Why digital rectal examinations are an important part of bowel assessments and how to perform them
Citation: Kyle G (2011) Digital rectal examination. Nursing Times; 107: 12, 18-19.
Author: Gaye Kyle is an independent lecturer and recognised teacher, University of Ulster.
- This article has been double-blind peer reviewed
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Assessing patients with bowel dysfunction presents many challenges. Health professionals have to overcome communication barriers associated with bowel habits and the embarrassment associated with an intimate rectal examination, but also bowel dysfunction may not result from a single, straightforward cause.
Assessment is based on considering all the possible causes of bowel dysfunction, checking in particular that it is not because of an underlying undiagnosed medical condition.
Evidence-based guidelines (National Institute for Health and Clinical Excellence, 2007) suggest a structured approach is needed when assessing patients with bowel dysfunction. All symptoms should be considered in the context of relevant medical history. The aim of assessment is to establish a symptom profile to plan individualised bowel care.
NICE (2007) identified the procedure of digital rectal examination (DRE) as an essential component of bowel assessment. However, recent results of the National Audit of Continence Care highlighted a lack of DRE in bowel assessment (Wagg et al, 2010). It was performed on less than half of the patients in primary care (29%) falling to 15% of those in care homes. Only in secondary care were more than half the patients examined rectally (53%). This is clearly unsatisfactory.
Need for consent
DRE is an intimate and invasive procedure, so valid consent must be obtained before it is performed. Consent is the legal means by which a patient gives valid authorisation for any treatment or care. Obtaining consent is a necessary part of good professional practice, ensuring trust between nurse and patient (Department of Health, 2009).
In the past, the intimate nature of DRE, together with fears of litigation and accusation of abuse, has led to confusion among nurses about their professional and legal responsibilities. Perhaps more alarmingly, some nurses believe they are not allowed to perform a DRE, thinking it part of a medical examination. These fears and anxieties are further compounded if a patient lacks the capacity to make a decision about this intimate procedure. However, the Mental Capacity Act 2007 gives nurses a statutory framework to empower and protect patients who are unable to make their own decisions.
Chronic constipation is one of the most common lower gastrointestinal disorders affecting people in the western world (Müller-Lissner et al, 2005) and it is estimated that 1-10% of adults are affected with faecal incontinence (NICE, 2007). These facts highlight the importance of nurses possessing the skills and knowledge to assess bowel dysfunction competently to make a clear nursing diagnosis.
Fitness to practise means having the required skills, knowledge and competency to provide a high standard of practice and care at all times. A failure to undertake a DRE during a bowel assessment may result in a patient receiving inappropriate or ill-timed bowel intervention.
The publication Bowel Care, Including Digital Rectal Examination and Manual Removal addressed many of the issues pertaining to the professional and legal aspects of DRE (Royal College of Nursing, 2008). The document identified Skills for Health bowel care competencies and emphasised the importance of appropriate training in order to undertake this procedure competently (SFH, 2008). Most continence services organise DRE training, which are available throughout the UK. The courses aim to improve knowledge and increase skills in the management of bowel dysfunction.
Rectal examination should always be performed as part of the bowel assessment process and never as a standalone investigation to evaluate treatment (SfH, 2008). Nurses who lack the necessary knowledge and expertise to perform a DRE competently must acknowledge the limits of their professional competence (Nursing and Midwifery Council, 2008). However, it is important that all nurses access their local DRE courses so that they are able to perform this important procedure. Effective bowel assessment, including a DRE, gives nurses the information they need in order to plan advice and interventions, measure outcomes and evaluate of care.
