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
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; Biopsy
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
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