Digital Rectal Examination & Manual Removal of Faeces

1. Digital Rectal Examination & Manual Removal of Faeces Cath Stansfield. Advanced Practitioner - Gastroenterology

2. Before you begin… • Review your A&P of the GI tract, in particular:- • The function of the colon • The anatomy and physiology of the rectum • Review the principles of constipation management

3. Anal & perianal observations Principles of DRE Principles of constipation management and manual evacuation Prescribing rectal medication Legal and ethic considerations of DRE and manual evacuation Objectives

4. Anatomy of the lower gi tract

5. The main function of the colon is the propulsion of faecal matter and absorption of fluid. colon

6. Why is the colon important in considering constipation? • Transit time • Length of time that food is in the colon. • The longer the transit time the more water is absorbed • The harder and more solid the evacuated stool will be • Total water content of the gut per 24 hours • Salivary glands 1500mls • Stomach 2500mls • Bile 500mls • Pancreas 1500mls • L & S bowel 1000mls • Only 200mls is expelled in faeces

7. The rectum is the last 15-17cm of the large colon. It is situated at the level of the pelvic floor, the last 2-3cm becomes the anal canal. The rectum and anal canal

8. Capable of distension Usually empty Gastro colic reflex is necessary for its function Affected by emotion Able to distinguish wind from solid Key characteristics of the rectum

9. The pelvic floor, in particular the pubo-rectalis muscle is important to maintain faecal continence and successful defecation Pelvic floor

10. mechanism • The junction of the sigmoid colon & the rectum is angled sharply 60° - 105 ° • Continence is maintained by • the acute angle • 2 Anal sphincters

11. Anal Sphincters • The Internal Anal Sphincter. • Surrounds the anal canal • Not under voluntary control • The External Anal Sphincter. • surrounds the bottom of the internal anal sphincter. • is under voluntary control.

13. And finally.. faeces • Product of elimination, consists of • 75 % water • 20 % Dead bacteria • 5 % Fat • Nitrogen • Bile pigments & undigested food • Colour usually brown influenced by food • Dark = protein • Black = Blood or iron • Clay = Fat

14. Assessing bowel function

15. Assessing bowel function – medical/ surgical history • Illness • Bowel disorders • Neurological illness • Chronic pain • Terminal illness • Injury • Child birth • Spinal injury • Surgery • Spinal surgery • Bowel surgery

16. Diarrhoea Antacids ( Magnesium) Antibiotics Antidepressants Beta Blockers Diuretics Iron preparations Hypoglycaemic preparations Sorbitol Constipation Antacids (Aluminium) Analgesics Anti-inflammatory drugs Antidepressants Anti hypertensives Diuretics Iron preparations Sedatives Motility drugs Assessing bowel function - medication

17. Bristol stool chart

18. Constipation

19. THE FACTS • 10% of the population are affected • 25% of the elderly are affected • More common in females • 13 out of 1000 GP consultations are for constipation

20. Impact of constipation • Loss of well being • Pain • Depression • Loss of mobility • Loss of appetite

21. Defining Constipation • Going less often • passing hard faeces • difficulty in passing a stool • Straining at stool • Going less than 3 times per week • Pain on defaecation

22. 3 Categories of Constipation • Primary • diet • Lifestyle • Secondary • Disease associated • Iatrogenic • 50% of medication can have constipatory affects on the bowel

23. Causes of constipation • Pregnancy and childbirth • Ignoring the call to stool • Diabetes • Depression • Lifestyle • Immobility – walking 0.5km per day will reduce constipation • Poor diet • Irregular meals

24. The Goal • The feeling you want to go is definite but not irresistible • Once you sit on the toilet there is no delay • No conscious effort or straining • The faeces glides out smoothly & comfortably • Followed by a pleasant feeling of relief

25. Digital Rectal Examination

26. DRE and MEF • Any concerns about scope of practice the RCN Guidance for DRE should be followed.

27. Before you do… • Understanding of A&P of the lower gastro-intestinal tract • Identification of possible causes of constipation • Planning stepped approach to nursing care to prevent & treat constipation

