Digital rectal examination (model)
PLAB 2 & PRES 3 · practical skills / surgery · medium · 8 minutes
Candidate brief
You are an FY2 doctor in a GP surgery. Mr Albert Mensah, 66, reports six weeks of fresh rectal bleeding and looser stools. A chaperone is present. A rectal examination model is provided. Please take a brief relevant history, then perform a digital rectal examination on the model, verbalising each step and your findings, and explain your findings and the referral plan to the patient.
What examiners look for
Inspection is half the examination and it comes first: fissures, prolapsing piles, skin tags, fistulae and excoriation are diagnosed by eye. A candidate who gloves up and reaches has skipped the half that often contains the answer. The glove is a laboratory: colour and content of what comes out — fresh blood, melaena, mucus, pale stool — is a formal finding. Withdraw, look, describe, document. Examiners specifically watch whether the glove is inspected or discarded unexamined. Learn the prostate vocabulary, because vague is marked wrong: size, surface (smooth/nodular), consistency (firm/hard), the median sulcus (present or obliterated), symmetry. "Benign-feeling" is a conclusion built from those four observations — a smooth, firm, enlarged gland with an intact sulcus. A normal DRE excludes almost nothing beyond the anal canal and lowest rectum. Most colorectal cancers are out of reach, and rectal bleeding in a 66-year-old with a changed bowel habit, weight loss and an affected brother is an urgent suspected cancer referral however reassuring the finger feels. The station's trap is false reassurance; the patient himself will hand you the line that exposes it. Referral thresholds are examinable knowledge: unexplained rectal bleeding at 50 and over earns an urgent suspected cancer pathway referral under NICE NG12, and change in bowel habit, unexplained weight loss and iron-deficiency anaemia reinforce it. Know the triggers, not just the technique. His brother's death is in the room. Matter-of-fact competence plus one honest sentence ("you did exactly right coming in — these symptoms always need checking properly") does more for this man than either fuss or jollity.
Guideline references
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