Digital rectal examination (DRE; la, palpatio per anum, PPA) is an internal examination of the
rectum
The rectum is the final straight portion of the large intestine in humans and some other mammals, and the Gastrointestinal tract, gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the s ...
, performed by a healthcare provider. Prior to a 2018 report from the
U.S. Preventive Services Task Force
The United States Preventive Services Task Force (USPSTF) is "an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services". ...
, the DRE was a common and "dreaded" component of annual exams for older men, as it was thought to be a reliable screening test for prostate cancer.
Usage
This examination may be used
* for the diagnosis of
prostatic
On either side of the urethral crest is a slightly depressed fossa, the prostatic sinus, the floor of which is perforated by numerous apertures, the orifices of the prostatic ducts from the lateral lobes of the prostate
The prostate is bo ...
disorders,
benign prostatic hyperplasia
Benign prostatic hyperplasia (BPH), also called prostate enlargement, is a noncancerous increase in size of the prostate gland. Symptoms may include frequent urination, trouble starting to urinate, weak stream, inability to urinate, or loss o ...
and the four types of
prostatitis
Prostatitis is an umbrella term for a variety of medical conditions that incorporate bacterial and non-bacterial origin illnesses in the pelvic region. In contrast with the plain meaning of the word (which means "inflammation of the prostate"), the ...
. Chronic prostatitis/chronic pelvic pain syndrome, chronic bacterial prostatitis, acute (sudden) bacterial prostatitis, and asymptomatic inflammatory prostatitis. The DRE has a 50%
specificity for benign prostatic hyperplasia. Vigorous examination of the prostate in suspected
acute prostatitis
Acute prostatitis is a serious bacterial infection of the prostate gland. This infection is a medical emergency. It should be distinguished from other forms of prostatitis such as chronic bacterial prostatitis and chronic pelvic pain syndro ...
can lead to seeding of
septic emboli and should never be done. Its utility as a screening method for
prostate cancer
Prostate cancer is cancer of the prostate. Prostate cancer is the second most common cancerous tumor worldwide and is the fifth leading cause of cancer-related mortality among men. The prostate is a gland in the male reproductive system that sur ...
however is not supported by the evidence;
* for the evaluation of certain clinical symptoms: a male with change in urinary ability,
impotence
Erectile dysfunction (ED), also called impotence, is the type of sexual dysfunction in which the penis fails to become or stay erect during sexual activity. It is the most common sexual problem in men.Cunningham GR, Rosen RC. Overview of male ...
, or dysuria (blood in the urine), pain with bowel movements;
* a DRE with a
FOBT might have value for the anemic patient in the emergency room who has no other identifiable cause for anemia, is not actively bleeding, and you are concerned that Gastrointestinal malignancy may be the cause for their anemia;
* a true active gastrointestinal bleed: vomiting blood, vomiting
coffee-grind like material,
defecating blood or ''black'' tarry stools that can not be easily attributed to facial trauma or oral surgery, eating beets or anything with red food dye or overuse of NSAIDS/over the counter pain medication. Doing a rectal exam to examine stool color may provide a clue as to the location of the bleed but is not a reliable indicator;
* for the
diagnosis
Diagnosis is the identification of the nature and cause of a certain phenomenon. Diagnosis is used in many different disciplines, with variations in the use of logic, analytics, and experience, to determine " cause and effect". In systems engin ...
of
appendicitis
Appendicitis is inflammation of the appendix. Symptoms commonly include right lower abdominal pain, nausea, vomiting, and decreased appetite. However, approximately 40% of people do not have these typical symptoms. Severe complications of a rup ...
or other examples of an
acute abdomen
An acute abdomen refers to a sudden, severe abdominal pain. It is in many cases a medical emergency, requiring urgent and specific diagnosis. Several causes need immediate surgical treatment.
Differential diagnosis
The differential diagnosis o ...
