Skill List > Digital Rectal Examination/Digital Removal of Faeces
Clinical Alert
You can undertake these procedures if you have been trained, assessed and deemed competent according to local policies.

Elsevier Clinical Skills covers the principles of this procedure. You must follow local policies and procedures regarding technique, equipment used and documentation.
Authors:
Written by: Juliana Tinhunu RN, BSc (Hons) Nursing Studies, MSc (Health Management)
Reviewed: February 2021

Learning Objective
The purpose of this learning material is to provide you with a resource to: • Facilitate the development of new knowledge • Build on existing knowledge • Test knowledge • Assess the skill in practice

Introduction

Digital rectal examination (DRE) and digital removal of faeces (DRF) are invasive and intimate procedures and should be carried out only when it is absolutely necessary following a holistic patient assessment (Peate 2016). DRE involves the insertion of a lubricated, gloved index finger into the rectum while DRF involves the manual removal of faeces from the rectum using a gloved index finger (RCN 2019, Lister et al. 2020).

Digital rectal examination (DRE)

Digital rectal examination (DRE) should be performed as part of the assessment of bowel dysfunction and is indicated where there is a need to: 

  • Establish the presence of faeces in the rectum.
  • Assess anal tone and sensation.
  • Evaluate the status of the anal and rectal area prior to administration of rectal interventions; ascertain the need for and/or effects of rectal medication; assess anal pathology for the presence of foreign objects; determine bowel emptiness in neurogenic bowel management; prior to investigative procedures (sigmoidoscopy/colonoscopy).
  • Identify the need for further interventions such as the administration of suppositories or an enema, placement of an anal plug/insert, before using transanal irrigation or when determining if digital removal of faeces (DRF) or digital rectal stimulation (DRS) is required (RCN 2019). 

Digital removal of faeces (DRF)

With the increased options for bowel emptying techniques including advances in oral medications and rectal and surgical treatments the need for the digital removal of faeces (DRF) in patients is reduced. However, some patients with neurogenic bowel dysfunction (spinal injuries, spina bifida, multiple sclerosis) may need assistance or rely on DRF as a routine element of their bowel care (RCN 2019, Lister et al. 2020) Therefore, prior to its use, a complete bowel assessment must be undertaken to understand the patient’s normal bowel habits (National Institute for Health and Care Excellence (NICE) 2007), their bowel history (including constipation, complications, medications), and their medical history. 

Patients with neurological conditions or spinal cord injuries (SCI), particularly those at or above the 6th thoracic vertebrae (T6), are at risk of a condition known as autonomic dysreflexia (AD).  It is an abnormal autonomic response to painful stimuli and/or manipulation or distension of the genitourinary or gastrointestinal tract, below the level of injury (Murray et al. 2019). AD is most likely to occur where bowel care is ineffective and essential interventions have been withheld (RCN 2019). A distended bowel caused by constipation can trigger AD and nurses should be aware that DRF may be a necessary and integral part of a patient’s bowel care management programme. Signs of AD can include headache, bradycardia, sweating, flushes, nasal obstruction, pallor below the level of spinal injury and hypertension (Mitchell 2019). It can also occur during and after a bowel care intervention and it is imperative that patients are assessed before the intervention and closely monitored throughout. If not adequately managed, AD can result in life-threatening complications including seizure, brain haemorrhage, hypertensive encephalopathy, myocardial infarction, and death (Murray et al. 2019, Holroyd 2020).

Indications for DRF include:

  • Faecal impaction/loading.
  • Incomplete defecation.
  • When other methods of bowel emptying have failed, or are deemed inappropriate.
  • Neurogenic bowel dysfunction.
  • Spinal cord injury.

Both DRE and DRF are contraindicated in a number of situations and conditions, including:

  • Active inflammatory bowel disease.
  • Acute diverticular disease.
  • Rectal or anal pain.
  • Rectal and anal sepsis, abscess and fistula.
  • Recent radiotherapy to pelvic area.
  • Recent rectal or anal surgery.
  • Obvious rectal bleeding.
  • Anal fistula or fissure.
  • Anal stenosis.
  • Inflamed and painful haemorrhoids.
  • Anal tissue fragility.
​(RCN 2019)

Digital rectal examination (DRE) can be undertaken by a registered nurse who can demonstrate professional competence to the level determined by the Nursing and Midwifery Council Code of Professional Conduct (NMC 2018). If local policy permits, the registered nurse may be expected to delegate care delivery to others who are not registered nurses or midwives, such as healthcare assistants and carers. In doing so, existing care must not be compromised, and the registered nurse remains accountable for ensuring that the person who carries out the task is able to perform it, and that adequate supervision or support is provided (RCN 2019).  