28. Think about…. • Invasive and should only be performed when necessary. • Awareness of cultural & religious beliefs. • There can be conflict over Manual Removal of Faeces between patient/carers/nurses. • Wide range of alternatives available, but not suitable for all. • Keep discomfort to a minimum

29. Why? • To establish the need and outcome of digital stimulation to trigger defecation by stimulating the recto anal reflex • (RCN, Bowel Care, Guidance for Nurses, March 2008) • To establish the presence, amount & consistency of faecal matter in the rectum • To establish anal tone, the ability to initiate a voluntary contraction and to what degree • Anal/rectal sensation • (

30. Preparing the patient • DO: • Complete a full bowel assessment • Consider ALL other treatment options with your team • Inform the patient of treatment options and risks • Gain valid consent

31. Preparing the patient • Don’t • Proceed if YOU do not feel competent (NMC 2002) • Proceed if there is a lack of consent • Proceed if the doctor has given specific instructions NOT to undertake the procedure • Proceed if the patient has recently undergone rectal, anal surgery or trauma.

32. Preparing the patient • Don’t proceed if • Active inflammatory bowel disease • Rectal pain • Obvious rectal bleeding • Spinal Injury at T6 or above- • consult local guidance and spinal injury team as allowing constipation to occur leads to a greater risk of autonomic dysreflexia (Getliffe et al 2007)

33. DRE • Introduction • Introduce yourself, check you have the right patient, explain procedure; “will involve examining back passage with a finger” • Explain WHY you are doing the procedure • Get verbal consent • Alcohol gel hands! • Get a chaperone if opposite sex and advised still if same sex.

34. DRE • Get patient to roll onto left hand side with knees up to chest. (Always examine from right hand side!) • Collect equipment: • Clean tray • Gel (lubricant) • Gloves • Gauze (for wiping)

35. observation • Look at perianal area what can you see??

36. Common perianal observations • Rectal prolapse • Haemorrhoids • Skin tags • Wounds/dressing/ discharge • Anal lesions • fistula • Abscesses • Fissure • excoriation

37. Abscesses • Discharge • Blood • Mucus • Faecal matter

38. Anal fissure • Document as clock:- • 6 o’clock • 12 o’clock • Common in Crohn’s and constipation

39. haemorrhoids • 1st degree- remain in rectum, 2nd degree- prolapse through but spontaneously reduce, • 3rd degree- as for 2nd but require digital reduction, • 4th degree- remain prolapsed persistently

40. Haemorrhoids • Haemorrhoids are abnormalities of these cushions which may slip due to : • Straining at stool • Pregnancy

42. Rectal Prolapse • Common in elderly females • There may be • Faecal incontinence due to stretching of the anal sphincter • Mucus discharge from the prolapsed bowel • Treatment of a complete rectal prolapse requires an operation (rectopexy) to fix the rectum within the pelvis

43. Fistula in Ano • Common causes:- • Constipation • Repeated enemas • Childbirth • Exploration and laying open of the fistula under general anaesthesia may be necessary

44. Anal Carcinoma • Present with • pruritus ani, • fissures, • perianal warts • bleeding mass • Treatment with surgery

45. Anal Warts • Commonest STD • Results from HPV • Associated genital warts in the sexual partner are common

46. Perianal Crohn's • Multiple signs • Skin tags • Erythema • Fistula • Abscesses • scarring • Anal strictures

47. Not significant Chronic straining Childbirth Constipation May become:- Thrombosed Oedematous Can lead to:- Pruritus Haemorrhoids Can be removed Skin tags

48. Examination • Inform patient you are going to examine with your finger now • Put blob of lubricant on finger • With your left hand, raise up the patient’s right buttock.

49. Assessing Sphincter function • Insert finger, • assessing sphincter tone • Is it hypertonic – difficult to insert finger • Remember patient may be anxious and can ask patient to take a deep breath • Indicative of Crohn’s disease, Fissure, stricture, nerves • Is it hypotonic - no resistance • Indicative of old age, nerve damage (spinal injury), muscle damage (multigravida)

50. Advance finger • If resistance noted - ask the patient to take a deep breath, or to push, as if they are going to the toilet. • If patient is unable to tolerate at any point STOP