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Digital Rectal
Examination & Manual
Removal of Faeces
Cath Stansfield.
Advanced Practitioner Gastroenterology
Before you begin…
• Review your A&P of the GI tract, in
particular:– The function of the colon
– The anatomy and physiology of the rectum
• Review the principles of constipation
management
Objectives
•Anal & perianal observations
•Principles of DRE
•Principles of constipation management
and manual evacuation
•Prescribing rectal medication
•Legal and ethic considerations of DRE
and manual evacuation
ANATOMY OF THE LOWER GI
TRACT
colon
• The main function of
the colon is the
propulsion of faecal
matter and absorption
of fluid.
Why is the colon important in
considering constipation?
• Transit time
– Length of time that food is in the colon.
– The longer the transit time the more water is absorbed
– The harder and more solid the evacuated stool will be
• Total water content of the gut per 24 hours
–
–
–
–
–
Salivary glands
Stomach
Bile
Pancreas
L & S bowel
1500mls
2500mls
500mls
1500mls
1000mls
• Only 200mls is expelled in faeces
The rectum and anal canal
• The rectum is the last 1517cm of the large colon.
• It is situated at the level of
the pelvic floor,
• the last 2-3cm becomes the
anal canal.
Key characteristics of the rectum
• Capable of distension
• Usually empty
• Gastro colic reflex is
necessary for its
function
• Affected by emotion
• Able to distinguish
wind from solid
Pelvic floor
• The pelvic floor, in
particular the puborectalis muscle is
important to maintain
faecal continence and
successful defecation
mechanism
• The junction of the
sigmoid colon & the
rectum is angled
sharply
60° - 105 °
• Continence is
maintained by
– the acute angle
– 2 Anal sphincters
Anal Sphincters
• The Internal Anal
Sphincter.
– Surrounds the anal canal
– Not under voluntary
control
• The External Anal
Sphincter.
– surrounds the bottom of
the internal anal sphincter.
– is under voluntary control.
And finally.. faeces
• Product of elimination, consists of
– 75 % water
– 20 % Dead bacteria
– 5 % Fat
– Nitrogen
– Bile pigments & undigested food
• Colour usually brown influenced by food
– Dark = protein
– Black = Blood or iron
– Clay = Fat
Assessing bowel function
Assessing bowel function –
medical/ surgical history
• Illness
–
–
–
–
Bowel disorders
Neurological illness
Chronic pain
Terminal illness
• Injury
– Child birth
– Spinal injury
• Surgery
– Spinal surgery
– Bowel surgery
Assessing bowel function medication
• Diarrhoea
–
–
–
–
–
–
–
Antacids ( Magnesium)
Antibiotics
Antidepressants
Beta Blockers
Diuretics
Iron preparations
Hypoglycaemic
preparations
• Sorbitol
• Constipation
– Antacids
(Aluminium)
– Analgesics
– Anti-inflammatory
drugs
– Antidepressants
– Anti hypertensives
– Diuretics
– Iron preparations
– Sedatives
– Motility drugs
Bristol stool chart
Constipation
THE FACTS
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•
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10% of the population are affected
25% of the elderly are affected
More common in females
13 out of 1000 GP consultations are for
constipation
Impact of constipation
•
•
•
•
•
Loss of well being
Pain
Depression
Loss of mobility
Loss of appetite
Defining Constipation
•
•
•
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Going less often
passing hard faeces
difficulty in passing a stool
Straining at stool
Going less than 3 times per week
Pain on defaecation
3 Categories of Constipation
• Primary
– diet
– Lifestyle
• Secondary
– Disease associated
• Iatrogenic
– 50% of medication can have constipatory
affects on the bowel
Causes of constipation
•
•
•
•
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Pregnancy and childbirth
Ignoring the call to stool
Diabetes
Depression
Lifestyle
– Immobility – walking 0.5km per day will
reduce constipation
– Poor diet
– Irregular meals
The Goal
• The feeling you want to go is definite but
not irresistible
• Once you sit on the toilet there is no
delay
• No conscious effort or straining
• The faeces glides out smoothly &
comfortably
• Followed by a pleasant feeling of relief
Digital Rectal Examination
DRE and MEF
• Any concerns about scope of practice the
RCN Guidance for DRE should be
followed.
