Editing Rectal examination

{{Short description|Medical assessment or diagnostic procedure}}{{Redirect|Digital exam|digital examination of the vagina|Pelvic examination}}{{Redirect|Anal probe|the use by aliens|Alien abduction}}{{multiple issues|
{{more citations needed|date=February 2018}}
{{too few opinions|date=February 2018}}
{{globalise|article|United States|date=February 2025}}
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{{Infobox interventions
| Name        = Rectal examination
| Image       = Digital rectal exam nci-vol-7136-300.jpg
| Caption     = Side view of male reproductive and urinary anatomy, including the prostate, rectum and bladder, with an index finger probing the anus
| ICD10       =
| ICD9        = 89.34
| MeshID      = D051517
| MedlinePlus = 007069
}}
'''Digital rectal examination''' (DRE), also known as a '''prostate exam''' ({{langx|la|palpatio per anum (PPA)|lit=palpation through the anus}}), is an internal examination of the [[rectum]] performed by a [[healthcare provider]].

Prior to a 2018 report from the [[United States Preventive Services Task Force]], a digital exam was a common component of [[annual medical examination]] for older men, as it was thought to be a reliable [[screening test]] for [[prostate cancer]].<ref>{{Cite web |title=Recommendation: Prostate Cancer: Screening {{!}} United States Preventive Services Taskforce |url=https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening |access-date=2022-11-19 |website=www.uspreventiveservicestaskforce.org |language=en}}</ref><ref>{{Cite web |title=It may be time to abandon dreaded digital rectal exam, research shows |url=https://www.sciencedaily.com/releases/2016/09/160906085834.htm |access-date=2022-11-19 |website=ScienceDaily |language=en|quote=The dreaded finger exam to check for prostate cancer used to be a mainstay of check-ups for older men.}}</ref>

