Post 85 The Rectal Examination ' Do as you would be done by'

 Recently, I had the unhappy experience of being curled up in the foetal position with my bottom overhanging the edge of the examination couch, whilst the urologist thrust his chunky finger up my

anus!    Actually, it wasn’t the only price I had to pay for developing the problem that is so common in gentlemen of my age; he charged me £250 for assaulting me at that first consultation, though curiously only £100 when he repeated the indignity at follow up! What happened to the old Maxim 'Doctors don't charge doctors.'

Having spent 40 years practising as an abdominal surgeon, I must have performed thousand of rectal examinations.     I had always understood that dropping one’s pants or knickers and exposing one’s rear end was embarrassing and it was my habit to precede the examination with an apology.    My apology though was expressed for potential embarrassment, not for any discomfort.  Certainly few of my patients have actually thanked me afterwards, but I can honestly say no one ever complained that it was painful.

My recent experience though has taught me a valuable lesson!    A rectal examination really can be quite painful.    The reason, I feel sure, was that only the tip of the examiner’s finger was lubricated, not

its entire length.   Significant anal pain was caused when the friction from the unlubricated base of the finger, dragged the anal ring upwards and inwards as the urologist strained to reach up high to feel my prostate gland.   Truly, it brought tears to my eyes.

Whether my consultant did or didn’t realise that it was painful, or whether he was perhaps just softening me up for the transrectal prostatic biopsies which came later, I don’t

know.     At the time, a sense of courtesy to an ex-colleague stopped me from complaining but I thought it worth telling this little tale, the moral of which is; when performing a rectal examination   a) always lubricate your finger to the hilt and    b) afterwards get feedback from your patients on the experience.

   Incidentally, I recall reading an article published in a learned medical journal many years ago that suggested that female doctors should not be allowed to practise as urologists or proctologists because in general their fingers are

shorter and therefore unable to reach and diagnose pathologies in the upper rectum. (I took it to be a misogynistic spoof, as it was published on April Fool’s Day!)

Quotation for the day

Mrs ‘Do As You Would Be Done By.’   A character in ‘The Water Babies’written by Charles Kingsley. 1819 - 1875

Good advice for medical students

If you don’t put your finger in it - one day you’ll put your foot in it!  The examination of the abdomen starts with the groin and external genitalia - and ends in the rectum.

Anatomical explanation

The discomfort of a rectal examination is of two types  1) dull discomfort due to distortion of the rectum which has stretch receptors but no pain receptors (autonomic supply via the hypogastric plexuses)  and  2) sharp pain from distortion of the anus (somatic supply via the inferior rectal nerves)