Women’s Rectal Health Matters
Why Women Should Advocate for Digital Rectal Examinations
TL;DR: Digital rectal examinations (DRE) are crucial for women's health, yet often overlooked due to misconceptions and time constraints in medical practice. Regular DREs can detect silent anorectal issues early, empowering women to take charge of their comprehensive health care.
As a gastroenterologist, I often find myself discussing topics that many would rather avoid. Today, let's talk about an often-overlooked but incredibly important aspect of women's health: the digital rectal examination (DRE).
Ladies, Why Aren’t We Talking About Our Rectums?
The answer might be that we don’t know we should be advocating for this exam. The importance of knowing that a rectal exam is something we should expect when seeing a gastroenterologist isn’t common knowledge. When we visit a gynecologist, we know the routine: the flower printed gown, the footie socks, the pelvic exam. We expect to be screened for cervical cancer, which can be caused by human papillomavirus (HPV). But when we see a gastroenterologist, this isn’t the typical workflow, even though HPV can also infect anorectal cells. Why is this?
Perhaps it’s because rectal exams are often associated with prostate exams, creating an inherent bias. Or it’s seen as a violating act, or simply perceived as too uncomfortable. Sometimes there’s an assumption that a proper rectal exam was done during the pelvic exam and pap smear, which isn’t always the case. Regardless, it’s important for women to think of this exam like any other part of a physical exam. Women might not always accurately identify issues around the rectum, as pain from pelvic muscles or other areas can refer to this region. You know your body best, and if something feels off, you should advocate for this area to be examined.
Notice the doctor getting informed consent for the rectal exam.
What Is a Digital Rectal Exam?
A digital rectal examination (DRE) can provide valuable information. Let’s break down the anatomy first. The final 10 cm of the gastrointestinal tract is a busy area with various cell types, nerve sensations, and blood supplies. The anal canal, about 4 cm in length, is where a doctor begins the DRE. This area has a transition zone of cells. The very end of the anal canal is lined with non-keratinized stratified squamous epithelium, sensitive to pain, temperature, touch, and pressure. Just above this, the cells transition to columnar epithelium, similar to the rectum, which can feel stretch but not pain. Understanding this anatomy is crucial for understanding the DRE.
Expectations for Your Doctor When They Perform a DRE
Obtain Consent: The doctor should first obtain your consent for the DRE, including consent to allow any learners, such as medical students, to participate.
Chaperone Introduction: The doctor should introduce you to the chaperone in the room.
Explain the Procedure: The doctor should explain why they are doing the exam and what they are looking for.
Step-by-Step Guidance: The doctor should talk you through every step of the exam to ensure there are no surprises.
The Details of a DRE
Here’s what happens during a DRE. The exam takes about 3-4 minutes. You’ll hopefully be given a gown and soft footies. After giving consent and ensuring a chaperone is present, you’re given privacy to collect yourself. You’ll lie on your left side with your hips and knees slightly flexed. The doctor first inspects the perianal skin for signs of inflammation, excoriation, fissures, prolapses, or growths. They may use a cotton tip to brush the skin around the anus, checking for neurological issues. You might be asked to strain, to reveal any abnormalities like an open anus or prolapsing tissue.
Next, the doctor uses a lubricated, gloved finger to examine the rectum in a 360-degree fashion. The doctor may tell you that the exam feels a bit like having a bowel movement, but this sensation is brief and temporary. In women, palpation can detect abnormalities of the cervix, retroverted uterus, rectocele, polyps, or cancer. The doctor will assess muscle tone at rest, during active squeeze (you may be asked to squeeze), and while pushing out. They may palpate the levator ani muscle in all four quadrants. After removing the finger, they’ll check for stool color and blood.
Situations Where You Should Ask for a Rectal Exam
Routine Health Check: Anytime, because you deserve to know your rectum is healthy.
History of Abnormal Pap Smears: Particularly with a history of HPV 16 or 18.
Personal Health History: If you have a history of Crohn’s disease.
Symptoms of Pain: Pain with defecation or sitting.
Pelvic Floor Dysfunction: If diagnosed through a DPT (pelvic floor physical therapist).
Surprise Diagnoses
I often see patients referred for hemorrhoids, only to find that the actual issue is something else entirely, like virus-induced condylomas (growth). These surprise diagnosis are especially more common in women aged 45 and up who missed the 2006 HPV vaccination program. It’s no surprise that anal cancer rates are rising in menopausal women. During screening colonoscopies, it’s not uncommon to discover HPV-related anal lesions, often leading to surprising post-procedure discussions.
Breaking the Stigma
This is an absolute must watch lecture from the 2023 American College of Gastroenterology conference, the Emily Couric Memorial Lecture, featuring Marcia Cross, a champion for HPV-related cancer awareness and an anal cancer survivor. She didn’t know she had an anal lesion until a routine exam by her gynecologist. Marcia Cross says she was lucky to have a doctor who performed a DRE, emphasizing the importance of this exam. While all gastroenterologists are trained to perform DREs, time constraints in clinical practice often prevent it. The process, including consent, finding a chaperone, and discussing findings, can exceed the typical 15-minute appointment slot.
Empowerment and Expectation
As a proponent of women feeling empowered and secure in their medical care, it’s reassuring to see the shift towards written informed consent and having a chaperone during exams. The Department of Health and Human Services now requires written informed consent before sensitive exams, especially in teaching hospitals. This ensures patients’ comfort and consent, even if it means less hands-on learning for medical students.
When to Ask for a Rectal Exam Based on Symptoms
Pain: Anal, rectal, or pelvic pain—regardless if you can't tell the difference.
Incontinence: Any form of incontinence.
Constipation: Persistent or severe constipation.
Bowel Habit Changes: Any significant changes in bowel habits.
Bleeding: Any rectal bleeding.
Prolapse Symptoms: Feeling tissue in the rectum or needing to push things back in.
Itching: Persistent anal itching.
The Bottom Line
A wise gastroenterologist once wrote, “The only valid reasons why a gastroenterologist should fail to perform a proper rectal examination are (a) the gastroenterologist has lost all of his or her fingers or (b) the patient is acutely ill and therefore there is a clear temporary contraindication.” Women should have a complete physical examination, including a DRE, whether in a primary care office, gastroenterology clinic, or during a colonoscopy. Sometimes you don’t know if everything is healthy until you have an examination.
End dictation.
Your Lady MD,
Emily
P.S. Please see the references page on the home page for important references and images about the anatomy of the rectum and rectal exam.