(i.e. acute abdominal symptoms indicating a serious underlying disease). Although a
Journal of Emergency Medicine paper concludes: "We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis.";
* for the estimation of the muscle tone of the
anal
Anal may refer to:
Related to the anus
*Related to the anus of animals:
** Anal fin, in fish anatomy
** Anal vein, in insect anatomy
** Anal scale, in reptile anatomy
*Related to the human anus:
** Anal sex, a type of sexual activity involvin ...
sphincter
A sphincter is a circular muscle that normally maintains constriction of a natural body passage or orifice and which relaxes as required by normal physiological functioning. Sphincters are found in many animals. There are over 60 types in the hum ...
, which may be useful in case of
fecal incontinence
Fecal incontinence (FI), or in some forms encopresis, is a lack of control over defecation, leading to involuntary loss of bowel contents, both liquid stool elements and mucus, or solid feces. When this loss includes flatus (gas), it is referred ...
or
neurologic
Neurology (from el, νεῦρον (neûron), "string, nerve" and the suffix -logia, "study of") is the branch of medicine dealing with the diagnosis and treatment of all categories of conditions and disease involving the brain, the spinal c ...
diseases, including traumatic spinal cord injuries;
* traditionally, the digital rectal examination (DRE) was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the DRE for injuries of the spinal cord, pelvis, and bowel is poor, and false positive and negative results are common. Thus, routine performance is unnecessary and generally unhelpful. The examination is warranted in cases where urethral injury or penetrating rectal injury is suspected;
* in
female
Female (Venus symbol, symbol: ♀) is the sex of an organism that produces the large non-motile ovum, ova (egg cells), the type of gamete (sex cell) that fuses with the Sperm, male gamete during sexual reproduction.
A female has larger gamet ...
s, for the limited
gynecological
Gynaecology or gynecology (see spelling differences) is the area of medicine that involves the treatment of women's diseases, especially those of the reproductive organs. It is often paired with the field of obstetrics, forming the combined area ...
palpations of internal organs when you are unable to access the vaginal vault or it is too painful (vaginal atrophy);
* for examination of the hardness and color of the feces (i.e. in cases of constipation, and
fecal impaction
A fecal impaction is a solid, immobile bulk of feces that can develop in the rectum as a result of chronic constipation.
A related term is fecal loading which refers to a large volume of stool in the rectum of any consistency. Fecal impaction i ...
);
* prior to a
colonoscopy
Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...
or
proctoscopy
Proctoscopy is a common medical procedure in which an instrument called a proctoscope (also known as a rectoscope, although the latter may be a bit longer) is used to examine the anal cavity, rectum, or sigmoid colon. A proctoscope is a short, stra ...
;
* to evaluate
hemorrhoids
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''hemo ...
although internal hemorrhoids are often too soft to be felt, a visual inspection may be more useful;
* in newborns to exclude
imperforate anus
An imperforate anus or anorectal malformations (ARMs) are birth defects in which the rectum is malformed. ARMs are a spectrum of different congenital anomalies which vary from fairly minor lesions to complex anomalies. The cause of ARMs is unknow ...
;
* through the insertion of medical devices including thermometers or specialized balloons; to identify
digestion
Digestion is the breakdown of large insoluble food molecules into small water-soluble food molecules so that they can be absorbed into the watery blood plasma. In certain organisms, these smaller substances are absorbed through the small intest ...
problems,
parasite
Parasitism is a close relationship between species, where one organism, the parasite, lives on or inside another organism, the host, causing it some harm, and is adapted structurally to this way of life. The entomologist E. O. Wilson has ...
s,
organ
Organ may refer to:
Biology
* Organ (biology), a part of an organism
Musical instruments
* Organ (music), a family of keyboard musical instruments characterized by sustained tone
** Electronic organ, an electronic keyboard instrument
** Hammond ...
damage, anal bruising, and foreign objects in the rectal cavity;
Usage as a screening tool
In colorectal cancer screening of asymptomatic adults aged 50 to 75
* Even though 1 in 4 colorectal cancers (CRC) is located in the rectum, little evidence supports the effectiveness of using the DRE for rectal cancer detection
and it is not recommended in the colorectal cancer screening guidelines. The DRE is inadequate as a screening tool for
colorectal cancer
Colorectal cancer (CRC), also known as bowel cancer, colon cancer, or rectal cancer, is the development of cancer from the colon or rectum (parts of the large intestine). Signs and symptoms may include blood in the stool, a change in bowel m ...
because it examines less than 10% of the colorectal mucosa;
sigmoidoscopy
Sigmoidoscopy (from the Greek term for letter " s/ς" + "eidos" + "scopy": namely, to look inside an "s"/"ς"-like object) is the minimally invasive medical examination of the large intestine from the rectum through to the nearest part of the col ...
is preferred.
