videos in clinical medicine

summary points

Julie R. Ingelfinger, M.D., Editor

Digital Rectal Examination and Anoscopy

Taufiek K. Rajab, M.D., Liliana G. Bordeianou, M.D., Arvind von Keudell, M.D.,
Hanna Rajab, and Haiyang Zhou, M.D.​​
Overview
A complete physical examination includes a digital rectal examination. If the From Brigham and Women’s Hospital,
digital rectal examination is inconclusive, then anoscopy can be used to further Harvard Medical School (T.K.R., A.V.K.),
and Massachusetts General Hospital
examine the anal canal.1 (L.G.B.) — both in Boston; the University
of Tübingen, Tübingen, Germany (H.R.);
Indications and Changzheng Hospital, Second Mili-
tary Medical University, Shanghai, China
Digital rectal examination is indicated in patients who present with anal or peri- (H.Z.). Address reprint requests to Dr.
anal pain, abdominal pain, rectal bleeding, an anorectal mass, perianal pruritus, Zhou at Shanghai Changzheng Hospital,
incontinence, constipation, or weight loss. Anoscopy is indicated if disease in the No. 415 Fengyang Rd., Shanghai, 200003,
China, or at ­haiyang1985_1@​­aliyun​.­com.
anal canal is suspected.2-4
N Engl J Med 2018;378:e30.
DOI: 10.1056/NEJMvcm1510280
Contraindications Copyright © 2018 Massachusetts Medical Society.
Absolute contraindications to digital rectal examination and anoscopy include lack
of patient consent and the absence of an anus owing to surgery or a congenital
condition. Relative contraindications to digital rectal examination and anoscopy
include recent anal surgery, anal strictures, and severe anal pain that mandates
examination while the patient is under anesthesia.5

Anatomy A
The rectum begins at the rectosigmoid junction, which is demarcated by the con-
fluence of the teniae coli. The anatomical structures that are anterior to the rectum
differ in females (Fig. 1A) and males (Fig. 1B).
The anal canal begins at the anorectal junction, which is demarcated by the
puborectalis muscle ring. In adults, the anal canal is approximately 3 to 5 cm long.
It terminates at the anal verge, the junction between the epithelium of the anal
canal and the perianal skin.
The anal canal is separated into upper and lower parts by the dentate line. B
Above the dentate line, the anal canal is lined by columnar epithelial cells of endo-
dermal origin. This part of the anal canal is innervated by diffuse autonomic nerve
fibers. Below the dentate line, the anal canal is lined by stratified squamous epi-
thelial cells of ectodermal origin. This part of the anal canal is richly innervated
by somatic nerve fibers, a fact that explains why a majority of anorectal conditions
that are associated with anal pain arise in the lower part of the anal canal.6
The inner muscular layer of the anal canal forms the internal anal sphincter.
This muscle provides continuous anal contraction, which is responsible for anal
continence between bowel movements. The outer muscular layer of the anal canal Figure 1. Anatomical Structures Anterior
forms the external anal sphincter. This muscle is under voluntary control and to the Rectum in Women and Men.
generally provides additional continence once the urge to defecate is perceived. In women, the vagina, uterus, and
peritoneal rectouterine pouch of
Douglas lie anterior to the rectum
Equipment
(Panel A). In men, the prostate, blad-
To perform digital rectal examination, you will need a pair of gloves, lubricant, der, and peritoneal rectovesical pouch
topical anesthetic (in case the patient has local discomfort), and a fecal occult lie anterior to the rectum (Panel B).

n engl j med 378;22 nejm.org  May 31, 2018 e30(1)

The New England Journal of Medicine
Downloaded from nejm.org by Christa Febby on March 15, 2020. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
 The n e w e ng l a n d j o u r na l of m e dic i n e

blood test. For anoscopy you will also need an anoscope, cotton swabs, tissue
paper, and a dedicated light source (Fig. 2).

Preparation of the Patient

Because of the sensitive nature of the anorectal examination, many patients will
have anticipatory anxiety or embarrassment. If the examination is to be successful,
the patient must be able to relax. Therefore, it is important to have a frank discus-
sion in which the procedure is explained to the patient and all the patient’s ques-
tions are answered. Moreover, the option of having a chaperone present should be Figure 2. Equipment Needed to
offered to every patient, and the decision regarding the presence of a chaperone Perform Digital Rectal Examination
should be documented. and Anoscopy.

