I don't have any initial requirements, and I work "from the top down." By about the middle of the exam, she is naked, and the bulk of the exam is concentrated on her "lower half," and the normal order is abdomen, lower abdomen, external genitals and anus (no penetration yet), then digital vaginal exam, bimanual exam (forefinger in vagina, 2nd finger in rectum, probing as deeply as I can), then vaginal speculum exam, then I announce the rectal exam. It's at this point the patient realizes she will get at least two thorough cleansing enemas. I've had a couple women "gulp," and start to protest, but after the statement that the cleansing is required to do a proper exam, they realize that there is no choice. By this time they are naked, or if they are cold, I let them put on a top, and I prepare the enema for them. I fill the bag (2 qt) with very warm water, have them get in the position I want, then lubricate them and insert the nozzle. I always use the douche nozzle and hold the bag myself. I tell them they must take the entire bag or we will have to repeat, and start the flow. Most women do fine, but their first enema often encounters a lot of fecal matter, so it goes slowly. I have never had a woman unable to take the full bag. It may take some coaxing and sternness, but they have always managed to take at least the 2 quarts. I often have them knee chest for one or both enemas, or if my mood is different, they get the first enema in the Sims position, the second bottoms up. The entire scenario is meant to exert control, so the patient understands it's "Doctor's orders," and I am fully in control. They must submit. I make that clear when the appointment is made, and that's what they came for--a stern doctor who will not ask permission, but do what he feels is necessary at the moment. It's role play, of course, but among my favorite things. As an aside, I have never had a woman refuse the enemas, even if they are very nervous about getting them, and even if the enemas are unpleasant (humiliating, painful, entirely new), they accept them as part of the examination. The final part of the exam is the rectal exam, and I have used both a rectal speculum and rigid sigmoidoscopy. For this part of the exam, she is "bottoms up." The exam may conclude with stimulation to orgasm, sometimes fisting (if she can tolerate it), anal stretching, etc. I try to give the woman as many orgasms as she can have, literally, vaginally, rectally(!!) but I don't normally have sex with her. My favorites, of course, are the things I do to her bottom end, especially the enemas.