latest prostrate examination 2022 with check list.pptx

Prostrate examination by digital rectal examination

1. Prostrate Examination Dr Shamshad Majmaah Medical College KSA

2. Objectives Identify the common indications for digital rectal examination (DRE). Identify the correct steps of digital rectal examination e. g (obtaining consent, explaining the procedure to the patient and correct positioning ). Apply correct technique of digital rectal examination . Detect common abnormalities of prostate. 10/1/2022 2

3. 10/1/2022 3 S no. Equipments/ instruments required for the skills 1. Hand sanitizer 3. Prostate manikin 5. Disposable gloves 6. Xylocain Lubricant ,Betadine lotion, sponge holder 7. Cotton gauge, green hole towel, 8. Good exposure of light (Lamp)

4. Definition: Digital Rectal Examination [DRE] The medical expert performs a physical examination by inserting a gloved index finger into an anal orifice to assess anal/rectal/ prostatic pathology, or anal sphincter tone. 10/1/2022 4 Anoscopy Examination of anal canal using a small ,Rigid , tubular instrument called anoscope or anal speculum. Proctoscopy Examination of anal cavity, rectum, sigmoid colon or prostrate using a short, straight, rigid, hollow tube , with a small light bulb mounted at the end called proctoscope . Approx. 5 inches long.

5. 10/1/2022 5 Anoscope Proctoscope 10 cms size 13 cms size

6. Indication of Digital Rectal Examination [DRE] Hemorrhoids, altered bowel habits, Neurologic deficits [Male] Prostatitis , Prostate cancer, Benign prostatic hyperplasia Anal and rectal cancers or bleeding, Anal condyloma, Fecal incontinence, Anal fissures, Inflammatory bowel disease, :   Ulcerative colitis & Crohn disease Urinary symptoms American Urological Association ( AUA): DRE is indicated for all men, starting at age 40, for a baseline determination of prostate status . 10/1/2022 6

7. Contraindication of Digital Rectal Examination [DRE] Imperforate Anus Immunocompromised patient Anal Stricture Severe to moderate anal pain Prolapsed thrombosed internal hemorrhoids Post-abdomino-perineal resection / Post-operative anal surgeries Recent acute MI Acute abdominal pain Unwilling patients Major rectal trauma 10/1/2022 7

8. Digital Rectal Examination [DRE] Inspection Palpation . 10/1/2022 8

9. Initial etiquettes Wash your hands, wear gloves, introduce yourself to the patient and clarify their identity. Explain the procedure and post examination complication Prepare the patient to tolerate slight discomfort or pain. Arrange for a chaperone MUST during examination. Obtain consent. Reassure the patient about privacy Arrange for good light exposure . Expose the part to be examined.[Do not over or under expose] 10/1/2022 9

10. Positioning of the patient Ask them to lie on their left hand side With hips flexed to 90 , knees less flexed to 110 . With their knees drawn up towards their chest , Feet pushed forwards and their anus exposed. Buttocks at edge of the examination table 5. Scrub the anal part with povidine solution and then with alcohol swab. 10/1/2022 10

11. 10/1/2022 11 Examination of anus and perineum region Describe the abnormalities including skin tags, hemorrhoids and fissures, fecal matter fresh bleeding,,,, etc Anterior aspect as 12 & posterior as 6 o clock position as shown in figure.

12. Inspection of anus and perineum region Separate the buttocks and inspect the area around the anus. Look for any abnormalities including skin tags, hemorrhoids and fissures, fecal matter fresh bleeding,,,, etc… 10/1/2022 12

13. …Inspection of anus and perineum region 10/1/2022 13 Ask the patient to cough and inspect for : Rectal prolapse: A mass with concentric rings of mucosa will be visible protruding through the anus . Internal haemorrhoids: Bluish , bulging vessels covered by mucosa become visible when the patient coughs .

14. Palpation 10/1/2022 14 Lubricate your gloved index finger with Xylocaine ointment . Inform the patient you are about to start the procedure. Place your pulp of your finger posterior anal verge so that it points anteriorly Apply pressure to the midline of the anus..

15. ..Palpation 10/1/2022 15 As you insert your finger, pull backwards to counteract the tone in the puborectalis muscle. Maintain the pressure so that your finger enters the rectum. Initially you need to assess anal tone by asking the patient to squeeze your finger.

16. ….Palpation 10/1/2022 16 8. Avoid force .Wait for the sphincter to relax. 9. If still difficult do not continue with the examination. 10 . Rotate your finger 360 degrees to assess the entirety of the rectum : This is done by sweeping the finger both clockwise and anti-clockwise around the entire circumference. Feel for any abnormalities such as impacted faeces, masses or ulcers .. Sweep clockwise Sweep anti-clockwise

17. ….Palpation 10/1/2022 17 Note: The size, location (e.g. 9 o’clock) and texture (e.g. smooth, irregular) of any rectal lumps (e.g. tumour , polyp, internal haemorrhoids). Feel for any hard stool present in the rectum. Any tenderness, indicate an anal fissure or thrombosed internal haemorrhoids.

