Digital Rectal Exam: Importance, Recommendations, and Findings

The digital rectal exam (DRE) is part of the physical examination where a medical provider assesses the anus, rectum, gastrointestinal, and reproductive organs. The technique involves a gloved finger inserted into the anus with lubrication. Position, privacy, chaperoning, and communication are all integrated into the exam to maximize patient comfort.

This examination is often underutilized in medical care but can provide many diagnostic benefits. It can assess bleeding in the gastrointestinal (GI) tract, constipation, neurological conditions, and hemorrhoids. 

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What is a Digital Rectal Exam?

The digital rectal exam can be intimidating for the patient, but understanding the steps and technique can relieve anxiety about it. A DRE is performed in a private setting by a medical provider with another person present (chaperone). 

The setting should have adequate lighting, and it is important that the provider describe the steps of the exam before and during to promote comfort. 

Steps of the DRE include:

1. The patient is positioned on their left side with their knees and hips flexed. 
2. The provider exposes the anus and assesses the skin and surrounding area.
3. The gloved examining index finger is lubricated and inserted into the anus at the 6 o'clock position. 
4. The tone of the anal muscles is examined by the patient contracting around the examining finger. 
5. The provider rotates their finger 180° to assess the rectal walls. 
6. If the patient has a prostate, it can be palpated in the anterior position. 
7. If the patient has a cervix or uterus, it can often be felt with the tip of the finger. 
8. The examining finger is removed, and the provider should assess for blood or unusual stool color. 

Patients do not need to undergo any specific preparation. However, they should know that the examination may be uncomfortable but not painful. 

When Does Someone Need A Digital Rectal Exam (DRE)?

Your healthcare provider may recommend a DRE for several reasons, including:

Indications for a DRE:

• Prostate Assessment: A DRE can help assess the size, shape, and texture of the prostate gland, which may support the early detection of potential prostate issues. It is often used as part of routine health screenings for men, particularly those over 50.
• Unexplained Rectal Bleeding: If someone is experiencing rectal bleeding, a DRE may be used as part of the evaluation to help identify the potential cause and determine if further testing is needed.
• Incontinence Evaluation: For individuals experiencing issues with bowel control, a DRE might help assess the function of the anal sphincter and surrounding structures.
• Secondary Exam for Cervix or Vagina: In some cases, a DRE can be used alongside a pelvic exam to provide additional information about the cervix, vagina, or other pelvic structures in women.
• Routine Screening: Regular DREs may be part of routine screenings for certain individuals, especially those at higher risk for conditions affecting the rectum, prostate, or surrounding areas.

Contraindications for a DRE:

While a DRE can provide valuable information, there are certain situations where it might not be recommended. Some contraindications include:

• Immunosuppression: Individuals with a weakened immune system may be more vulnerable to infections or complications, so a DRE may be deferred in favor of other diagnostic methods.
• Anal Pain: If a patient is experiencing significant pain in the anal region, a DRE might exacerbate the discomfort, and alternative evaluations may be considered first.
• Abdominal Pain: Severe abdominal pain could indicate an underlying condition that might be aggravated by a DRE, so other diagnostic approaches might be preferred.
• Coagulation Disorders: Patients with blood clotting disorders may be at increased risk of bleeding complications from a DRE, necessitating careful consideration of the risks and benefits.
• Rectal Trauma or Recent Surgery: If there has been recent trauma or surgery involving the rectal area, performing a DRE may interfere with healing or cause further injury.
• Recent Heart Attack or Valvular Heart Disease: Certain cardiovascular conditions may increase the risk of complications from a DRE. In such cases, other evaluation methods might be recommended to avoid unnecessary strain on the heart.

Digital Rectal Exam and Prostate Health

One of the most essential functions of the DRE is the prostate assessment. Approximately 8% of men 31 to 40 years of age have an enlarged prostate; this number increases to 80% after age 80. 

In the United States, 236,659 cases of prostate cancer were reported in 2023, and 33,363 men died from prostate cancer. These statistics emphasize the importance of proper assessment of the prostate to catch disease early. 

During the DRE, the provider can examine the prostate and assess its size, surface characteristics, tenderness, nodularity, and presence of prostatic fluid. The normal size is 3.5 cm wide; it should feel rubbery, smooth, and firm. 

The prostate is normally non-tender without any palpable nodules. The DRE can provide early detection of bumps, dents, or any unusual findings that may indicate prostate cancer.

Clinical Guidelines and Recommendations

Screening for prostate cancer is a topic with much ongoing research weighing risks versus benefits. Prostate cancer screenings are done with a blood test measuring prostate-specific antigen (PSA). This test is not specific to cancer but can provide information about the health of the prostate.

Testing with PSA can be repeated every one to two years with or without a DRE. For men aged 55 to 69, there is no universal screening recommendation. The choice of whether or not to screen for prostate cancer should be reached through shared decision-making. Screening can detect cancer, but the benefit is small. 

It is not recommended to screen men over 70 years old for prostate cancer. Providers should remember that these recommendations are frequently updated, and staying up-to-date on new guidelines is vital. 

Digital Rectal Exam Findings

Normal findings during a DRE include:

• Prostate size of 3.5 cm wide, protruding 1 cm into the rectum
• Non-tender prostate without nodules
• Smooth, rubbery, firm prostate surface
• Rectal tone should be present
• Intact skin surrounding the anus 

Abnormal findings during a DRE:

• Enlarged prostate
• Tenderness
• Nodularities or abnormal surface characteristics
• Lack of rectal tone
• Anal fissures or fistula
• Internal or external hemorrhoids 
• Genital warts
• Skin abnormalities
• Rectal prolapse
• Bleeding
• Abnormal stool color

Follow-up for abnormal findings may include imaging studies, specialty consults (e.g., gynecology, oncology, or urology), or further lab testing. 

Addressing Patient Concerns and Misconceptions

Proper education and preparation before a DRE can ease patient anxiety and promote comfort. A common misconception is that a DRE is painful. This is not typically the case. The exam can be uncomfortable, but acute pain is abnormal. 

Explaining positioning, privacy, and chaperoning prior to the exam can all make the experience more comfortable. Additionally, patient consent is always obtained before a DRE, and the patient can request that the exam be stopped at any time. 

Expertise and Experience in Performing DRE

Digital rectal exams are performed by healthcare practitioners who have undergone training in proper technique. Finding a healthcare provider who provides proper education, obtains informed consent, and promotes patient comfort can help make the examination as comfortable as possible. 

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Key Takeaways

• The digital rectal exam (DRE) is a crucial yet often underutilized part of a physical exam. It helps assess the anus, rectum, and surrounding organs, including the gastrointestinal and reproductive systems. Despite being simple, it can detect a wide range of conditions, from prostate abnormalities to gastrointestinal issues.
• The DRE is especially valuable for prostate assessment, a critical concern given the rising prevalence of prostate conditions as men age. Early detection through DRE can be vital in identifying potential cancerous changes.
• Addressing misconceptions about DRE is essential. Many patients fear pain or discomfort, but these concerns can be mitigated with proper technique and communication. 
• The DRE remains an essential tool in detecting significant health conditions early.  Encouraging regular screenings and fostering open communication with patients can lead to better outcomes, improved comfort, and, ultimately, more effective care.