The Importance of Doing a Rectal Exam Before Nozzle/ Tube Inser

Most of the enthusiasts on this website probably already perform this step before administering an enema, but it's very important that you do a digital rectal exam before inserting any tube or nozzle. You never know if the person whom you are administering an enema or colonic has a bowel obstruction or impaction, inflamed appendix, cysts, fissures, hemorrhoids, or swollen/inflamed prostate in the case of males. Attempting to insert a tube or nozzle in any one of these cases can cause serious injury, result in the spread of an existing infection, or in some rare cases, lead to death. The quickest and easiest way to avoid this is by performing an external examination of the anus, and a brief internal digital rectal exam. Most nurses are now being taught to make this step mandatory, purely for safety and to cover the medical institution from a lawsuit. Many injuries have occurred as a result of failure to perform the examination. During my recent certification on becoming a colon hydrotherapist, learning to do rectal exams before speculum insertions was a mandatory part of the curriculum. I now work part time for a clinic providing colonics, and I require each client to submit to a rectal exam, and that is to cover myself and the clinic from injury lawsuits. Just about all of my clients have cooperated well with this, especially when you explain the risks of not doing so. They also realize it's not going to hurt to have it done. If a client can comfortably tolerate having a 1" dia speculum inserted 4 1/2", then an index finger going in 2 1/2" will feel even less uncomfortable. It's really not that big of a deal, though I understand to some it can be a little embarrassing. Hospital patients seem to be the most reluctant, but clients receiving colonics already know the nature of what's going happen when they get in the treatment room, and don't seem to mind.

When doing an internal rectal exam, the first step should be to prepare the enema solution and have it ready nearby. Warm the water temperature in the machine if you're giving a colonic. Take the enema nozzle/ rectal catheter or colonic speculum from it's protective plastic, inspect it for safety, and lubricate the first 3"-5" liberally. Attach the nozzle/catheter to the enema tubing, or place the rectal speculum on a sterile towel nearby. Put on a pair of examination gloves, nitrile preferred for latex sensitive clients. Next, have the recipient lay on their left side, and bend both knees as close to the chest as they comfortably can. Lubricate the gloved index finger of your dominant hand with a liberal amount of K-Y Jelly, Surgilube, or coconut oil. Raise the patient's right buttock to expose the anus. Look for contraindications such as tears, fissures, hemorrhoids, or signs of bleeding. If no contraindications are present, place the lubricated pad of your index finger at the patient's anus, and apply a slight pressure. It takes a little practice, but most of the time the external sphincter will relax enough so you can proceed to push the tip of your finger up the anal canal with little effort, till you meet resistance at the internal sphincter. Encourage the patient to relax and breath through the mouth. When the sphincter relaxes, take care to point the finger toward the abdomen, and with gentle pressure slip it up the rectum as far as it will go( 2"-3"). If may feel as if your finger is being drawn in by the rectum, but it's just a muscle contraction. A patient will immediately let you know if there is an undiagnosed problem with the appendix, as any rectal insertion will cause pain where appendicitis is present. Gently feel from side to side for lumps or tears. You may feel hard stool at the farthest reach of your finger tip. Note this, as a cleansing enema may be necessary to clear the rectum for an adequate speculum insertion. For male patients, check the area that's 2" or so inside the frontal wall of his rectum for prostate inflammation or hard lumps. A normal prostate will be about the size of a walnut and be firm but not hard to the touch. Older males sometimes have slightly larger prostates, but that can be considered normal in most cases where other contraindications aren't present. In either case of performing the examination, try to be brief as possible. The whole process shouldn't take more than 10 or 15 seconds once you achieve full insertion. Remove your finger slowly and gradually. While the patient's internal sphincter is still relaxed, take the enema nozzle or rectal speculum that's been pre-lubricated in the same hand you performed the exam. Raise the right buttock once again, place the tip of the nozzle/speculum at the anus, and with gentle pressure in the direction of the abdomen, it should glide very easily up the rectum 3"- 5". You can now proceed with the enema or colonic.

I've found that some people out there are squeamish at doing rectal exams. I was when I did my first in nursing school. But trust me, it's an easy process. I've given at least 300+ rectal exams since I became a colon hydrotherapist. You just need to be patient with the person receiving the exam, and above all, GENTLE.

Great advice Nurse Nikki! Most colon hydrotherapists that I have patronized will perform a rectal exam. There has usually been some discussion about hemorrhoids, fissures, rectal bleeding, etc. While I would never object to the rectal exam, many therapists or medical people apologize in advance. I wonder if most people object due to psychological conditioning rather than true discomfort or aversion. After all, if I'm up for a colonic, a little additional prep would never be unwelcomed.

Thanks Nurse, great run down of what to expect and how to conduct a rectal exam. One more reason to trust your (knowledgeable) play doctor and submit to a rectal exam for enema. I'd imagine it is a good precaution to any kind of anal insertion/play aswell.

Wow, what a great play by play on how to do a great rectal exam, thank you, Nurse Nikki.

My colon hydrotherapist is an RN and always does a digital exam before she inserts the speculum. It helps me relax down there and makes what's coming next more comfortable. Women are more used to these exams.

Another example of how lawyers have limited sound medical practices. In Ohio, it's illegal for anyone to insert anything into the body, this includes colon hydrotherapists, but not Docs., or R.N.'s with a Doc's order. I am guessing that LPN's and nursing ass'ts. are also permitted to do so with a Doc's order.

