Digital rectal examination (DRE)

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Digital rectal examination (DRE)

The immediate anterior relationship of the rectum in the male is the prostate. The DRE is the mainstay of examination of the prostate.

Explain the need for the examination. Ensure the examination is done in privacy. DRE is usually done in the left lateral position with the patient lying on their left side and with the hips and knees flexed to 90 degrees or more. 

Examine the anal region for fistulae and fissures. Apply plenty of lubricating gel to the gloved finger. Lift the tight buttock upwards with your other hand to expose the anus and gently and slowly insert your index finger into the anal canal and then into the rectum.

Palpate anteriorly with the pulp of your finger, and feel the surface of the prostate. Note its consistency (normal or firm), its surface (smooth or irregular), and estimate its size. (It can be helpful to relate its size to common objects (e.g. fruit or nuts!) A normal prostate is the size of a walnut, a moderately enlarged prostate that of a tangerine, and a big prostate the size of an apple or orange.) The normal bilobed prostate has a groove (the median sulcus) between the two lobes and in prostate cancer this groove may be obscured.

Many men find DRE uncomfortable or even painful and the inexperienced doctor may equate this normal discomfort with prostatic tenderness. Prostatic tenderness is best elicited by gentle pressure on the prostate with the examining finger. If the prostate is really involved by some acute, inflammatory condition such as acute, infective prostatitis or a prostatic abscess, it will be very tender.

DRE should be avoided in the profoundly neutropenic patient (risk of septicaemia) and in patients with an anal fissure (DRE would be very painful).

Other features to elicit in the DRE

The integrity of the sacral nerves that innervate the bladder and of the sacral spinal cord can be established by eliciting the bulbocavernosus reflex (the BCR) during a DRE. The sensory side of the reflex is elicited by squeezing the glans of the penis or the clitoris (or in catheterized patients, by gently pulling the balloon of the catheter onto the bladder neck). The motor side of the reflex is tested by feeling for contraction of the anus during this sensory stimulus. Contraction of the anus represents a positive BCR and indicates that the afferent and efferent nerves of the sacral spinal cord (S2 to 4) and the sacral cord are intact.

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