* Although the DRE is commonly used as a way to obtain a stool sample for a FOBT (
fecal occult blood test
Fecal occult blood (FOB) refers to blood in the feces that is not visibly apparent (unlike other types of blood in stool such as melena or hematochezia). A fecal occult blood test (FOBT) checks for hidden (occult) blood in the stool (feces).
...
) in an office based setting, ''this is an insufficient way of screening for colorectal cancer and is not recommended.''
A single office-based FOBT (fecal occult blood test) performed following a digital rectal examination (DRE) is not an adequate screen due to low sensitivity for advanced tumor and colorectal cancer.
Screening for colon cancer this way does not meet
HEDIS, Medicare or
American Cancer Society
The American Cancer Society (ACS) is a nationwide voluntary health organization dedicated to eliminating cancer. Established in 1913, the society is organized into six geographical regions of both medical and lay volunteers operating in more than ...
standards. The FOBT has never been validated for any purpose other than as a take home colon cancer screening test.
A paper published in the
Journal of General Internal Medicine
The ''Journal of General Internal Medicine'' is a monthly peer-reviewed medical journal established in 1986 and covering internal medicine. It is published by Springer Nature and is the official journal of the Society of General Internal Medicine. ...
states, "While FOBT done appropriately (taken home and used according to the instructions) is an important screening option, in-office FOBT may be worse than no screening at all because it misses 95% of cases of advanced tumor, giving many patients a false sense of reassurance."
In
prostate cancer screening
Prostate cancer screening is the screening process used to detect undiagnosed prostate cancer in men without signs or symptoms. When abnormal prostate tissue or cancer is found early, it may be easier to treat and cure, but it is unclear if early ...
of asymptomatic men aged 55 to 69
* In men aged 55–69 who have been counseled on the known harms and potential benefits of prostate cancer screening, the U.S. Preventive Service Task Force (
USPSTF
The United States Preventive Services Task Force (USPSTF) is "an independent panel of experts in primary care and prevention that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventive services". ...
) May 2018 statement states, "The use of digital rectal examination as a screening modality is not recommended because there is a lack of evidence on the benefits."
The American Academy of Family Physicians (
AAFP
The American Academy of Family Physicians (AAFP) was founded in 1947 to promote and maintain high-quality standards for family medicine, an offshoot of the classical general practitioner. It is headquartered in Leawood, Kansas.
AAFP is one of ...
) states, "Digital Rectal Exam does not improve detection of prostate cancer and should not be performed as a part of screening." The American Urology Association (
AUA) 2013 (reviewed and validity confirmed 2018) guideline panel states, "The literature supporting the efficacy of digital rectal exam (DRE) for screening with the goal of reducing prostate cancer mortality provide limited evidence to draw conclusions." "The guideline panel could find no evidence to support the continued use of DRE as a first-line method of screening."
Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age.
[
* A meta-analysis published in the ]Annals of Family Medicine
''Annals of Family Medicine'' is a bimonthly peer-reviewed medical journal that was established in May/June 2003. It publishes original research from the clinical, biomedical, social and health services sciences, as well as contributions on methodo ...
concluded: "Given the considerable lack of evidence supporting its efficacy, we recommend against routine performance of DRE to screen for prostate cancer in the primary care setting."[
]
Procedure
The digital rectal examination is a relatively simple medical procedure. The patient undresses and is then placed in a position where the anus
The anus (Latin, 'ring' or 'circle') is an opening at the opposite end of an animal's digestive tract from the mouth. Its function is to control the expulsion of feces, the residual semi-solid waste that remains after food digestion, which, d ...
is accessible (lying on the side, squatting
Squatting is the action of occupying an abandoned or unoccupied area of land or a building, usually residential, that the squatter does not own, rent or otherwise have lawful permission to use. The United Nations estimated in 2003 that there ...
