Rectal Examination & Male External Genitalia Examination

Clinical Scope of Rectal Examination

  • A rectal examination encompasses the evaluation of the following anatomical areas:

    • Perineum

    • Anal canal

    • Rectum

    • Prostate (in males)

  • Clinical Significance: It is a critical diagnostic method for assessing gastrointestinal (G-I) diseases and evaluating the prostate gland.

  • Prostate Examination: Digital rectal examination (DRE) is the primary method for a physician to examine a patient's prostate and serves as the optimal screening method for prostate cancer.

Patient Perspectives and Clinical Data on DRE

  • Patient Experience Statistics:

    • Post-procedure Acceptance: In research studies, the percentage of patients qualifying the digital rectal exam as "acceptable" increased from 59.4%59.4\% to 91.5%91.5\% after the procedure was completed.

    • Repeat Rate: 88.04%88.04\% of patients would repeat the exam the following year.

    • Peer Encouragement: 94.05%94.05\% of patients would encourage a friend to get tested.

  • Barriers to Examination:

    • Consultation Delay: 66.66%66.66\% of patients admit to having delayed a medical consultation specifically to avoid the rectal exam.

    • Perceived Helpfulness: 73%73\% of patients were not convinced the test was helpful prior to undergoing it.

  • Post-Procedure Expectations:

    • Patients can immediately return to normal activities.

    • Potential rare side effects include mild discomfort, the sensation of needing to urinate, and light bleeding.

Preparation and Equipment for Rectal Examination

  • Preliminary Steps:

    • Explain the nature and purpose of the examination to the patient.

    • Ensure a private setting to maintain patient dignity.

    • A chaperone must be present during the procedure.

    • The patient will typically change into a hospital gown.

  • Required Equipment:

    • Non-sterile gloves.

    • Water-soluble lubricant.

    • Good light source.

    • Proctoscope (optional/as indicated).

Procedure: Positioning and Inspection

  • Patient Positioning:

    • The patient is placed in the left lateral position.

    • The hips are flexed to 90∘90^\circ.

    • The knees are flexed to approximately 110∘110^\circ.

    • The buttocks should be positioned close to the edge of the examination couch.

  • Inspection Technique:

    • Lift the right (uppermost) buttock with the left hand to expose the peri-anal region.

    • Systematically look for:

      • Rashes and excoriation.

      • Ulceration or masses.

      • Haemorrhoids.

      • Fissures or Fistulae.

      • Rectal prolapse.

      • Evidence of malignancy.

    • Dynamic Assessment: Ask the patient to strain (as if passing a stool) while looking for a patulous anus, prolapse of the rectum, or leakage of faeces.

Procedure: Palpation Technique

  • Initial Insertion:

    • Apply lubricant to the examining finger and the anal opening.

    • Instruct the patient to breathe in and out through the mouth to relax the sphincter.

    • Place the pulp of the finger over the center of the anus, with the finger parallel to the perineum.

    • Slowly and gently introduce the finger into the anal canal.

    • Push backwards to overcome the tone of the anal sphincter and the puborectalis muscle.

  • Canal and Rectal Assessment:

    • Palpate the anal canal; if severe tenderness is present, consider an Examination Under Anaesthesia (EUA).

    • Tone Assessment: Ask the patient to squeeze the finger to assess the tone of the external sphincter.

    • Content Assessment: Note the presence of faeces or masses.

    • Mucosal Assessment: Rotate the finger to palpate the rectal mucosa in all directions (left lateral wall, posterior hollow, and right lateral wall).

    • Documentation: If any abnormality is palpated, record its distance from the anal verge and describe the lesion.

  • Prostate Palpation:

    • The prostate gland is located anterior to the rectum.

    • Normal Prostate: Firm, symmetrical, and smooth. It consists of two lobes approximately 2.5 cm2.5\,\text{cm} in length, separated by a central furrow or sulcus. It may feel firmer with age.

  • Completion of Procedure:

    • Remove the finger and inspect the glove for faeces, blood, mucus, or pus.

    • Clean the area and thank the patient.

    • Explain findings to the patient and relevant senior staff.

Clinical Findings: Anal and Rectal Pathology

  • Haemorrhoids:

    • External Thrombosed Haemorrhoids: Small (< 1\,\text{cm}), tense, blue, and painful.

    • Prolapsed Haemorrhoids: Classified by degrees. Third-degree haemorrhoids are prolapsed and may show thickening of the epithelium (white appearance). They are often associated with constipation and straining.

  • Rectal Prolapse:

    • Mucosal Prolapse: Characterized by red mucosal folds; may become fibrosed and appear as a "fibrosed anal polyp.".

    • Full Thickness Prolapse: Circumferential folds of mucosa protruding through the anus; often associated with a gaping anus due to loss of sphincter tone.

  • Fissure-in-ano and Fistula-in-ano:

    • Anal Fissure: A tear in the anal wall, usually found posteriorly in the midline. It can be painful enough to prevent a digital exam.