Digital Rectal Examination

Digital rectal examination and anoscopy can be performed with the patient in nu-
merous positions, including the standing, lithotomy, knee-to-chest, and prone posi-
tions. The choice of position depends on physician preference and any factors that
affect the patient, such as the ability to assume a position. This video will demon-
strate the procedure with the patient in the left lateral decubitus position (Fig. 3).
Before beginning the examination, put two gloves on your dominant hand and
one glove on your nondominant hand. Start the examination with inspection of
the perineum. Spread the buttocks gently with both hands to inspect the perianal
region. This maneuver may reveal the presence of external lesions. Inspection may Figure 3. Digital Rectal Examination
also lead to a diagnosis. A digital rectal examination may not be needed in a Performed in the Left Lateral
patient with severe anal pain if a fissure or a thrombosed external hemorrhoid Decubitus Position.
is clearly visualized. In patients whose symptoms suggest prolapse, a Valsalva
maneuver may reveal prolapsing hemorrhoids or mucosa.
Next, prepare to palpate the anal canal and rectum. Apply lubricant to the
gloved index finger of your dominant hand and to the patient’s anus. Instruct the
patient to bear down, which will relax the anal sphincter and increase patient
comfort as your index finger is inserted into the anal canal. Insert your index
finger slowly, aiming for the umbilicus of the patient. Advance your finger into
the rectum. You will feel the anorectal junction as the last muscular ring before
you sense a decrease in pressure as your finger enters the capacious rectum. Once
your fingertip is inside the rectum, rotate your hand around the circumference of
the rectum to feel its walls throughout. Small lesions on the rectal wall may not
be detected unless you rotate your finger slowly and carefully during palpation.
Next, pull your finger back into the anal canal and ask the patient to squeeze
and bear down. This action will allow you to determine sphincter tone and to feel
nodules or irregularities within the anal canal and will reveal areas of tenderness.
While examining the anal canal in male patients, rotate your finger anteriorly to
palpate the prostate gland. Note the size, shape, and consistency of the prostate
and identify any nodules or tenderness.
Before you remove your finger, ask the patient to bear down again. Once the
patient relaxes the anal sphincter, withdraw your finger from the anus. Note the
presence of any visible blood and the quality of any fecal matter on your gloved
finger. If there is no gross blood, perform a fecal occult blood test on any residual
fecal matter on the glove. Remove the outer glove from your dominant hand and
proceed to the anoscopy.

Anoscopy
A wide variety of anoscopes are available. For most adults, an anoscope with a
tapered external diameter of 19 mm is used. For pediatric patients, or patients

n engl j med 378;22 nejm.org May 31, 2018 e30(2)

The New England Journal of Medicine
Downloaded from nejm.org by Christa Febby on March 15, 2020. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.
 The n e w e ng l a n d j o u r na l of m e dic i n e

with painful conditions or with anal stenoses, a smaller anoscope with a tapered A
external diameter of 8 to 14 mm should be used.
Apply lubrication generously to the anoscope and the obturator. Spread the but-
tocks and gently insert the anoscope with the obturator into the anal canal. The
insertion may be easier if you ask the patient to take a few deep breaths and bear
down. Gently advance the anoscope in the direction of the previously palpated anal
canal until the full length of the anoscope has been inserted (Fig. 4A). Remove the
obturator and visualize the anal mucosa (Fig. 4B). Any fecal matter can be removed
with a large swab. B
Note the gross appearance of the mucous membranes and vasculature as well
as the presence of any lesions. When you are ready to examine another area, rein-
sert the obturator and slowly rotate the anoscope. Remove the obturator and repeat
the inspection. Inspection of the entire circumference of the anal canal generally
requires three or four turns of the anoscope.
Once the examination is complete, continue to inspect the anal canal as you gently
withdraw the anoscope. After the device has been fully withdrawn from the patient’s
anal canal, gently wipe any excess lubricant off the patient’s anus with tissue paper. Figure 4. Insertion of the Anoscope
and Visualization of the Anal Canal.
Documentation Panel A shows insertion of the ano-
Carefully document the findings of the physical examination. When identifying scope into the anal canal and Panel B
visualization of the anal canal with the
lesions, describe their anatomical location as anterior, posterior, left, or right and
use of an anoscope.
their proximity to normal anatomical structures. Referring to the anatomical loca-
tion of a lesion is less ambiguous than referring to its position in relation to a
clock face, since the position of a number on a clock depends on the position in
which you have performed the examination.

Complications
The complications associated with a digital rectal examination and an anoscopy
are rare and relatively minor. Patient discomfort and perianal abrasions may occur,
but these problems can largely be prevented with the generous use of lubricant. If
the patient has severe discomfort, a local anesthetic can be applied. If a local
anesthetic is not sufficient, then referral for examination while the patient is under
general anesthesia will be necessary.7

Summary
Digital rectal examination is part of a complete physical examination and involves
inspection of the perianal skin, palpation of the distal rectum and anal canal, and
performance of fecal occult blood tests. If the digital rectal examination is insuf-
ficient to make a conclusive diagnosis, then anoscopy is a straightforward bedside
method for conducting further examination of the anal canal.
No potential conflict of interest relevant to this video was reported.
Disclosure forms provided by the authors are available at NEJM.org.

References
1. Long KC, Menon R, Bastawrous A, Billingham R. Screening, surveillance, and treatment of anal intra-
epithelial neoplasia. Clin Colon Rectal Surg 2016;29:57-64.
2. Hennigan TW, Franks PJ, Hocken DB, Allen-Mersh TG. Rectal examination in general practice. BMJ 1990;
301:478-80.
3. Ng DP, Mayberry JF, McIntyre AS, Long RG. The practice of rectal examination. Postgrad Med J 1991;67:904-6.
4. Manimaran N, Galland RB. Significance of routine digital rectal examination in adults presenting with
abdominal pain. Ann R Coll Surg Engl 2004;86:292-5.
5. Muris JW, Starmans R, Wolfs GG, Pop P, Knottnerus JA. The diagnostic value of rectal examination. Fam
Pract 1993;10:34-7.
6. Barleben A, Mills S. Anorectal anatomy and physiology. Surg Clin North Am 2010;90:1-15.
7. Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol 2008;
103:820-2.
Copyright © 2018 Massachusetts Medical Society.

n engl j med 378;22 nejm.org May 31, 2018 e30(3)

The New England Journal of Medicine
Downloaded from nejm.org by Christa Febby on March 15, 2020. For personal use only. No other uses without permission.
Copyright © 2018 Massachusetts Medical Society. All rights reserved.