Before you do…
• Understanding of A&P of the lower gastrointestinal tract
• Identification of possible causes of
constipation
• Planning stepped approach to nursing
care to prevent & treat constipation
Think about….
• Invasive and should only be performed when
necessary.
• Awareness of cultural & religious beliefs.
• There can be conflict over Manual Removal of Faeces
between patient/carers/nurses.
• Wide range of alternatives available, but not suitable
for all.
• Keep discomfort to a minimum
Why?
• To establish the need and outcome of
digital stimulation to trigger defecation by
stimulating the recto anal reflex
– (RCN, Bowel Care, Guidance for Nurses, March 2008)
• To establish the presence, amount &
consistency of faecal matter in the rectum
• To establish anal tone, the ability to initiate
a voluntary contraction and to what degree
• Anal/rectal sensation
Preparing the patient
• DO:
– Complete a full bowel assessment
– Consider ALL other treatment options with
your team
– Inform the patient of treatment options and
risks
– Gain valid consent
Preparing the patient
• Don’t
– Proceed if YOU do not feel competent (NMC 2002)
– Proceed if there is a lack of consent
– Proceed if the doctor has given specific
instructions NOT to undertake the procedure
– Proceed if the patient has recently undergone
rectal, anal surgery or trauma.
Preparing the patient
• Don’t proceed if
– Active inflammatory bowel disease
– Rectal pain
– Obvious rectal bleeding
– Spinal Injury at T6 or above– consult local guidance and spinal injury team as allowing
constipation to occur leads to a greater risk of autonomic
dysreflexia (Getliffe et al 2007)
DRE
• Introduction
– Introduce yourself, check you have the right patient,
explain procedure; “will involve examining back
passage with a finger”
•
•
•
•
Explain WHY you are doing the procedure
Get verbal consent
Alcohol gel hands!
Get a chaperone if opposite sex and advised
still if same sex.
DRE
• Get patient to roll onto left hand side with
knees up to chest. (Always examine from
right hand side!)
• Collect equipment:
– Clean tray
– Gel (lubricant)
– Gloves
– Gauze (for wiping)
observation
• Look at perianal area what can you see??
Common perianal observations
•
•
•
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Rectal prolapse
Haemorrhoids
Skin tags
Wounds/dressing/
discharge
• Anal lesions
• fistula
• Abscesses
• Fissure
• excoriation
Abscesses
• Discharge
– Blood
– Mucus
– Faecal matter
Anal fissure
• Document as
clock:– 6 o’clock
– 12 o’clock
• Common in
Crohn’s and
constipation
haemorrhoids
• 1st degree- remain in
rectum, 2nd degreeprolapse through but
spontaneously
reduce,
• 3rd degree- as for 2nd
but require digital
reduction,
• 4th degree- remain
prolapsed persistently
Haemorrhoids
• Haemorrhoids are
abnormalities of these
cushions which may
slip due to :
– Straining at stool
– Pregnancy
Rectal Prolapse
• Common in elderly
females
• There may be
– Faecal incontinence due to
stretching of the anal
sphincter
– Mucus discharge from the
prolapsed bowel
• Treatment of a complete
rectal prolapse requires
an operation (rectopexy)
to fix the rectum within
the pelvis
Fistula in Ano
• Common causes:– Constipation
– Repeated enemas
– Childbirth
• Exploration and laying
open of the fistula
under general
anaesthesia may be
necessary
Anal Carcinoma
• Present with
• pruritus ani,
• fissures,
• perianal warts
• bleeding mass
• Treatment with
surgery
Anal Warts
• Commonest STD
• Results from HPV
• Associated genital
warts in the sexual
partner are common
Perianal Crohn's
• Multiple signs
–
–
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–
–
Skin tags
Erythema
Fistula
Abscesses
scarring
• Anal strictures
Skin tags
• Not significant
– Chronic straining
– Childbirth
– Constipation
• May become:– Thrombosed
– Oedematous
• Can lead to:– Pruritus
– Haemorrhoids
•
Can be removed
Examination
• Inform patient you are going to examine
with your finger now
• Put blob of lubricant on finger
• With your left hand, raise up the patient’s
right buttock.
