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Rectal examination (PR) is a relatively common OSCE station.  You’ll be expected to pick up the relevant clinical signs using your examination skills and demonstrate appropriate communication skills. This rectal examination OSCE guide provides a clear concise, step by step approach to rectal examination.

Check out the rectal examination mark scheme here.


Introduction

Introduce yourself

Confirm patient details – name / DOB

Explain the examination:

“I need to perform a rectal examination, this will involve me inserting a finger into the back passage. It will be a little uncomfortable, but shouldn’t be painful and will only last a very short time.”

Gain consent

Request a chaperone


Gather equipment

  • Gloves
  • Apron
  • Lubricant 
  • Paper towels
  • Rectal examination equipment
    Gather equipment

Preparation

1. Wash hands

2. Don apron and gloves

3. Gain adequate exposure:

  • Ask patient to remove their underwear and cover themselves with the blanket provided
  • Leave the room and allow them time to do this

4. Position the patient in the left lateral position with their knees to their chest

  • Don apron
    Don apron

Inspection

Separate the buttocks and inspect for:

  • Skin excoriation (sphincter dysfunction/incontinence)
  • Skin tags
  • Rashes (don’t forget STIs)
  • Haemorrhoids (are they thrombosed?)
  • Anal fissures (majority are located posteriorly in the midline)
  • External bleeding (e.g. brisk GI bleeding or anal pathology such as squamous cell anal cancer)
  • Fistulae and abscesses (e.g. perianal Crohn’s disease)
  • Rectal examination
    Inspection

Palpation

1. Lubricate the examining finger

2. Warn the patient you are about to insert the finger

3. Insert finger gently into the anal canal

4. Palpate the prostate anteriorly (in males):

  • Comment on the size, symmetry and texture of the prostate
  • A normal prostate is approximately walnut sized with a palpable midline sulcus
  • It should be symmetrical and its texture is often described as “Tip of the nose” like
  • Boggy texture is associated with prostatitis
  • Enlargement and loss of the sulcus can be due to benign prostatic hypertrophy (smooth) or malignancy (irregular)

 

5. Rotate the finger 360 degrees to assess the entirety of the rectum:

  • Note location and texture of any masses or irregularities – e.g. 2cm irregular mass at 11-o’clock
  • Is there stool in the rectum? – soft vs impacted

 

6. Assess anal tone by asking the patient to squeeze your finger

 

7. Withdraw finger:

  • Inspect for blood – fresh red vs melaena
  • Inspect for stool / mucous
  • Lubricate finger
    Lubricate the examining finger.

8. Clean patient using paper towels

9. Cover patient with the sheet provided and explain the examination is over

10. Allow patient privacy to clean themselves further and get dressed

11. Dispose of clinical waste

12. Wash hands

  • Rectal examination
    Clean any excess lubricant.

To complete the examination…

Thank the patient

Summarise your findings

 

Suggest further assessments and investigations


REVIEWED BY

Dr Ally Speight

Consultant Gastroenterologist


 

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