    • Fistula-in-ano: Multiple openings may be seen behind or to the left of the anus. Causes include Crohn's disease and perianal abscesses.

  • Malignancy and Other Lesions:

    • Carcinoma of the Anus: May present as a fungating mass at the anal verge or spreading into the skin of the perineum.

    • Condyloma accuminata (warts).

    • Pelvic Abscess: A palpable mass felt within the rectum.

    • Amoebic granuloma (rare) and foreign bodies.

Clinical Findings: Prostate Pathologies

  • Benign Prostatic Hyperplasia (BPH): Results in a regularly enlarged prostate.

    • Prostatitis: The gland feels boggy, swollen, and is very painful/tender to palpation.

    • Prostate Cancer: Suggested by an irregularly enlarged or nodular gland, or a very hard nodule. The central sulcus may be obliterated.

Examination of Male External Genitalia: Preparation

  • Professional Approach: Maintain a professional demeanor and be aware of the patient's sensitivity during the exam.

  • Patient Preparation:

    • The patient must undress, removing both trousers and underwear.

    • Cover the patient until the moment of examination.

    • Positioning: Initially standing up, then moving to a supine position.

  • Equipment:

    • Gloves.

    • Torch (flashlight).

Inspection and Palpation of the Penis

  • Anatomic Landmarks to Inspect:

    • Pubic hair (covering site of pubic symphysis).

    • Root, body, and dorsum of the penis.

    • Glans penis and corona of the glans.

    • External urethral orifice (meatus).

  • Clinical Elements:

    • Identify if the patient is circumcised or uncircumcised. If uncircumcised, retract the foreskin to expose the glans.

    • Check for urethral discharge (e.g., purulent discharge in Gonorrhoea).

    • Inspect for ulcers or vesicles:

      • Syphilis: Characterized by a painless chancre (ulcer).

      • Herpes Simplex: Present as small vesicles (Type 22 infection).

      • Chancroid: Can present as multiple lesions.

    • Anatomical Variations:

      • Hypospadias: A congenital abnormality where the urethra opens on the ventral surface of the penis proximal to its normal position.

Penile Abnormalities: Phimosis and Paraphimosis

  • Phimosis:

    • Definition: A narrowed end of the prepuce (foreskin) that prevents its retraction over the glans penis.

    • Aetiology: Can be congenital or the result of scarring from infection or trauma.

  • Paraphimosis:

    • Definition: A condition where a narrowed prepuce becomes stuck behind the glans penis, often occurring during an erection.

    • Consequences: It impedes venous blood flow, leading to oedema and congestion of the glans. This makes the reduction of the prepuce progressively more difficult.

  • Miscellaneous Conditions:

    • Candida Balanitis: Fungal infection of the glans.

    • Penile Carcinoma.

    • Strangulation: May be caused by external objects like a metal ring.

Examination of the Scrotum and Testes

  • Inspection:

    • Assess symmetry and size. The left testis is usually lower than the right.

    • Observe for scrotal swellings.

  • Palpation Technique:

    • Verify that both testes are present in the scrotum (absence may indicate Cryptorchidism).

    • Systematically feel the spermatic cord, epididymis (readily felt at the top of the testis), and the body of the testis.

    • Note consistency, surface texture, and tenderness.

  • Ectopic Testis: Potential sites for an ectopic testis include:

    • Superficial inguinal pouch.

    • Femoral triangle.

    • Base of the penis.

    • Perineum.

Evaluation of Scrotal Swellings

  • Diagnostic Questions for Classification:

    1. Can you "get above" the swelling? (Possible for true scrotal swellings; not possible for inguinal hernias descending into the scrotum).

    2. Can the testis and epididymis be identified separately from the mass?

    3. Is the swelling translucent (transillumination)?

    4. Is the swelling tender?

  • Common Causes by Demographics:

    • Young Men: Tumours, trauma, and acute infections.

    • Older Men: Hydrocoele and hernias.

  • Specific Conditions:

    • Varicocele: A dilatation of the veins (pampiniform plexus); more common on the left side.

    • Hydrocele: A collection of fluid; it is translucent upon transillumination and non-reducible.

    • Epididymitis: Inflammation of the epididymitis, often tender.

    • Torsion of the Testis: Typically affects adolescents and men in their early twenties; constitutes a surgical emergency.

    • Saphenous Varix: A dilatation of the vein at the junction with the femoral vein; characterized by a "jet of water" sensation on palpation and disappears when supine.

Tanner Staging of Pubic Hair

  • Pubic hair growth is categorized into five stages:

    • Stage 1: No hair present.

    • Stage 2: Appearance of downy hair.

    • Stage 3: Scant terminal hair.

    • Stage 4: Terminal hair that fills the entire triangle overlying the pubic region.

    • Stage 5: Terminal hair that extends beyond the inguinal crease onto the thigh.