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Digital rectal examination

Definition

A digital rectal examination (DRE) is an invasive procedure that can be carried out as part of a nursing assessment by a registered nurse who can demonstrate competence to an appropriate level in accordance with The Code (NMC [178]). The procedure involves the nurse inserting a lubricated gloved finger into the rectum.

Evidence‐based approaches

Rationale

Indications

This examination can be performed in the following circumstances:

to establish whether faecal matter is present in the rectum and, if so, to assess the amount and consistency
to ascertain anal tone and the ability to initiate a voluntary contraction and to what degree
to teach pelvic floor exercises
to assess anal pathology for the presence of foreign objects
prior to administering rectal medication to establish the state of the rectum
to establish the effects of rectal medication
to administer suppositories or an enema prior to endoscopy
to determine the need for digital removal of faeces (DRF) or digital rectal stimulation and to evaluate for bowel emptiness
to assess the need for rectal medication and to evaluate its efficacy in certain circumstances, for example in patients who have diminished anal and/or rectal sensation
to trigger defaecation by digitally stimulating the rectoanal reflex (Peate [193])
to establish anal and rectal sensation (RCN [206]).

Clinical governance

As DRE is an invasive and intimate procedure, it is important that consent is obtained from the patient prior to it being performed (Kyle [120], Steggall [232]). A DRE should form part of the bowel assessment, rather than being a stand‐alone procedure (Kyle [120]), and can be undertaken by registered nurses who demonstrate competency in this procedure, possessing the knowledge, skills and abilities required for lawful, safe and effective practice (RCN [206]).

As nursing roles develop, nurse specialists and nurse practitioners are increasingly involved in areas of care that necessitate undertaking DRE as part of a physical assessment or procedure. Such instances may include:

the assessment of prostate size, characterization, mobility and anatomical limits
during procedures such as the placement of a rectal probe or sensor prior to urodynamic studies or the placement of catheters used in the treatment of constipation or anismus
prior to using transanal irrigation
during the placement of an endoscope prior to colonoscopy or sigmoidoscopy (RCN [206]).

Pre‐procedural considerations

Specific patient preparation

Before carrying out a DRE, the perineal and perianal area should be checked for signs of rectal prolapse, haemorrhoids, anal skin tags, fissures or lesions, foreign bodies, scarring, infestations or a gaping anus. The condition of the skin should be noted, as should the type and amount of any discharge or leakage. If any of these abnormalities are seen, a DRE should not be carried out until advice is taken from a specialist nurse or medical practitioner (RCN [206], Steggall [232]).

Precautions

Special care should be taken in performing DRE in patients whose disease processes or treatments in particular affect the anus or bowel mucosa. These conditions include (RCN [206]):

active inflammation of the bowel, for example ulcerative colitis
recent radiotherapy to the pelvic area
rectal and/or anal pain
rectal surgery or trauma to the anal and/or rectal area in the past 6 weeks
obvious rectal bleeding – consider possible causes for this
spinal cord injury at or above the sixth thoracic vertebra, because of the risk of autonomic dysreflexia
known allergies, for example latex
a known history of abuse
tissue fragility related to age, radiation or malnourishment.

Procedure guideline 6.23