on the examination table, bent over it, or lying down with feet in stirrups). If the patient is lying on his/her side, the physician will usually have her/him bring one or both legs up to his/her chest. If the patient bends over the examination table or the back of a chair, the physician will have her/him place his/her elbows on the table and squat down slightly. If the patient uses the supine position, the physician will ask the patient to slide down to the end of the examination table until his/her buttocks are positioned just beyond the end and then place her/his feet in the stirrups. The physician spreads the buttocks apart and will usually examine the external area (anus and perineum) for any abnormalities such as hemorrhoids
Hemorrhoids (or haemorrhoids), also known as piles, are vascular structures in the anal canal. In their normal state, they are cushions that help with stool control. They become a disease when swollen or inflamed; the unqualified term ''hemo ...
, lumps, or rashes. Then, as the patient relaxes and bears down (as if having a bowel movement), the physician slips a lubricated finger into the rectum through the anus and palpates the insides for a short time.
Society and culture
Due to the taboos surrounding the anus and the potential for discomfort and embarrassment, the rectal exam is a common comedic device Comedic device refers to a kind of device used to make a statement more humorous. In layman's terms, it is what makes things funny.
List of comedic devices
Repetition
Repetition is the essential comedic device and is often used in combination with ...
, including in episodes of ''Saturday Night Live
''Saturday Night Live'' (often abbreviated to ''SNL'') is an American late-night live television sketch comedy and variety show created by Lorne Michaels and developed by Dick Ebersol that airs on NBC and Peacock. Michaels currently serves a ...
'', ''Impractical Jokers
''Impractical Jokers'' is an American hidden camera Reality television#Hidden cameras, reality show with improvisational elements. Produced by NorthSouth Productions, ''Impractical Jokers'' premiered on truTV on December 15, 2011 starring the m ...
'', ''Futurama
''Futurama'' is an American animated science fiction sitcom created by Matt Groening for the Fox Broadcasting Company. The series follows the adventures of the professional slacker Philip J. Fry, who is cryogenically preserved for 1000 years a ...
'', ''Family Guy
''Family Guy'' is an American animated sitcom originally conceived and created by Seth MacFarlane for the Fox Broadcasting Company. The show centers around the Griffin family, Griffins, a dysfunctional family consisting of parents Peter Griff ...
'', ''South Park
''South Park'' is an American animated sitcom created by Trey Parker and Matt Stone and developed by Brian Graden for Comedy Central. The series revolves around four boys Stan Marsh, Kyle Broflovski, Eric Cartman, and Kenny McCormickand th ...
'' and the movie '' Fletch'', with M. Emmet Walsh
Michael Emmet Walsh (born March 22, 1935) is an American actor who has appeared in over 200 films and television series, including small but important supporting roles in dozens of major studio features of the 1970s and 1980s. He starred in ''Bl ...
as the general practitioner and Chevy Chase
Cornelius Crane "Chevy" Chase (; born October 8, 1943) is an American comedian, actor and writer. He became a key cast member in the first season of ''Saturday Night Live'', where his recurring ''Weekend Update'' segment became a staple of the ...
as the patient being examined. Similar activities to the rectal exam are attributed to extraterrestrials in video games such as ''Saints Row IV
''Saints Row IV'' is a 2013 action-adventure game developed by Volition and published by Deep Silver. It is the sequel to 2011's '' Saints Row: The Third'', the fourth installment of the ''Saints Row'' series, and the final main installment i ...
'', ''Gaia Online
Gaia Online is an English-language, anime-themed social networking and forums-based website with Chibi-style animations. It was founded as go-gaia on February 18, 2003, by Derek Liu, Long Vo, Josh Gainsbrugh, and the name was changed to GaiaOn ...
'' and ''Destroy All Humans!
''Destroy All Humans!'' is an open world action-adventure video game franchise that is designed as a parody of Cold War-era alien invasion films. '' Destroy All Humans!'' and '' Destroy All Humans! 2'' are available for the PlayStation 2 and Xbo ...
''. The practice of rectal exams without prior consent by medical students has been an area of concern.
