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Bowel care, part 5 – a practical guide to digital rectal examination

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Digital rectal examination (DRE) is an invasive procedure involves observing the perianal area and inserting a lubricated gloved finger into a patient’s rectum.

Kyle, G. (2007) Bowel care, part 5 – a practical guide to digital rectal examination. Nursing Times; 103: 45, 28-29.

Keywords: Assessment, Digital Rectal Examination, Bowel Care

Author

Gaye Kyle, MA, BA, RGN, is senior lecturer, Faculty of Health and Human Science, Thames Valley University.

Digital rectal examination (DRE) is an invasive procedure and should only be performed after completion of a full assessment of constipation (NT Practical Procedures, 16 October, p26). It involves observing the perianal area and inserting a lubricated gloved finger into a patient’s rectum. Its intimate nature and fears of litigation/accusation of abuse have led to confusion among nurses about their professional and legal responsibilities.

Obtaining a patient’s legal consent is a necessary part of good professional practice ensuring trust between nurse and patient. RCN (2006) guidance addresses many of the issues related to the professional and legal aspects of DRE and clearly states that nurses should receive appropriate training to competently undertake the procedure. Many continence services have responded by providing DRE training study days.

A DRE may be performed for a number of reasons. It can establish the presence, amount and consistency of faecal matter in the bowel. It is also used to assess the need for rectal medication or digital removal of faeces in extreme cases of faecal impaction. DRE is also a method of gauging anal sphincter function and tone, rectal sensation and the size and consistency of the prostate gland. A lack of faecal matter does not necessarily signify that a patient is not constipated. Constipation of the sigmoid colon was found in 30% of patients with an empty rectum (Smith and Lewis, 1990).

Before carrying out a DRE, observe the perineal and perianal area for signs of:

  • Rectal prolapse and its degree, colour, swelling and any ulceration. This occurs when the internal anal sphincter is incompetent and pelvic floor muscles are weak;

  • Haemorrhoids. Note number, size and any signs of bleeding;

  • Anal skin tags;

  • Anal lesions or swelling. These could indicate anal/rectal malignancy;

  • Gaping anus. This may indicate poor sphincter tone. If faecal matter is observed this can indicate faecal impaction;

  • Skin condition, broken areas, pressure ulcers. Excoriation or puritus indicates possible signs of faecal incontinence;

  • Soiling. This indicates faecal incontinence;

  • Bleeding, or mucus discharge. This may indicate inflammatory bowel disease
    or malignancy;

  • Infestation. This may indicate anal warts caused by a virus or threadworms;

  • Foreign bodies.

Any of the above abnormalities should be documented and reported.

Equipment

  • Plastic-backed absorbent sheet;

  • Non-latex disposable gloves;

  • Gauze swabs;

  • Lubricating jelly.

Procedure

  • Explain the procedure and potential risks to the patient, and document that consent has been given;

  • Encourage the patient to empty their bladder, as DRE may cause discomfort to a full bladder;

  • Ensure the patient has privacy as this is an invasive and embarrassing procedure;

  • Ensure a commode or toilet is nearby as DRE can stimulate the bowel giving the urge to defecate;

  • Remove any clothing below the waist and ensure the patient is covered with a blanket to avoid unnecessary embarrassment;

  • Assist the patient to adopt, if possible, the left lateral position with knees flexed to expose the perineum and perianal area (Fig 1). The left side is preferred as it allows DRE to follow the natural anatomy of the bowel but it is not essential, for example if a patient has a left-sided weakness;

  • Wash hands, and put on disposable apron and gloves (Fig 2);

  • Observe the perineal and perianal area (Fig 3), checking for rectal prolapse, haemorrhoids, anal skin tags, wounds, discharge, anal lesions, gaping anus, bleeding, infestation and foreign bodies;

  • Place a plastic-backed absorbent sheet under the patient;

  • Place some lubricating gel on a swab and onto the gloved index finger;

  • Inform the patient of imminent examination to ensure they are ready and as relaxed as possible;

  • Part the buttocks and gently insert the gloved index finger into the anus to avoid trauma to the anal mucosa and prevent forced over-dilation of the anal sphincter (Fig 4);

  • On insertion of finger, assess anal sphincter control – resistance should be
    felt. Digital insertion with resistance indicates good internal sphincter control. Conversely, a lack of resistance indicates poor sphincter tone;

  • Insert finger more than 5cm to ensure examination of the rectum (the anal canal is about 5cm long);

  • Assess external sphincter tone by asking the patient to contract the anus. Those who cannot hold a contraction may complain of an urgency to defecate;

  • Note the presence and consistency of faecal matter within the rectum to establish constipation or faecal impaction and the need for intervention (Fig 5);

  • Wipe the perianal area with a clean swab to leave the patient comfortable and clean and prevent excoriation of the anal area (Fig 6);

  • Remove gloves and apron, and dispose of appropriately.

  • Wash hands;

  • Help the patient into a more comfortable position;

  • Record all observations, findings and actions taken to aid assessment and evaluate care.

References

RCN (2006) Digital Rectal Examination and Manual Removal of Faeces: Guidance for Nurses. London: RCN

Smith, R.G., Lewis, S. (1990) The relationship between digital rectal examination and abdominal radiographs in elderly patients. Age and Ageing; 19: 142–143.

Professional responsibilities

This procedure should be undertaken only after approved training, supervised practice and competency assessment, and carried out in accordance with local policies and protocols.

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