==Usage==
This examination may be used:
* for the diagnosis of [[prostate|prostatic]] disorders, [[benign prostatic hyperplasia]] and the four types of [[prostatitis]]. Chronic prostatitis/chronic pelvic pain syndrome, chronic bacterial prostatitis, acute (sudden) bacterial prostatitis, and asymptomatic inflammatory prostatitis. The DRE has a 50% [[Sensitivity and specificity|specificity]] for benign prostatic hyperplasia.<ref>{{Cite book|title=Rapid Review Pathology Third Edition|last=Goljan|first=Edward|publisher=Mosby Elsevier|year=2011|isbn=978-0-323-08438-3|pages=429}}</ref> Vigorous examination of the prostate in suspected [[acute prostatitis]] can lead to seeding of [[Sepsis|septic]] emboli and should never be done. Its utility as a screening method for [[prostate cancer]] however is not supported by the evidence;<ref name=pmid29531107>{{cite journal |doi=10.1370/afm.2205 |pmid=29531107 |pmc=5847354 |title=Digital Rectal Examination for Prostate Cancer Screening in Primary Care: A Systematic Review and Meta-Analysis |journal=The Annals of Family Medicine |volume=16 |issue=2 |pages=149–154 |year=2018 |last1=Naji |first1=Leen |last2=Randhawa |first2=Harkanwal |last3=Sohani |first3=Zahra |last4=Dennis |first4=Brittany |last5=Lautenbach |first5=Deanna |last6=Kavanagh |first6=Owen |last7=Bawor |first7=Monica |last8=Banfield |first8=Laura |last9=Profetto |first9=Jason }}</ref>
* for the evaluation of certain clinical symptoms: a male with change in urinary ability, [[Erectile dysfunction|impotence]], or dysuria (blood in the urine), pain with bowel movements;<ref name=":0">{{Cite web|url=https://www.pri-med.com/online-education/podcast/rectal-exam-frankly-speaking-73|title=Pri-Med &#124; Put That Finger Down! The End of the...|website=Pri-Med|access-date=2022-01-09|archive-date=2022-08-12|archive-url=https://web.archive.org/web/20220812212956/https://www.pri-med.com/online-education/Podcast/rectal-exam-frankly-speaking-73|url-status=dead}}</ref>
* a DRE with a [[Faecal occult blood (FOB) test|FOBT]] might have value for a person with anemia in the emergency room who has no other identifiable cause for anemia, is not actively bleeding, and there is concern that gastrointestinal malignancy may be the cause for their anemia;<ref name=":1" /><ref name="pmid29601803">{{cite journal|last1=Gupta|first1=Arjun|last2=Tang|first2=Zhouwen|last3=Agrawal|first3=Deepak|year=2018|title=Eliminating In-Hospital Fecal Occult Blood Testing: Our Experience with Disinvestment|journal=The American Journal of Medicine|volume=131|issue=7|pages=760–763|doi=10.1016/j.amjmed.2018.03.002|pmid=29601803|s2cid=5046971}}</ref><ref name="pmid11316179">{{cite journal|last1=Sharma|first1=Virender K.|last2=Komanduri|first2=Sri|last3=Nayyar|first3=Sanjay|last4=Headly|first4=Anna|last5=Modlinger|first5=Paul|last6=Metz|first6=David C.|last7=Verghese|first7=Vino J.|last8=Wanahita|first8=Anna|last9=Go|first9=Mae F.|last10=Howden|first10=Colin W.|year=2001|title=An audit of the utility of in-patient fecal occult blood testing|journal=The American Journal of Gastroenterology|volume=96|issue=4|pages=1256–1260|doi=10.1111/j.1572-0241.2001.03709.x|pmid=11316179|s2cid=20602869}}</ref><ref name="auto">{{Cite journal|last=Monash|first=Bradley|date=2017-07-01|title=Fecal occult blood testing in hospitalized patients with upper gastrointestinal bleeding|journal=Journal of Hospital Medicine|language=en|volume=12|issue=7|pages=567–569|doi=10.12788/jhm.2773|pmid=28699947|doi-access=free}}</ref>
