Introduction

1. Greet the patient and introduce yourself
2. Confirm patient details ✍
3. Explain the procedure in a patient friendly manner 
4. Explain a chaperone will be present 
5. Get consent ✍
6. Check the patient is not in any pain
7. Explain to the patient that they must remove their underwear and use the sheet to cover themselves whilst you leave the room

Equipment

1. Disposable gloves ✋
2. Apron
3. Paper towels
4. Lubricant

Preparation

1. Wash hands ✋
2. Put apron and gloves on ✋
3. Ask the patient to lie on their side, bending their knees up to their chest ❓
4. Ensure the patient is comfortable with you removing the sheet to begin

Inspection

Inspect the region for any signs that may be clinically relevant:

👉 Skin tags: can be associated with IBD

👉 Anal fistula: pus discharge from the fistulae, caused by perianal Crohn’s disease/diverticulitis/chronic anal abscess

👉 Anal fissure: anal canal tear due to constipation

👉 Skin excoriation: caused by haemorrhoids/constipation/faecal incontinence

👉 External bleeding: caused by anal cancer/external haemorrhoids/ brisk gastrointestinal bleeding 

👉 External haemorrhoids: ‘lump’ located just inside the anus

Ask the patient coughs inspect for:

👉 Internal haemorrhoids: bluish, bulging vessels covered in mucosa

👉 Rectal prolapse: concentric rings of mucosa on a mass

Inflammatory Bowel Disease (IBD):

👉 IBD: blanket term encompassing disorders which cause the gastrointestinal tract (GIT) to become chronically inflamed.

👉 Crohn’s disease: IBD subtype, affects any part of the GIT, causes rectal bleeding, abscesses, more than one skin tag or perianal fistulas

👉 Ulcerative colitis: IBD subtype, affects rectum and colon, causes excess mucous and loose, stool with blood in it

Palpation

1. Apply lubricant to the finger 👆 you will use for the examination
2. Inform the patient you are ready to insert your finger 👆 into the anal canal
3. Gently insert finger
4. Male patients: asses the size, texture and symmetry of the prostate gland by palpating it anteriorly, identifying abnormalities:
   • Prostate cancer: hard, asymmetrical and irregular prostate gland, may also be a nodule in one of the lobes which you can palpate
   • Prostatitis: spongy, tender prostate gland
   • Benign prostatic hypertrophy: smooth and enlarged prostate with no groove in the midline
5. Assess the rectum by circularly rotating your finger 👆 360°
   1. Record 📏 the size, texture, location and any lumps
   2. Identify any hard stool indicative of constipation
   3. Identify any tenderness indicative of anal fissure/thrombosed internal haemorrhoids
6. Ask the patient to exert pressure on your finger 👆 to allow you to assess the tone
   1. Reduced anal tone is caused by spinal cord pathology, IBD and prior surgery
7. Remove your finger 👆 from the anus and inspect it
   • Fresh red blood: indicates lower GI bleeding 
   • Dark sticky blood (melaena): indicates upper GI bleeding 
   • Excess mucous: indicates IBD
8. Using paper towels, clean the patient
9. Cover the patient  and leave the room, explain they can now get dressed
10. Dispose of equipment appropriately
11. Wash hands ✋

Completion

1. Thank patient 
2. Document the examination 
3. Summarise what the examination revealed ✍

Subsequent investigations

👉 Blood tests: for concerns about GI bleeding 

👉 CT abdomen and pelvis: for concerns about lower GI malignancy

👉 Abdominal examination: for concerns about intra-abdominal pathology

👉 Flexible colonoscopy/sigmoidoscopy: for concerns about lower GI malignancy or bleeding 

👉 Faecal occult blood test: for concerns about lower GI malignancy

Summary:

1. Greet the patient and briefly explain the examination
2. Prepare by washing your hands, putting on PPE, and asking patient to lie on their side with their knees at their chest
3. Inspect the rectal area for any clinically relevant signs, and ask the patient to cough
4. Palpate the rectum
5. Complete the procedure by thanking the patient and giving them privacy to change