He will co operate.
Do not forget to wipe the anus with tissue paper. It is a good gesture
About the interpretation of findings, making diagnosis and taking
biopsy text books and many articles have mentioned lot.
Describe procedure to pt.
Pt. in Sim position: on table, lying on L side, knees up towards
chest, facing away from
- Skin tags (normal, Crohn's, hemorhoids).
- Rectal prolapse.
- Anal fissure.
- Anal warts.
- Signs of incontinence, diarrhea.
External inspection: straining
- Ask pt. to strain.
- Rectal prolapse upon straining.
- Hemorrhoid prolapse.
- Ask if straining is painful.
Lubricate index finger.
Insert finger slowly, assessing external sphincter tone as enter.
Male: palpate prostate [anterior of rectum]:
Hard nodule (prostate cancer).
Female: palpate cervix [anterior of rectum]:
Mass in pouch of Douglas.
Rotate finger, palpating along left, posterior, right walls.
Wipe lubricant off pt.
Ask if was significant pain during examination.
Inspect withdrawn fingertip for:
If indicated, do a fecal occult blood test: blue result means