18. ….Palpation 10/1/2022 18 11. In males assess the prostate gland . This lies anteriorly and feel for it. Check the size, symmetry , texture , consistency & presence of the midline groove . A normal prostate is approximately walnut-sized with a palpable midline sulcus . It is symmetrical and its consistency similar to that of the tip of the nose .

19. ….Palpation 10/1/2022 19 12. Anal tone assessment Assess anal tone by asking the patient to bear down on your finger. Causes of reduced anal tone include spinal cord pathology (e.g. cauda equina syndrome), inflammatory bowel disease and previous rectal surgery.

20. 10/1/2022 20 The Digital Rectal Examination Scoring System (DRESS) Resting Score for anal tone No discernable tone at rest, an open or patulous anal canal 1 Very low tone 2 Mildly decreased tone 3 Normal 4 Elevated tone, snug 5 Very high tone, a tight anal canal, difficult to insert a finger . Squeeze Score No discernable increase in tone with squeezing effort 1 Slight increase 2 Fair increase but below normal 3 Normal 2 Fair increase but below normal 3 Normal 4 Strong squeeze 5 Very strong squeeze, to the point of being painful to the examiner

21. 10/1/2022 21 The Digital Rectal Examination Scoring System (DRESS ) interpretation The system utilizes an analog scale of 0 to 5 Anal tone : A score of 3  N ormal A score of 5  Very high pressures & tight anal canal A score of 0  A n open or patulous anal canal at rest with separation of the buttocks. Squeeze score : A score of 5 V ery strong squeeze, almost painful to examiner A score of  N o discernable increase in pressure from rest with maximal patient effort .

22. ….Palpation 10/1/2022 22 13. After examining the anal canal and rectum. Place your other hand on the abdomen and examine the contents of the pelvis bimanually.

23. Final steps 10/1/2022 23 1. Withdraw your finger and inspect for blood or mucous and colour of any faeces stains Interpretation : Dark sticky blood [melena] up. GI bleeding (stomach ulcer). Fresh red blood  low. GI bleeding (rectal malignancy, fissure). Excess mucous  inflammatory bowel disease (ulcerative colitis).

24. ..Final steps 10/1/2022 24 Clean the patient using paper towels . Remove and dispose your gloves along with used disposable equipments in the clinical waste bin. Cover the patient with the sheet , inform that procedure is complete and Allow the patient to dress in privacy. T hank the patient. Wash your hands and report your findings to the examiner.

25. Reference: 1. http :// www.osceskills.com/e-learning/subjects/rectal examination /#sthash.yG3uvPXH.dpuf 2. Oxford Handbook of Clinical Examination and Practical Skills, by Vishal, 1st edition (2007). 3 . http ://www.uptodate.com. 4 . Hutchison’s Clinical Methods: An Integrated Approach to Clinical Practice, 22nd edition (2007), by Michael Glynn and William M Drake . 5: The digital rectal examination scoring system ( DRESS) December 2010Diseases of the Colon & Rectum 53(12): 1656-60 DOI : 10.1007/DCR.0b013e3181f23c85 SourcePubMed Bruce OrkinBruce OrkinSvetlana B SinykinPatricia C Lloyd 6: Figure from internet . 10/1/2022 25

26. 10/1/2022 26 Equipments/ instruments required for the skills Hand sanitizer, Prostate manikin ,Disposable gloves ,Lubricant ,Betadine lotion, sponge holder Cotton gauge, green hole towel. Introduce yourself. Confidentiality and respect patient privacy. Try to see from patient point of view. Listening Questioning: simple/clear/avoid medical terms/open, leading, interrupting, direct questions and summarizing. Always record personal details: name, age, address, sex, ethnicity, occupation, religion, Marital status. Record date of examination Wash your hands, introduce yourself to the patient and clarify their identity.  Explain what you would like to do and obtain consent.  This is a slightly uncomfortable procedure so you should warn the patient of this. A chaperone is required for this examination . Positioning of the patient in this procedure is very important. Ask them to lie on their left hand side with their knees drawn up towards their chest, their feet pushed forwards and their anus exposed . Having washed your hands and put on your gloves, separate the buttocks and inspect the area around the anus. Look for any abnormalities including skin tags, haemorrhoids and fissures . After inspecting, lubricate your right index finger . Tell the patient you are about to start the procedure. Place your finger on the anus so that it points anteriorly and apply pressure to the midline of the anus . Examination Prostrate by DRE

27. 10/1/2022 27 Maintain the pressure so that your finger enters the rectum. Initially you need to assess anal tone by asking the patient to squeeze your finger Next you need to systematically examine each part of the rectum. This is done by sweeping the finger both clockwise and anti-clockwise around the entire circumference . You should be feeling for any abnormalities such as impacted faeces, masses or ulcers . One of the main reasons for performing a rectal examination in males is to assess the prostate gland. This lies anteriorly and should always be felt. You should check the size, consistency and presence of the midline groove . Remove your finger and examine the glove for the colour of any faeces as well as the presence of any mucus or blood . Clean off any lubricant left around the anus and remove and dispose of your gloves in the clinical waste bin . Allow the patient to dress and thank them. Wash your hands and report your findings to the examiner. Rectal (PR) examinations are performed for a number of clinical reasons e.g. altered bowel habit, rectal bleeding, urinary symptoms and is a skill surgeons perform on all patients and it is an important skill to know