As with DRE, DRF must only be performed by a nurse deemed to be competent and with the knowledge, skills, and ability to provide safe practice (Nursing and Midwifery Council (NMC) 2018). Bowel-dysfunction training should have been successfully completed including the practical and theoretical aspects of DRF and in line with local protocols and policies. 

The practices of DRE and DRF can be potentially dangerous and the nurse undertaking the procedure must take care to avoid damage to the vagus nerve in the rectal wall (leading to a reduction in the patient’s heart rate). It is also imperative when performing DRF to minimise the risk of rectal trauma, bleeding or perforation of the bowel (Mitchell 2019). 

Nurses need to provide necessary information to allow for informed decision making and obtain the patient’s consent (Taylor 2018). Without this, the care or treatment may be considered unlawful (RCN 2019). Patients must be informed also that they have the right to request a chaperone. The chaperone is present to safeguard the patient and the nurse, and to ensure continuing consent (RCN 2019). Therefore, the chaperone should be a healthcare practitioner who has clinical knowledge of the procedure (Marinaccio-Joseph 2019). If a chaperone is not available, the patient must be informed and given the option of not proceeding. Likewise, the patient also has the right to decline a chaperone. 

When performing intimate and invasive procedures such as DRE and DRF, consideration must be given also to patient’s individual, cultural and/or religious beliefs that may impact on the acceptability of the procedure being performed by a member of the opposite sex (RCN 2019). To avoid potential misunderstanding or false accusations, all decisions should be documented in the patient’s record along with the name of the chaperone (RCN 2019). It is also important to note that these procedures can be distressing and uncomfortable and the nurse performing the procedure must listen and respond to the patient’s concerns and preferences, treat them with dignity and respect and act in their best interest. 

Preparation and safety for DRE/DRF

  • Perform hand hygiene before patient contact. 
  • Check the patient’s identity – using the patient’s name band and/or verbally,  according to local policy.
  • Introduce yourself and provide a brief explanation of the purpose of the procedure, to obtain the patient’s consent and cooperation. Ensure that the patient understands the procedure. Answer questions as they arise, and reinforce information as needed (NMC 2018).
  • Offer the patient a chaperone and ensure one is available
  • Check with the patient to ensure they are not allergic to latex or any of the ingredients in the anaesthetic lubricating gel e.g. lidocaine.
  • Encourage the patient to empty their bladder. A full bladder can cause discomfort during the procedure.
  • Raise the bed to a safe working height. Ask or assist the patient to remove clothing below the waist and lie in the left lateral position.
  • Keep the patient covered as much as possible to ensure warmth, comfort, and dignity.
  • Ensure the patient’s privacy and dignity are maintained throughout.
  • Perform hand hygiene and put on a disposable apron and non-sterile gloves. Wear personal protective equipment where necessary.