Veterinary medicine
In veterinary medicine
Veterinary medicine is the branch of medicine that deals with the prevention, management, diagnosis, and treatment of disease, disorder, and injury in animals. Along with this, it deals with animal rearing, husbandry, breeding, research on nutri ...
rectal examination is useful in dog
The dog (''Canis familiaris'' or ''Canis lupus familiaris'') is a domesticated descendant of the wolf. Also called the domestic dog, it is derived from the extinct Pleistocene wolf, and the modern wolf is the dog's nearest living relative. Do ...
s for analysis of the prostate
The prostate is both an Male accessory gland, accessory gland of the male reproductive system and a muscle-driven mechanical switch between urination and ejaculation. It is found only in some mammals. It differs between species anatomically, ...
(as in men), pelvic urethra
The urethra (from Greek οὐρήθρα – ''ourḗthrā'') is a tube that connects the urinary bladder to the urinary meatus for the removal of urine from the body of both females and males. In human females and other primates, the urethra con ...
, sublumbar lymph node
A lymph node, or lymph gland, is a kidney-shaped organ of the lymphatic system and the adaptive immune system. A large number of lymph nodes are linked throughout the body by the lymphatic vessels. They are major sites of lymphocytes that inclu ...
s, and anal gland
Anal may refer to:
Related to the anus
*Related to the anus of animals:
** Anal fin, in fish anatomy
** Anal vein, in insect anatomy
** Anal scale, in reptile anatomy
*Related to the human anus:
** Anal sex, a type of sexual activity involving s ...
s. In horse
The horse (''Equus ferus caballus'') is a domesticated, one-toed, hoofed mammal. It belongs to the taxonomic family Equidae and is one of two extant subspecies of ''Equus ferus''. The horse has evolved over the past 45 to 55 million y ...
s it is a vital component of the clinical examination for colic
Colic or cholic () is a form of pain that starts and stops abruptly. It occurs due to muscular contractions of a hollow tube ( small and large intestine, gall bladder, ureter, etc.) in an attempt to relieve an obstruction by forcing content out ...
, to determine the presence or absence of bowel torsion, impaction, or displacement. When horses undergo a rectal examination there is a small risk of a rectal
The rectum is the final straight portion of the large intestine in humans and some other mammals, and the gut in others. The adult human rectum is about long, and begins at the rectosigmoid junction (the end of the sigmoid colon) at the le ...
tear occurring, which can be a life-threatening event, rapidly leading to peritonitis
Peritonitis is inflammation of the localized or generalized peritoneum, the lining of the inner wall of the abdomen and cover of the abdominal organs. Symptoms may include severe pain, swelling of the abdomen, fever, or weight loss. One part or ...
and septic shock
Septic shock is a potentially fatal medical condition that occurs when sepsis, which is organ injury or damage in response to infection, leads to dangerously low blood pressure and abnormalities in cellular metabolism. The Third International Con ...
. It is also a common procedure in cattle, and is one method of diagnosing pregnancy in both the horse and the cow.
The procedure in dogs and cats is similar to humans. For the horse, the patient stands in a stock
In finance, stock (also capital stock) consists of all the shares by which ownership of a corporation or company is divided.Longman Business English Dictionary: "stock - ''especially AmE'' one of the shares into which ownership of a company ...
and may be sedated. The examiner puts on a long glove that extends to the shoulder. The examiner inserts the hand and arm into the rectum as far as necessary.
See also
* Body cavity search
A body cavity search, also known simply as a cavity search, is either a visual search or a manual internal inspection of body cavities for prohibited materials (contraband), such as illegal drugs, money, jewelry, or weapons. Body cavities frequen ...
* Colonoscopy
Colonoscopy () or coloscopy () is the endoscopic examination of the large bowel and the distal part of the small bowel with a CCD camera or a fiber optic camera on a flexible tube passed through the anus. It can provide a visual diagnosis (''e. ...
* GCC homosexuality test
Gulf Cooperation Council homosexuality test was a proposed homosexuality test that would have been used in Gulf states to prevent any homosexual travelers from entering the countries. The director of public health Yousuf Mindkar from the Kuwaiti ...
References
External links
Rectal Examination
{{Digestive system procedures
Diagnostic gastroenterology
Physical examination
Rectum