1. Setting up
2. External inspection
3. External inspection: straining
4. Internal palpation
5. Stool examination

Setting up

• Describe procedure to pt.
• Pt. in Sim position: on table, lying on L side, knees up towards chest, facing away from Dr.
• Gloves on.

External inspection

• Piles.
• Skin tags (normal, Crohn's, hemorhoids).
• Rectal prolapse.
• Anal fissure.
• Fistula.
• Anal warts.
• Carcinoma.
• Signs of incontinence, diarrhea.

External inspection: straining

• Ask pt. to strain.
• Rectal prolapse upon straining.
• Hemorrhoid prolapse.
• Incontinence.
• Ask if straining is painful.

Internal palpation

• Lubricate index finger.
• Insert finger slowly, assessing external sphincter tone as enter.
• Male: palpate prostate [anterior of rectum]:
  • Hard nodule (prostate cancer).
  • Tender (prostatitis).
• Female: palpate cervix [anterior of rectum]:
  • Mass in pouch of Douglas.
• Rotate finger, palpating along left, posterior, right walls.
• Withdraw finger.
• Wipe lubricant off pt.
• Ask if was significant pain during examination. 

Stool examination

• Inspect withdrawn fingertip for:
  • Blood, melena.
  • Stool color.
  • Pus.
  • Mucous.
• If indicated, do a fecal occult blood test: blue result means blood.