* a true active gastrointestinal bleed: vomiting blood, vomiting [[Coffee ground vomiting|coffee-grind like material]], [[Hematochezia|defecating blood]] or ''black'' tarry stools that can not be easily attributed to facial trauma or oral surgery, eating beets or anything with red food dye or overuse of NSAIDS/over the counter pain medication. Doing a rectal exam to examine stool color may provide a clue as to the location of the bleed but is not a reliable indicator;<ref>{{Cite web|url=https://www.uptodate.com/contents/approach-to-acute-upper-gastrointestinal-bleeding-in-adults#H684000|title=UpToDate|website=www.uptodate.com|access-date=2019-11-13}}</ref><ref>{{Cite journal|last1=Jensen|first1=D. M.|last2=Machicado|first2=G. A.|date=December 1988|title=Diagnosis and treatment of severe hematochezia. The role of urgent colonoscopy after purge|url=https://pubmed.ncbi.nlm.nih.gov/3263294/|journal=Gastroenterology|volume=95|issue=6|pages=1569–1574|doi=10.1016/s0016-5085(88)80079-9|issn=0016-5085|pmid=3263294}}</ref><ref name=":1" /><ref name="pmid29601803" /><ref name="pmid11316179" />
* for the [[medical diagnosis|diagnosis]] of [[appendicitis]] or other examples of an [[acute abdomen]] (i.e. acute abdominal symptoms indicating a serious underlying disease). Although a ''[[Journal of Emergency Medicine]]'' paper concludes: "We found the DRE to have a limited role in the diagnosis of acute, undifferentiated abdominal pain and acute appendicitis.";<ref name="pmid22883714">{{cite journal |doi=10.1016/j.jemermed.2012.06.015 |pmid=22883714 |title=Utility of the Digital Rectal Examination in the Emergency Department: A Review |journal=The Journal of Emergency Medicine |volume=43 |issue=6 |pages=1196–1204 |year=2012 |last1=Kessler |first1=Chad |last2=Bauer |first2=Stephen J. }}</ref><ref name=":1">{{Cite web|url=https://www.bumc.bu.edu/emergencymedicine/2018/05/28/fobt-and-dres-in-the-ed-june-2018/|title=FOBT and DRE's in the ED (June 2018) » Emergency Medicine {{!}} Blog Archive {{!}} Boston University|website=www.bumc.bu.edu|access-date=2019-02-20}}</ref>
* for the estimation of the muscle tone of the [[Human anus|anal]] sphincter, which may be useful in case of [[fecal incontinence]] or [[neurologic]] diseases, including traumatic spinal cord injuries;
* traditionally, the digital rectal examination (DRE) was considered an essential part of the physical examination for all trauma patients. However, the sensitivity of the DRE for injuries of the spinal cord, pelvis, and bowel is poor, and false positive and negative results are common. Thus, routine performance is unnecessary and generally unhelpful. The examination is warranted in cases where urethral injury or penetrating rectal injury is suspected;<ref>{{Cite web|url=https://www.uptodate.com/contents/initial-management-of-trauma-in-adults?search=TRAUMA&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H11715737|title=UpToDate|website=www.uptodate.com|access-date=2019-10-22}}</ref><ref>{{Cite journal|last1=Shlamovitz|first1=Gil Z.|last2=Mower|first2=William R.|last3=Bergman|first3=Jonathan|last4=Crisp|first4=Jonathan|last5=DeVore|first5=Heather K.|last6=Hardy|first6=David|last7=Sargent|first7=Martine|last8=Shroff|first8=Sunil D.|last9=Snyder|first9=Eric|last10=Morgan|first10=Marshall T.|date=July 2007|title=Poor test characteristics for the digital rectal examination in trauma patients|url=https://pubmed.ncbi.nlm.nih.gov/17391807/|journal=Annals of Emergency Medicine|volume=50|issue=1|pages=25–33, 33.e1|doi=10.1016/j.annemergmed.2007.01.022|issn=1097-6760|pmid=17391807}}</ref>
* in [[female]]s, for the limited [[gynecology|gynecological]] [[Rectovaginal examination|palpations of internal organs]] when the vaginal vault cannot be accessed or it is too painful (vaginal atrophy);
* for examination of the hardness and color of the feces (i.e. in cases of constipation, and [[fecal impaction]]);
* prior to a [[colonoscopy]] or [[proctoscopy]];
* to evaluate [[hemorrhoids]] although internal hemorrhoids are often too soft to be felt, a visual inspection may be more useful;<ref>{{Cite web | url=https://www.mayoclinic.org/diseases-conditions/hemorrhoids/diagnosis-treatment/drc-20360280 | title=Hemorrhoids - Diagnosis and treatment - Mayo Clinic| website=[[Mayo Clinic]]}}</ref>
* in newborns to exclude [[anal atresia|imperforate anus]];
* through the insertion of medical devices including thermometers or specialized balloons; to identify [[digestion]] problems, [[parasite]]s, [[organ (anatomy)|organ]] damage, anal bruising, and foreign objects in the rectal cavity;

