Per Rectal Examintaion

In surgical posting, PR examination is necessary in most cases found. The PR is a must!!! Unless the doctor has no fingers or the patient has no anus. Bahaha. So, prepare yourself for that, keep your nail short would be appreciated. You don't want it to damage your glove and poke into the ractal mucosa. Damn, that hurts, a lot!

1. First of all, of course you need to gain consent and screen!!! Why would you want to show patient's butt to the other people in the ward. Crazy ka?
2. exposure should be appropriate and adequate, in view of the modesty.
3. position, ideally left lateral. Can also be jet knife or lithotomy. but have never seen that.
4. equipment : gloves, inert lubricating gel, good light.
5. TELL THE PATIENT FIRST AND DESCRIBE WHAT ARE YOU GOING TO DO TO ELEVATE THE ANXIETY. "Encik, sekarang ni saya nak periksa keadaan tempat keluar najis, kalau ada apa-apa yang tak normal. Lepas tu saya nak masukkan jari saya lah dalam tempat keluar najis tu, mungkin agak tak selesa sikit ye. Kalau ada sakit, bagitau ye."
6.  Inspection
• lif uppermost buttock with left hand to observe anus, peri anal skin, perineum
• look for any 
• rashes and excoriation
• fecal soiling, blood, mucus
• scarring, fistula, fissure, ulcer
• lump, bump, polyp, mass
7. palpation  should be proceeded if no painful anal contraction. "Buatlah kalau nak kena tendang keluar tingkap dengan patient" bak kata Mr Mizam.
• ask if there is any history of pain on defecation  : "Pakcik, maaf tanya, bila buang air besar ada rasa sakit tak bahagian luar lubang najis?"
• place fingers on the either side of anus and GENTLY strecth the anal orifice to look for any spasm. Spasm is associated with fissure which might be visible. If no, continue lah.
• look at finger when remove from rectum...note color of feces or presence of blood or mucus
8. note the tone of the sphincter
• any pain or tenderness
• any thickening or masson the wall describe it, the position (clock)
• if reduced anal tone suggestive of neuro problem.
9. feel around the rectum, Pulasssss jari tu. Feel as high as possible limited to the lentgh of the finger to detect any intraluminal mass and note the texture. If there is mass, try to decide if it is within or outside the wall by testing the mobility of mucosa over it. Feel the content of the rectum whether it is
• empty and collapsed
• empty and balloned out
• full of faeces, soft or hard
• ask the patient to strain if necessary. Kalau dia kentut tu, bertabahlah. But, I never ask patient tu strain pun. Hehe.
10. Turn finger around to detect any masses outside the rectum
• bogginess anteriorly, pelvic abcess???
• prostate and cervix, by experiences, you can tell what is normal and wat is not. Baru perform once. Hmmmm...sad.

And someone asked me how to palpate for BPH...if you have done two to three times...YOU CAN ACTUALLY RECOGNIZE THEM. a doctor taught me that they estimate the size (by grams) by relating how far the index finger can reach above the mass...and if the finger cannot reach the top of the mass, that means it is big. 

Reference : Browse, N.L, et. al, Browse’s Introduction to the Symptoms and Signs of Surgical Disease(2005), Fourth Edition, Hodder Arnold, UK.