3 - How to Examine the Anorectal Region

Abstract

Digital rectal examination (DRE) is often the first step in evaluating a patient with a suspected anorectal disorder, but unfortunately it is rarely performed in routine clinical practice. Furthermore, there is a lack of training in how to perform a good DRE, and trainees seem to lack the confidence in performing this examination. Although a detailed history and diagnostic tools, such as anorectal manometry (ARM), and imaging, such as MRI defecography, and anal ultrasound, have improved our understanding of the structural and functional changes in the anorectum, without a meticulous DRE a clinician is often misinformed about the clinical problem. DRE when compared with ARM has a positive correlation coefficient of 0.82 for resting and 0.81 for squeeze sphincter pressure. Likewise, the sensitivity and specificity of DRE for identifying dyssynergic defecation were 75% and 87% with a positive predictive value of 97% when compared to ARM and balloon expulsion test. A normal DRE will probably exclude significant anorectal dysfunction. Thus DRE is a useful bedside tool for a comprehensive evaluation of a patient with suspected with fecal incontinence, dyssynergic defecation, anorectal neuropathy, anal fissure, levator-ani syndrome, rectocele, and rectal prolapse. Gastroenterologists should learn the technique of and perform a comprehensive DRE.