== Usage as a screening tool ==

=== In [[colorectal cancer screening]] of asymptomatic adults aged 50 to 75 ===
* Even though 1 in 4 colorectal cancers (CRC) is located in the rectum, little evidence supports the effectiveness of using the DRE for rectal cancer detection<ref name=pmid17868406>{{cite journal |doi=10.1111/j.1463-1318.2007.01381.x |pmid=17868406 |title=The diagnostic value of digital rectal examination in primary care for palpable rectal tumour |journal=Colorectal Disease |volume=10 |issue=8 |pages=789–792 |year=2008 |last1=Ang |first1=C. W. |last2=Dawson |first2=R. |last3=Hall |first3=C. |last4=Farmer |first4=M. |s2cid=639158 |doi-access=free }}</ref><ref>{{Cite web|url=https://www.uptodate.com/contents/screening-for-colorectal-cancer-strategies-in-patients-at-average-risk#H9|title=UpToDate|website=www.uptodate.com|access-date=2019-02-18}}</ref> and it is not recommended in the colorectal cancer screening guidelines.<ref>{{Cite web|url=https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/colorectal-cancer-screening#Pod2|title=Final Recommendation Statement: Colorectal Cancer: Screening - US Preventive Services Task Force|website=www.uspreventiveservicestaskforce.org|access-date=2019-02-07}}</ref> The DRE is inadequate as a screening tool for [[colorectal cancer]] because it examines less than 10% of the colorectal mucosa; [[sigmoidoscopy]] is preferred.{{cn|date=January 2022}}
* Although the DRE is commonly used as a way to obtain a stool sample for a FOBT ([[faecal occult blood|fecal occult blood test]]) in an office based setting, ''this is an insufficient way of screening for colorectal cancer and is not recommended.''<ref name=pmid16734049>{{cite journal |pmid=16734049 |url=http://www.aafp.org/link_out?pmid=16734049 |year=2006 |last1=Wender |first1=R. C. |title=Colorectal cancer screening: Don't just do it, do it right |journal=American Family Physician |volume=73 |issue=10 |pages=1707–8 }}</ref><ref name=pmid22766663>{{cite journal |doi=10.1097/SMJ.0b013e31825bfdc5 |pmid=22766663 |title=Digital Rectal Examination Versus Spontaneous Passage of Stool for Fecal Occult Blood Testing |journal=Southern Medical Journal |volume=105 |issue=7 |pages=357–361 |year=2012 |last1=Ashraf |first1=Imran |last2=Paracha |first2=Shafaq R. |last3=Arif |first3=Murtaza |last4=Choudhary |first4=Abhishek |last5=Matteson |first5=Michelle L. |last6=Clark |first6=Robert E. |last7=Godfrey |first7=Jonathan D. |last8=Hammad |first8=Hazem T. |last9=Bechtold |first9=Matthew L. |s2cid=22573405 }}</ref><ref name=pmid15657156>{{cite journal |doi=10.7326/0003-4819-142-2-200501180-00007 |pmid=15657156 |title=A National Survey of Primary Care Physicians' Methods for Screening for Fecal Occult Blood |journal=Annals of Internal Medicine |volume=142 |issue=2 |pages=86–94 |year=2005 |last1=Nadel |first1=Marion R. |last2=Shapiro |first2=Jean A. |last3=Klabunde |first3=Carrie N. |last4=Seeff |first4=Laura C. |last5=Uhler |first5=Robert |last6=Smith |first6=Robert A. |last7=Ransohoff |first7=David F. |s2cid=24639260 }}</ref> A single office-based FOBT (fecal occult blood test) performed following a digital rectal examination (DRE) is not an adequate screen due to low sensitivity for advanced tumor and colorectal cancer.<ref name=pmid15657155>{{cite journal |doi=10.7326/0003-4819-142-2-200501180-00006 |pmid=15657155 |title=Accuracy of Screening for Fecal Occult Blood on a Single Stool Sample Obtained by Digital Rectal Examination: A Comparison with Recommended Sampling Practice |journal=Annals of Internal Medicine |volume=142 |issue=2 |pages=81–5 |year=2005 |last1=Collins |first1=Judith F. |last2=Lieberman |first2=David A. |last3=Durbin |first3=Theodore E. |last4=Weiss |first4=David G. |author5=Veterans Affairs Cooperative Study #380 Group |s2cid=29833684 }}</ref> Screening for colon cancer this way does not meet [[HEDIS]], Medicare or [[American Cancer Society]] standards.<ref>{{Cite web|url=https://www.cancer.org/cancer/colon-rectal-cancer/detection-diagnosis-staging/screening-tests-used.html|title=Colorectal Cancer Screening Tests|website=www.cancer.org|access-date=2019-10-12}}</ref> The FOBT has never been validated for any purpose other than as a take home colon cancer screening test.<ref name="auto"/>  A paper published in the ''[[Journal of General Internal Medicine]]'' states, "While FOBT done appropriately (taken home and used according to the instructions) is an important screening option, in-office FOBT may be worse than no screening at all because it misses 95% of cases of advanced tumor, giving many patients a false sense of reassurance."<ref name=pmid20383599>{{cite journal |doi=10.1007/s11606-010-1328-7 |pmid=20383599 |pmc=2896587 |title=Fecal Occult Blood Testing Beliefs and Practices of U.S. Primary Care Physicians: Serious Deviations from Evidence-Based Recommendations |journal=Journal of General Internal Medicine |volume=25 |issue=8 |pages=833–839 |year=2010 |last1=Nadel |first1=Marion R. |last2=Berkowitz |first2=Zahava |last3=Klabunde |first3=Carrie N. |last4=Smith |first4=Robert A. |last5=Coughlin |first5=Steven S. |last6=White |first6=Mary C. }}</ref>

