Per-rectal examination






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	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. Importance 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. Preparation Of Instruments / Of the patient Taking consent 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 don’t 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 lamp). Variety of proctoscopes; Hand gloves, finger stall; Torch; Water soluble lubricant (KY Jelly); Tissue paper; A long non tooth forceps; Biopsy forceps; Procedure 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 patient’s anus. It is an unhygienic practice. It also stains the undergarments, because nobody shows courtesy to gently wipe off patient’s 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, don’t 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 towards patient. About the interpretation of findings, making diagnosis and taking biopsy text books and many articles have mentioned lot. Rectal Exam Setting up Describe procedure to pt. Pt. in Sim position: on table, lying on L side, knees up towards chest, facing away from Dr. Gloves on. External inspection Piles. Skin tags (normal, Crohn's, hemorhoids). Rectal prolapse. Anal fissure. Fistula. Anal warts. Carcinoma. Signs of incontinence, diarrhea. External inspection: straining Ask pt. to strain. Rectal prolapse upon straining. Hemorrhoid prolapse. Incontinence. Ask if straining is painful. Internal palpation Lubricate index finger. Insert finger slowly, assessing external sphincter tone as enter. Male: palpate prostate [anterior of rectum]: • Hard nodule (prostate cancer). • Tender (prostatitis). Female: palpate cervix [anterior of rectum]: • Mass in pouch of Douglas. Rotate finger, palpating along left, posterior, right walls. Withdraw finger. Wipe lubricant off pt. Ask if was significant pain during examination. Stool examination Inspect withdrawn fingertip for: • Blood, melena. • Stool color. • Pus. • Mucous. If indicated, do a fecal occult blood test: blue result means blood.