When I was getting radiation for colon cancer, the radiation oncologist used to do a DRE on me every other day. I thought this was excessive and asked one of the RN's if the Doc. was gay. She laughed and said that no, he was doing this to feel the thickness of the rectal wall tissue before the radiation treatment. It would have been nice if HE would have told me why this was done.

I found your contribution to be very informative. I learned a lot from what you've written Nurse Nikki. I have a question about the procedure however. Please understand that in no way do I mean this question to be lewd or offensive. My question is this; in your experience have you ever had a patient become aroused during the examination, or during the administration of an enema?

Nikki, you sound like one fabulous colonic hydrotherapist. Gentle and thorough. I'm curious about your colonic training. Care to elaborate?

I think I need that treatment Nurse Nikki :-)

I have had colonics from about 20 therapists, and enemas from perhaps 50 nurses (RN's,LVN''s and CNA's). Not one of them has ever done a DRE.

You can not diagnose a bowel obstruction by doing a digital rectal exam, an impaction yes but not an obstruction. You can not palpate an anal fissure with a digital exam, I would recommend you get rectal spedulum. Most internal hemorrhoids are above the pectinate line and are not palpable. It be very rare to palpate an ovarian cyst rectally unless it was massive. Digital exams to diagnose appendicitis is unlikely, best to get a CT scan and a CBC. BPH and prostatitis can be evaluated by DRE. The only real reason to have digital exam before an enema is that it feels good.

Personally speaking I always do a rectal exam prior to any treatment that involves that area. Medically speaking it just makes sense. If I am inserting a suppository this is especially important because you can't stick a suppository into fecal matter, it won't work. It has to be against the rectal wall for it to be effective. Oddly enough they don't teach you that in nursing school. That is one of the things that I make sure I teach when I have a new nurse, or any nurse for that matter.

Jimmy, in Ohio a nurses aide cannot give an enema or do a rectal exam, or do any rectal stim. LPN's are absolutely permitted to do all of the above granted there is a doctors order allowing this. In Ohio there isn't much difference between what an RN can do and what an LPN can do. Also an Ohio LPN license is equal to that of a 2 year RN degree in most other states. LPN's here in Ohio are allowed to do things here that they can't do in other states. As a matter of fact, in other states an LPN or LVN license is equal to Ohio's nurses aides certificate which is a 2 week class here.

While most people think that I am an RN, I am in fact an Ohio LPN. I got into a slight argument once in Buffalo with this lady standing in line in front of Doc and I. She was a RN. Somehow we got on the topic of LPN's vs RN's. I made a comment about being a supervisor. She said "oh, so you are an RN like me". I said no, I'm an LPN. Then she basically called me a liar and said that LPN's cant be supervisors, especially over RN's. Well Doc came to my rescue actually and told her that they can in Ohio. With the exception of my first 3 years of practice I have been a supervisor in every job I have had. In Ohio a lot of it depends on experience, not education. I ran a vent/trach unit for 3 years. I had 25 patients total, 19 were vent patients, of the 25, 21 had trachs, and all but one were tube feeds. It was my first job out of nursing school and was the hardest job I have ever had. It was that job however that put me way ahead of most other LPN's in my state. I was pushing propofol, an LPN/LVN in any other state I believe is not by law permitted to do this, however we can. Not sure why I went on this rant, lol, sorry.

Back to the topic at hand, I believe that a brief rectal exam is necessary before inserting anything into the rectum. Just my opinion though.

Mashie

..and of course you would ask the person if there has been any pain and/or bleeding.

Hi Nurse Nikki,

Thanks for the info on the "DRE." Both of my Colon Therapists in So. Cal. when I lived there peformed the procedure before Colonics. Definitely a good idea. Also congratulations on your Colon Therapist Certification!! My current therapist here in La. just went for her Advanced level Certification.

with a "Click!,"

highwater

I wish the doctors that performed this with me (all men except one woman) would've used this approach. I must be quick to point out that the woman doc did this during a pre-employment physical and she knew how do do it right!

I have never had any of this done when getting an enema in the hospital not even when i had my colonascopy

Nikki, you've highlighted some pretty good reasons for doing a rectal exam pre-insertion. For all those scenarios it's important. Not just from a litigation POV, but also from patient experience.

A nursing friend of mine gave a small enema to a patient with haemorrhoids, but had been started on blood thinners, and the nozzle punctured one of them. She ended up needing a flexi sig and banding, nearly needed a blood transfusion. It wasn't the worst thing that could have happened, but it still wasn't the best outcome.

Looks like mashie’s back.

love to see you posting

please take extra special care, you have been on a long journey to very close to edge.

@Nurse_Nikki I thought a lubed gloved finger to lube inner rectum and do a simple dre was a good idea before doing my enemas. Now I believe in doing so even more!

Happy Holidays and HUGS,

Megan

Mashie: Right, a suppository inserted into a rectum full of waste won't work. Since the substances in the suppository may be slightly irritating to the rectal wall, it may actually trigger a bowel movement, and thus the suppository is wasted.

This is why my mother, prior to inserting medicated suppositories (not the laxative ones, obviously) would always ask me to go try having a bowel movement and would ask whether it worked.