=== In [[prostate cancer screening]] of asymptomatic men aged 55 to 69 ===
* In men aged 55–69 who have been counseled on the known harms and potential benefits of prostate cancer screening, the [[United States Preventive Services Task Force|U.S. Preventive Service Task Force]] May 2018 statement states, "The use of digital rectal examination as a screening modality is not recommended because there is a lack of evidence on the benefits."<ref name=pmid29801017>{{cite journal |doi=10.1001/jama.2018.3710 |pmid=29801017 |title=Screening for Prostate Cancer |journal=JAMA |volume=319 |issue=18 |pages=1901–1913 |year=2018 |last1=Grossman |first1=David C. |last2=Curry |first2=Susan J. |last3=Owens |first3=Douglas K. |last4=Bibbins-Domingo |first4=Kirsten |last5=Caughey |first5=Aaron B. |last6=Davidson |first6=Karina W. |last7=Doubeni |first7=Chyke A. |last8=Ebell |first8=Mark |last9=Epling |first9=John W. |last10=Kemper |first10=Alex R. |last11=Krist |first11=Alex H. |last12=Kubik |first12=Martha |last13=Landefeld |first13=C. Seth |last14=Mangione |first14=Carol M. |last15=Silverstein |first15=Michael |last16=Simon |first16=Melissa A. |last17=Siu |first17=Albert L. |last18=Tseng |first18=Chien-Wen |last19=Tseng |first19=C. W. |doi-access=free }}</ref> The [[American Academy of Family Physicians]] states, "Digital Rectal Exam does not improve detection of prostate cancer and should not be performed as a part of screening."<ref>{{Cite web|url=https://www.aafp.org/patient-care/clinical-recommendations/all/prostate-cancer.html|title=Prostate Cancer - Clinical Preventive Service Recommendation|website=www.aafp.org|access-date=2019-02-18}}</ref> The [[American Urological Association]] 2013 (reviewed and validity confirmed 2018) guideline panel states, "The literature supporting the efficacy of digital rectal exam (DRE) for screening with the goal of reducing prostate cancer mortality provide limited evidence to draw conclusions."<ref>{{Cite web|url=https://www.auanet.org/guidelines/prostate-cancer-early-detection-(2013-reviewed-for-currency-2018)|title=American Urological Association -|website=www.auanet.org|access-date=2019-02-20}}</ref> "The guideline panel could find no evidence to support the continued use of DRE as a first-line method of screening."<ref name=uptodate>{{cite web |url=https://www.uptodate.com/contents/screening-for-prostate-cancer |title=Screening for prostate cancer |website=UpToDate |first1=Richard M |last1=Hoffman |date=Jun 25, 2018 }}</ref> Although DRE has long been used to diagnose prostate cancer, no controlled studies have shown a reduction in the morbidity or mortality of prostate cancer when detected by DRE at any age.<ref name=uptodate/><ref>{{Cite book |author=Epstein JI |chapter=Pathology of prostatic neoplasia |title=Campbell's Urology |edition=8th |editor=Walsh PC |publisher=Saunders |location=Philadelphia |year=2002 }}</ref>
* A meta-analysis published in the ''[[Annals of Family Medicine]]'' concluded: "Given the considerable lack of evidence supporting its efficacy, we recommend against routine performance of DRE to screen for prostate cancer in the primary care setting."<ref name=pmid29531107/>

==Procedure==
The digital rectal examination is a relatively simple medical procedure. The patient undresses and is then placed in a position where the [[Human anus|anus]] is accessible (lying on the side, [[Squatting position|squatting]] on the examination table, bent over it, or lying down with feet in stirrups). If the patient is lying on their side, the physician will usually have them bring one or both legs up to their chest. If the patient bends over the examination table or the back of a chair, the physician will have them place their elbows on the table and squat down slightly. If the patient uses the supine position, the physician will ask the patient to slide down to the end of the examination table until their buttocks are positioned just beyond the end and then place their feet in the stirrups. The physician spreads the buttocks apart and will usually examine the external area (anus and perineum) for any abnormalities such as [[hemorrhoids]], lumps, or rashes. Then, as the patient relaxes and bears down (as if having a bowel movement), the physician slips a lubricated finger into the rectum through the anus and palpates the insides for a short time.{{medical citation needed|date=July 2023}}
{{Further|Blumer's shelf}}

