Rectal Examination and Inguinal Orifices

Rectal Examination

Intro

  • Wash hands, introduce self, check patient name and DOB/CHI, explain procedure and gain consent
  • Offer a chaperone
  • Warn the patient that this may be unfortable

Preparation

  • Ensure you have gloves, lubricant and tissues
  • Ask the patient to undress from the waste down (ensure privacy and offer cover)
  • Ask the patient to lie on their left side with their knees tucked into their chest
  • Wash your hands and put on gloves/apron

Procedure

  • Separate the buttocks and inspect the anus and surround skin.  Look for any abnormalities e.g. skin tags, haemorrhoids, warts, ulcers or fissures
    • If appropriate, ask the patient to squeeze their bottom and look for anal sphincter competency; and ask the patient to push down and look for any rectal prolapse
  • Lubricate the gloved finger of the right hand and approach the anus from posteriorly.  Pause when the finger is over the anus and wait for the sphincter to relax
    • Advance the finger into the anus
      • Comment on the consistency of any faeces
      • Ask the patient to bear down (bringing higher rectal lesions down) and squeeze their bottom (testing anal tone)
      • Do a 360° sweep (half sweep clockwise, half anticlockwise) feeling for any masses/wall thickenings
      • In men, feel the 2 lobes of the prostate gland and comment on any masses, symmetry, consistency and size
  • Remove the finger and wipe on a cotton wool gauze or tissue- look for any faeces, mucous or blood
  • Clean the anus

Finish

  • Dispose of equipment appropriately
  • Thank the patient, cover them over and let them dress in privacy
  • Document the procedure, chaperone and any findings in patient notes
  • Suggest further investigations based on findings e.g. PSA, rectal USS, stool sample, scan etc

Inguinal Hernia

  • Wash hands, introduce self, check patient name and DOB/CHI, explain procedure and gain consent
  • Ask for a chaperone
  • Ask the patient to pull down their clothes to fully expose the groin and inguinal orifices (offer privacy and covering for the patient); ask them to lie on their back

Inspection/palpation

  • Inspect the groins for any obvious lumps (note size, position, relation to other anatomy, colour); scars
    • palpate any lumps for tenderness, reducibility, consistency, temperature, (transillumination)
  • Ask the patient to stand and look again
  • Check the cough impulse- observe for any exaggeration of the lump with coughing; palpate the lump and feel for an impulse too
  • If satisfied that this is an inguinal hernia, ask the patient to reduce it.
    • Place two fingers over the inguinal ring (deep- midway between the ASIS and pubic tubercle) and ask the patient to cough again
      • If it reappears- direct hernia; if you feel the impulse and it does not reappear it is more likely indirect (NB this differentiation can be very difficult in reality)
    • Release and watch the hernia reappear if not already done so
    • If it cannot be reduced, try again with the patient lying down
  • If there is a scrotal hernia, check to see that you cannot get above the scrotal lump
    • see if it disappears on lying supine (may or may not)

Percussion/Auscultation

  • Percuss and auscultate the lump for any resonance of bowel gas and bowel sounds

Finish

  • Examine the abdomen also if necessary; also examine the femoral pulses and inguinal lymph nodes
  • Wash hands, thank patient and allow them privacy to get dressed.
  • Document any findings in the notes, suggesting thoughts on diagnosis, further investigation/management.
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