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Digital rectal exam (DRE) Introduction  The main method for carrying out a prostate exam. The patient should be informed of the reasons for performing a DRE and care should be taken to preserve the dignity of the patient at all times. Use abundant lubrication and proceed very gently, especially in cases of anal fissure, neutropenia, or acute prostatitis (to prevent sepsis). Procedure  Position: There are several positions in which a DRE can be performed: - Left lateral decubitus position with hip and knee flexion >90 degrees. - Supine position with flexed knees and hips. - Knee‐chest position.  Inspection of the anal area to look for anorectal abnormalities/pathologies.  Technique: after applying a sufficient amount of lubricant to the index finger, the finger is inserted slowly into the anal canal and then into the rectum. The surface of the prostate is palpated anteriorly with the tip of the finger. Rectal exams and prostate disease  Indications: - Men with lower urinary tract symptoms. - Prostate cancer screening in asymptomatic patients. Although DRE has been used in most large screening studies, its value for early diagnosis of prostate cancer has been questioned. The screening process involves looking for indurated nodules or  diffuse glandular consistency. DRE has a sensitivity of 70‐80% and a specificity of 93.5%. Bi‐
opsy is always indicated for a suspicious DRE result, regardless of PSA. - Suspected local recurrence after radical prostatectomy. Characteristic Results Consistency Surface Size Limits Mobility Normal, firm (prostate cancer) Smooth, irregular (prostate cancer) Normal (walnut), medium (tangerine), or large (orange) Well or poorly defined Mobile or not mobile (adhered to neighboring planes) Other conditions assessed with DRE  Anorectal pathologies: a DRE can reveal fissures, fistulas, strictures, tumors (polyps, carcinomas, ulcers, hemorrhoids). Useful in suspected appendicitis due to pain in the right iliac fossa or in suspected pelviperitonitis because of pain at the base of the Douglas pouch. Can identify hard stools (coprolites) or even a large fecaloma resulting from constipation. The total absence of stools may indicate intestinal obstruction. After conducting the exam, the end of the finger should be examined for traces of blood or stool.  Neurological pathologies: useful in LUTS and in suspected neurological disease: - Superficial anal reflex: contraction of the anal sphincter occurs when the perineal area is stimulated or when finger is inserted into the rectum. For evaluating the pudendal nerve and nerves of the sacral spinal cord (S2‐4). - Visceral reflexes  Bulbocavernosus: when the glans is compressed, the clitoris pinched, or with the traction of a Foley probe, a spastic contraction of the anal sphincter is observed. For examining the pudendal nerve and nerves of the sacral spinal cord (S2‐4).  Cough test: When the patient is made to cough, contraction of the anal sphincter is synchronized to the cough. For assessing the nerves of the spinal cord (D6‐12). 
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