==Society and culture==
Due to the taboos surrounding the anus and the potential for discomfort and embarrassment, the rectal exam is a common [[comedic device]], including in episodes of ''[[Saturday Night Live]]'',<ref>''New York Magazine'' - Vol. 28, No. 11. "Saturday Night Live at twenty"</ref> ''[[Impractical Jokers]]'', ''[[Futurama]]'', ''[[Stewie Loves Lois|Family Guy]]'', ''[[Cartman Gets an Anal Probe|South Park]]'', ''[[Letterkenny (TV series)|Letterkenny]]'', and the movie ''[[Fletch (film)|Fletch]]'', with [[M. Emmet Walsh]] as the general practitioner and [[Chevy Chase]] as the patient being examined. Similar activities to the rectal exam are attributed to extraterrestrials in video games such as ''[[Saints Row IV]]'', ''[[Gaia Online]]'' and ''[[Destroy All Humans! (series)|Destroy All Humans!]]''.<ref>{{cite web| title =Alien anal probe saw Saints Row IV refused classification in Australia | publisher =IGN Entertainment Inc. | date =June 25, 2013 | url =http://au.ign.com/articles/2013/06/26/alien-anal-probe-saw-saints-row-iv-refused-classification-in-australia | access-date =July 19, 2014}}</ref> The practice of rectal exams without prior consent by medical students has been an area of concern.<ref name=pmid21251051>{{cite journal |doi=10.1111/j.1365-2923.2010.03911.x |pmid=21251051 |title=Medical students learning intimate examinations without valid consent: A multicentre study |journal=Medical Education |volume=45 |issue=3 |pages=261–272 |year=2011 |last1=Rees |first1=Charlotte E. |last2=Monrouxe |first2=Lynn V. |s2cid=3372919 }}</ref> In 2024, the US [[United States Department of Health and Human Services|Department of Health and Human Services]] banned  rectal examination (and pelvic and breast exams) without written informed consent, when such exams are undertaken by medical students, nurse practitioners, or physician assistants for "educational and training purposes".<ref>{{Cite web|url=https://apnews.com/article/pelvic-exams-consent-federal-government-hhs-52331c180249daa1aa12c470f8d70061|title=Hospitals must obtain written consent for pelvic and similar exams, the federal government says|date=April 1, 2024|website=AP News}}</ref>

==Veterinary medicine==
In [[veterinary medicine]] rectal examination is useful in [[dog]]s for analysis of the [[prostate]] (as in men), pelvic [[urethra]], sublumbar [[lymph node]]s, and [[anal gland]]s. In [[horse]]s it is a vital component of the clinical examination for [[equine colic|colic]], to determine the presence or absence of bowel torsion, [[Fecal impaction|impaction]], or displacement. When horses undergo a rectal examination there is a small risk of a [[rectal]] tear occurring, which can be a life-threatening event, rapidly leading to [[peritonitis]] and [[septic shock]]. It is also a common procedure in cattle, and is one method of diagnosing pregnancy in both the horse and the cow.{{Citation needed|date=March 2019}}

The procedure in dogs and cats is similar to humans. For the horse, the patient stands in a [[stock (cage)|stock]] and may be sedated. The examiner puts on a [[long glove]] that extends to the shoulder. The examiner inserts the hand and arm into the rectum as far as necessary.{{Citation needed|date=March 2019}}

==See also==
* [[Body cavity search]]
* [[Colonoscopy]]
* [[GCC homosexuality test]]

==References==
{{reflist|30em}}

==External links==
* [http://www.patient.info/doctor/Rectal-Examination.htm Rectal Examination]

{{Physical exam}}
{{Digestive system procedures}}

[[Category:Diagnostic gastroenterology]]
[[Category:Physical examination]]
[[Category:Rectum]]