Procedure – DRE

  1. Perform hand hygiene and put on non-sterile gloves.
    Rationale – To prevent cross-infection.
  2. Record the blood pressure and pulse rate in patients with spinal cord injury at thoracic level 6 (T6) or above. Record pulse rate for patients before and during DRF if it is an acute intervention.
    Rationale – A baseline blood pressure is necessary for comparison in patients with spinal cord injury at T6 and above as they are at risk of developing autonomic dysreflexia. For patients where this procedure is part of a well-established bowel routine, this is not required.
  3. Raise the bed to a safe working height and ask/assist the patient to lie on their left side with the knees drawn up to the chest. 
    Rationale – To prevent stooping. It is necessary for the patient to be in the left lateral position because of the position of the rectum and even left-handed nurses must use their right hand as it facilitates easy insertion of the finger into the rectum.
  4. Place the disposable absorbent pad underneath the buttocks.
    Rationale – To reduce potential infection caused by soiled linen. To avoid embarrassing the patient if faecal staining occurs during the procedure.
  5. Inform the patient that you are to begin and that you will be observing and examining the outer and internal area.
    Rationale – To gain patient cooperation.
  6. Separate the buttocks and examine the perianal area for any abnormalities such as skin soreness, swelling, excoriation, haemorrhoids, anal skin tags, infestation, foreign bodies or a rectal prolapse. Swelling may be indicative of a mass or abscess. Report any abnormalities such as bleeding, discharge or prolapse, stop the procedure and  seek medical advice.
    Rationale – To maintain patient safety.
  7. Lubricate your gloved index finger and inform the patient that you are about to insert your finger and to take deep breaths. Put your index finger on the anus for few seconds and then proceed gently to insert same into the anus/rectum. Be cautious in those patients with SCI above T6.
    Rationale – Lubrication facilitates easy insertion and reduces trauma to anal mucosa. Taking deep breaths helps to prevent anal sphincter spasm or difficulty on insertion. Putting finger on the anus will allow the anus to contract and then relax thereby making insertion easier and less painful.
  8. Assess for internal anal sphincter tone (slight resistance indicates good internal sphincter control). Also assess the external sphincter tone by asking the patient to squeeze upwards and hold. 
    Rationale – Lax anal sphincter can result in faecal incontinence.
  9. If the patient has an SCI above T6, observe the patient throughout the procedure for signs of autonomic dysreflexia.
    Rationale – This patient group are prone to having autonomic dysreflexia.
  10. Sweep clockwise and then anticlockwise, palpate for irregularities internally. Noting the presence of any tenderness, mass or irregularities. Establish the content of the rectum and amount and consistency of faecal matter using Bristol Stool Chart.
    Rationale – May identify faecal loading or constipation. To see if there is need for onward referral, investigations or treatment.
  11. Observe patient’s response and periodically assess the pulse rate. Look for signs of pain (such as grimacing), bleeding and discomfort. If the patient feels any pain or abdominal cramps, ensure that they are happy for you to continue with the procedure. If patient bleeds or heart rate drops, discontinue and inform the medical team.
    Rationale – For early detection of signs of autonomic dysreflexia. Bleeding denotes anal trauma.
    NB: If patient is having autonomic dysreflexia, remove your finger, sit patient up where possible and administer prescribed medication such as nifedipine. Inform medical team.
  12. Gradually remove index finger. Examine the finger for visible blood, faecal consistency and colour.
    Rationale – To determine the need for further intervention.
  13. Use gauze swab to clean perianal area of any gel/faecal matter. Wash and dry the patient’s buttocks and anal area.  Cover the patient and assist them into a comfortable position.
    Rationale – To preserve dignity, maintain patient’s hygiene, prevent any irritation or excoriation.
  14. In patients with an SCI at T6 or above, record the blood pressure and pulse rate.
    Rationale – Blood pressure and pulse recording is undertaken for early detection of AD and initiation of treatment to avoid complications.
  15. Remove and dispose all equipment including gloves and apron and perform hand hygiene.
    Rationale – To ensure safe disposal of contaminated equipment and prevent cross infection.
  16. Document all observations, findings and actions.
    Rationale – To ensure continuity of care and initiation of appropriate corrective action.

Procedure – DRF

Follow steps 1 to 7 of procedure for DRE

  1. Check the stool type. If it is type 1 on the Bristol Stool Chart, remove one lump at a time until no more faecal matter can be felt. If the stool is soft gently circle the finger continuously to remove faeces.
    Rationale – Removal of one lump at a time will relieve patient discomfort.
  2. If the faecal matter is solid, use the index finger to split it and remove individual pieces at a time, taking care not to cause rectal trauma. Avoid using a hooked finger to remove faecal matter.
    Rationale – Use of hooked finger may cause damage to the rectal mucosa and anal sphincter (Mitchell 2019). It can also lead to scratching or scoring of the mucosa (RCN 2019).
  3. If the faecal matter is more than 4 cm across and is too hard and solid to break up, discontinue the procedure and discuss other approaches with the multidisciplinary team. 
    Rationale – To avoid any pain or damage to the anal sphincter It may be necessary for the procedure to be carried out under local/general anaesthetic.
  4. As it is removed, place faecal matter in an appropriate receptacle.
    Rationale –  To reduce cross-infection and environmental contamination. 
  5. Continue to clear the rectum and allow patient to rest at intervals.
    Rationale – Allowing the patient to rest is important if there is a large volume of faeces in the rectum. If appropriate, ask the patient to breathe in and force air out of the mouth with the nose closed (Valsalva manoeuvre) as it can assist with the passage of faeces into the rectum (Mitchell 2019).
  6. Once the rectum is empty, carry out a final digital check after 5 minutes.
    Rationale – To ensure that evacuation is complete.

Follow step 11 to 16 of procedure for DRE.

Ongoing care, monitoring and support for DRE/DRF

  • Ensure the patient is dry and comfortable.
  • Reassess vital signs and compare to baseline values.
  • Leave the patient comfortable and with a buzzer if assistance is likely to be required.

Documentation

  • Document informed consent.
  • Report any adverse reactions, abnormalities/observations, colour, consistency, and amount of stool using Bristol Stool chart.
  • Report any adverse reactions, abnormalities or any changes in vital signs. Record patient’s tolerance to procedure and vital signs.
  • Document the refusal of chaperone if applicable and name of chaperone and job title.
  • Outcome of any intervention.
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