Synopsis
Perform digital rectal examination and proctoscopy respectfully and safely, describe the accessible anatomy precisely, stop when consent or tolerance changes, and act on findings without overstating a limited examination.
- Explain the intimate examination separately, offer a chaperone and confirm the patient may pause or stop.
- Inspect the perianal skin before insertion for fissure, prolapse, thrombosis, fistula opening, blood or discharge.
- Introduce a lubricated finger gently, assessing tone, tenderness, contents and accessible rectal walls without force.
Key red flags
Severe pain, peritonism, major ongoing bleeding or physiological instability should shorten the local examination and trigger urgent assessment; repeated instrumentation must not delay resuscitation.
Reasoning priorities
confirm that an intimate examination is necessary, understood and acceptable
Consent is an active process; lack of capacity, severe distress or refusal changes how and whether the examination proceeds.
Worked reasoning
A 62-year-old with intermittent painless rectal bleeding reports soft tissue prolapsing during defaecation that returns spontaneously. They accept digital examination and proctoscopy after explanation and a chaperone offer; observations are normal and there is no severe anal pain.
- Inspect the perianal skin in the left lateral position and find no fissure, prolapse, thrombosis, fistula opening or active external bleeding.
- Introduce a lubricated gloved finger gently while explaining each movement. Tone is normal, no mass or tenderness is felt, and brown stool with a small fresh-blood streak is present on the glove.
- After separate consent, insert a lubricated proctoscope and identify two internal haemorrhoidal cushions that prolapse with gentle strain and reduce spontaneously, consistent with grade II haemorrhoids; there is no active bleeding and the distal rectal mucosa otherwise appears normal.
- Explain that these findings may contribute but do not examine the proximal rectum or colon, so persistent unexplained bleeding still requires FIT and risk-based colonic assessment.
- Document consent, chaperone, position, examination reach and actual results, and verify that the planned FIT result and any referral are reviewed.