Assessing Sphincter function
• Insert finger,
• assessing sphincter tone
– Is it hypertonic – difficult to insert finger
• Remember patient may be anxious and can ask
patient to take a deep breath
• Indicative of Crohn’s disease, Fissure, stricture,
nerves
– Is it hypotonic - no resistance
• Indicative of old age, nerve damage (spinal injury),
muscle damage (multigravida)
• Advance finger
– If resistance noted - ask the patient to take a
deep breath, or to push, as if they are going to
the toilet.
– If patient is unable to tolerate at any point
STOP
WHAT ARE YOU FEELING FOR:• What is in rectum/anal canal;
– is it empty?
– full of compact material?
• Rotate posteriorly, feeling each side
systematically
• Are there any:– polyps – these will feel soft and mobile
– cancers; fixed, hard, irregular, lumpy.
• Describe according to site, size, shape,
smoothness, surface, surroundings.
And twist finger round.
• Prostate; walnut
sized, 2 lobes,
separated by sulcus.
In prostatic cancer
you lose the sulcus.
• In a woman, you are
likely to feel in the
region of the cervix
when you feel
anteriorly.
And finally…
• At the end, take out finger, and look at it;
check if any blood, faeces, mucus
• Can take swab if necessary.
• Wipe the patients or ask them to wipe
themselves (use your discretion).
• Take off glove, thank patient
• THANK PATIENT! And WASH HANDS!
MANUAL REMOVAL OF
FAECES
Indications for manual removal of faeces
•
•
•
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Faecal impaction/loading
Incomplete defecation
Inability to defecate
Other bowel emptying techniques have failed
• Neurogenic bowel function – although alternatives
should be considered
• In patients with spinal injury
Exclusions for Manual
Removal of Faeces
• Lack of consent
• A doctor has given specific instructions that
these procedures are not to take place
• The patient has recently undergone rectal/anal
surgery or trauma.
• The patient gains sexual satisfaction and the
nurse performing them finds this embarrassing.
• The presence of abnormalities on the perianal
area
• Rectal pain
Consent and Manual Removal
of Faeces
1. Consent should be given by someone
with the mental ability to do so.
2. Sufficient information should be given to
the patient to make an informed decision.
3. Consent must be given freely.
(RCN, 2006)
Undertaking Manual Removal of Faeces
• Explain the procedure and its necessity to the
patient, to gain co-operation and consent.
• Document consent has been given.
• Ask patient if they wish to use the toilet prior to
undertaking the procedure.
Manual Removal of Faeces
• Position patient: left lateral with knees
flexed, ensuring privacy at all times.
• Take the patient’s pulse rate prior to
commencing the procedure
• Wash hands with soap and water put on
disposable gloves.
• Observe and examine anal/perianal area
Manual Removal of Faeces
• In spinal injuries as an acute intervention
– blood pressure should be monitored at rest, during
and at the end of the procedure
• For patients who have a manual evacuation
performed on a regular basis
– Place some lubricating jelly on index finger
• For patients who have not had a manual
evacuation of faeces before.
– Lubricate index finger and anus with anaesthetic gel,
following manufacturer’s guidelines for gel to take
effect.
Manual Removal of Faeces
• Inform patient of imminent examination
when finger is to be inserted.
• Insert gloved finger slowly and encourage
patient to relax when it is in situ – Use one
finger only.
Manual Removal of Faeces
– In scybala type stool
(type 1,2), remove one
lump at a time .
– In a solid mass (type
3) gently, push finger
into middle of the
mass, split it and
remove small pieces
at a time.
– Soft stool, remove
small amounts at a
time
Manual Removal of Faeces
• A period of rest may allow further faecal
matter to descend into the rectum.
• If mass too hard or large to divide STOP
procedure and refer to GP
• Extra lubrication may be required
• Place faecal matter into receptacle as it is
removed.
Manual Removal of Faeces
• Check patient’s pulse rate during the procedure.
• Stop the procedure if the heart rate drops or
rhythm changes.
• When the procedure is complete, wash and dry
patient’s buttocks and anal area.
• Remove and dispose of equipment. Wash hands
• Make patient comfortable and ensure patient
has access to commode or toilet if needed.
Manual Removal of Faeces
• Record outcome, documenting:– Consent
– Stool type
– Communicate findings to patient/carer and
doctor if appropriate.
– Referral to doctor (where indicated)
ANY QUESTIONS?