Box 1. Equipment
- Incontinence sheet
- Non-latex disposable gloves
- Gauze swabs
- Lubricating jelly
Box 2. Contraindications
- Lack of valid consent or if a patient refuses (DH, 2009)
- If the patient’s doctor has given specific instructions not to undertake the procedure
- If the patient has recently undergone rectal or anal surgery or trauma
- If the nurse does not feel competent (NMC, 2008)
Box 3. Cautions
Take special care when undertaking a DRE if the patient:
- Has active inflammatory bowel disease, such as Crohn’s disease, ulcerative colitis and diverticulitis
- Has had recent radiotherapy to the pelvic area
- Has rectal or anal pain
- Has had recent rectal or anal surgery
- Has obvious rectal bleeding
- Has spinal cord injury to T6 or above because of autonomic dysreflexia
- Has a history of abuse
- Gains sexual pleasure from the procedure
Any concerns should be addressed with the patient’s doctor
Box 4. Assessment using digital rectal examination
Consult local policies and procedures before undertaking a DRE.
Stage 1. Observe the perineal perianal area (SFH, 2008) for any abnormalities or signs of:
- Rectal prolapse: (protrusion of rectal tissue through the anus to the exterior of the body occurs when the internal anal sphincter is incompetent and/or pelvic floor muscles are weak) observe the degree of protrusion, colour, swelling and signs of any ulceration
- Haemorrhoids: note number, size and for signs of bleeding
- Anal skin tags: note number, position and condition
- Anal lesions or swelling: could indicate anal/rectal malignancy
- Gaping anus: may indicate poor sphincter tone, if faecal matter is observed this can indicate faecal impaction
- Skin condition, broken areas, pressure ulcers: excoriation or pruritus indicates possible signs of faecal incontinence
- Soiling: may indicate faecal incontinence or inability to maintain personal hygiene
- Bleeding, or mucus discharge: may indicate inflammatory bowel disease or malignancy
- Infestations: may indicate anal warts caused by a virus, or threadworms
- Foreign bodies
Any of these abnormalities should be documented and reported to the team. Observation of any perineal movement and anal sphincter squeeze is useful, as poor muscle co-ordination may indicate obstructive defaecation.
Stage 2. Following local procedures for DRE, insert a lubricated gloved finger into the patient’s rectum to:
- Establish the presence of faecal matter in the bowel (CC09, SFH)
- Assess the amount and consistency of faecal matter (CC01, SFH)
- Assess the need for rectal medication or the need for a digital removal of faeces in extreme cases of faecal impaction (CC09, SFH)
- Assess anal sphincter function and tone (CC10, SFH)
- Assess rectal sensation (CC10, SFH)
- Assess size, consistency of the prostate gland (usually part of specialist nurse practitioner’s role)
The normal state of the rectum is empty so a lack of faecal matter on DRE does not necessarily signify the absence of constipation. Constipation of the sigmoid colon was found in 30% of patients with an empty rectum (Smith and Lewis, 1990)
- Digital rectal examinations (DREs) are an essential part of bowel assessments
- Valid consent must be obtained before performing a DRE
- Failure to undertake DREs during a bowel assessments may result in patients receiving inappropriate or ill-timed bowel interventions
- DREs should always be used as part of the bowel assessment process and never as a stand-alone investigation to evaluate treatment
- Training in DRE is essential. Most continence services organise DRE courses and they are available throughout the UK
Department of Health (2009) Reference guide to consent for examination or treatment. London: DH.
Müller-Lissner SA et al (2005) Myths and misconceptions about chronic constipation. American Journal of Gastroenterology; 100: 232-242.
National Institute of Clinical Excellence (2007) Faecal Incontinence. London: NICE. www.nice.org.uk/CG49
Nursing Midwifery Council (2008) Code of Professional Conduct. London: NMC.
Royal College of Nursing (2008) Bowel care, including digital rectal examination and manual removal of faeces. London: RCN.
Skills for Health (2008) Continence care competencies. London: SKF. www.skillsforhealth.org.uk
Smith RG, Lewis S (1990) The relationship between digital rectal examination and abdominal radiographs in elderly patients. Age and Ageing; 19: 142-143.
Wagg A et al (2010) National Audit of Continence Care. London: Royal College of Physicians.