Differentials
| Presenting Feature | What might it be? | What might I find? | |
| Rectal bleeding |
Haemorrhoids |
Risk factors: pregnancy, constipation, obesity, age.
May be asymptomatic; may cause anal pain and itching. Painless bright red blood on wiping, not mixed w/stool. May be internal or external thus may or may not be visible on anal inspection, may be palpable on rectal exam. |
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Diverticular disease |
Risk factors: increased age, low fibre diet, obesity.
Diverticulosis: presence of diverticula – can cause bleeding associated with LIF pain and constipation. Diverticulitis: inflamed diverticula – can cause bleeding with LIF pain, fever, diarrhoea, nausea and vomiting. |
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Inflammatory bowel disease |
Crohn’s Disease & Ulcerative Colitis (bleeding with UC).
Typically younger patient. Associated weight loss, diarrhoea, abdominal pain, fatigue. Raised stool faecal calprotectin and blood WCC/CRP. |
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Colorectal cancer |
Risk factors: older age, family hx, IBD, smoking, poor diet.
Rectal bleeding mixed with stool. Associated with weight ↓, changed bowel habit, anaemia. |
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Upper GI bleed |
Altered blood (malaena) passed per rectum.
Dark, sticky, tar-like substance. Indicative of UGI bleeding e.g., gastric, duodenal, or oesophageal. |
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| Anal pain |
Anal fissure |
Risk factors: constipation, IBD, pregnancy.
Sharp pain when passing stool followed by burning pain. May be associated with bright red blood on wiping. Tiny cut visible on rectal examination. |
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Anal fistula |
Risk factors: anal abscess, IBD, diverticulitis, H.Suppurativa.
Anal pain, worse on sitting, associated discharge/blood. Perianal swelling and redness/discharge, visible opening, |
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Thrombosed haemorrhoid |
Purplish, tender, swollen lumps around anus.
Patient unlikely to be able to tolerate rectal exam. |
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STI |
Risk factors: condomless sex, anal sex.
May be associated with sore, warts or discharge from anus. |
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Trauma |
Trauma from anal sex, foreign body, or large hard stools. | ||
| Anorectal mass |
Anal cancer |
As for colorectal ca, HPV exposure, immunosuppressed.
Perianal pain, itching, mucous, presence of a lump/ulcer. |
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Rectal polyp |
Risk factors: family history, increasing age, IBD, smoking.
Often asymptomatic; distal polyp can be felt w/rectal exam. May cause change in bowel habit, rectal bleeding or mucus. |
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Rectal prolapse |
Risk factors: constipation, weak pelvic floor, chronic cough.
Anal protruding lump present with increased intra-abdominal pressure e.g., straining, coughing, standing. Prolapse may reduce itself or need manually reducing. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Chaperone | ||
| Position patient lying on left side with knees drawn up | ||
| Ask patient to cover with sheet | ||
| Inspection | Expose perianal area | |
| Put on gloves | ||
| Part buttocks | ||
| Skin colour | ||
| Blood/discharge | ||
| Excoriation marks | ||
| Anal fissures | ||
| Skin tags | ||
| Haemorrhoids | ||
| Rashes | ||
| Ulceration | ||
| Prolapse (bear down) | ||
| Palpation | Lubricate finger | |
| Insert finger into rectum | ||
| 360° palpation of rectal walls | ||
| Masses | ||
| Tenderness | ||
| Presence of stool | ||
| Ask patient to bear down | ||
| Check anal tone | ||
| Withdraw finger | ||
| Inspect withdrawn finger for stool/blood | ||
| Finishing | Wipe away excess lubricant from patient | |
| Re-cover patient | ||
| Wash hands |
Explanation
Preparation
Wash, name, explain:
- Wash your hands
- Introduce yourself by name and role
- Check the patient’s name and date of birth
- Explain the procedure and get consent
- Explain the presence and purpose of the chaperone
“I have been asked to carry out a rectal examination. This involves looking at your bottom and then feeling inside the rectum with my finger. You will feel some pressure and the cold jelly, but it should not be painful. You can ask me to stop at any time. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”
Ask the patient to undress from the waist down and position them lying on the examination couch on their left side, with knees drawn up to the chest. Cover the patient with a blanket until you are ready to start the examination.
Inspection
Put on gloves for the examination. Expose the patient and check they are comfortable. Part the buttocks and observe the perianal area. Note the skin colour, any redness or breakdown of skin integrity, and any excoriation marks indicating sore or itchy perianal skin. Also observe the presence, colour, and amount of any stool, blood or discharge around the anus.
Examine the perianal area for:
- Fissures
- Skin tags
- Haemorrhoids
- Rashes
- Ulceration
Ask the patient to bear down as if to pass stool and observe for the presence of a rectal prolapse.
Palpation
Apply lubricating jelly to the index finger of the dominant hand. Ensure the patient is ready and position the finger at the posterior aspect of the patient’s anus. Insert finger into the rectum.
Perform 360° palpation of rectal walls. Note the following:
- Masses – note the location, size, consistency, mobility
- Tenderness
- Presence of stool in rectum noting if this is soft or hard and impacted
Ask the patient to bear down as if to pass stool to assess any more proximal masses by bringing them into range of palpation. Ask the patient to squeeze as if to stop the passage of stool and assess anal tone.
Withdraw finger and inspect for presence, colour, and amount of stool, blood or mucus.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the rectal examination findings you may wish to carry out further investigations, including blood tests, stool samples, FIT testing, or referral for endoscopy or further imaging such as a CT scan.
Last updated Dec 2024
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