Table 2. Components of Digital Rectal Exam (Reproduced with permission from (22).

Exam Component	Technique	Findings & Grading of response(s)
I. Inspection of the anus and surrounding tissue	Place patient in the left lateral position with hips flexed to 90°. Inspect perineum under good light	Skin excoriation, skin tags, anal fissure, scars or hemorrhoids
II. Testing of perineal sensation and the anocutaneous reflex	Stroke the skin around the anus in a centripetal fashion, in all four quadrants, by using a stick with a cotton bud	Normal: brisk contraction of the perianal skin, the anoderm and the external anal sphincter Impaired: no response with the soft cotton bud, but anal contractile response seen with the opposite (wooden) end Absent: no response with either end
III. Digital palpation and maneuvers to assess anorectal function
Digital palpation	Slowly advance a lubricated and gloved index finger into the rectum and feel the mucosa and surrounding muscle, bone, uterus, prostate and pelvic structures	Tenderness, mass, stricture, or stool and the consistency of the stool
Resting tone	Assess strength of resting sphincter tone	Normal, weak (decreased) or increased
Squeeze maneuver	Ask the patient to squeeze and hold as long as possible (up to 30 seconds)	Normal, weak (decreased) or increased
Pushing and bearing down maneuver	In addition to the finger in the rectum, place a hand over the patients' abdomen to assess the push effort. Ask the patient to push and bear down as if to defecate	(i) Push effort: Normal, weak (decreased), excessive (ii) Anal relaxation: normal, impaired, paradoxical contraction (iii) Perineal descent: Normal, excessive, absent