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Rectal (PR) OSCE Examination Quiz

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A 61-year-old man is referred by his GP with rectal bleeding and new urinary symptoms. You have just finished a digital rectal examination: the prostate feels hard and asymmetrical, and there is no impacted stool. Which plan best completes the examination and sets out immediate management?

Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then start an alpha blocker for the urinary symptoms and a bulk-forming laxative, with a plan to repeat the digital rectal examination after the urinary symptoms improve; the rectal bleeding can be managed as haemorrhoids. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him, record the findings and chaperone, then summarise and plan blood tests including PSA, a stool test, bowel assessment, a prostate MRI and urology referral. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then request a PSA and a prostate MRI, refer to urology after the PSA result is available, and arrange bowel assessment after the bleeding has settled. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a PSA and a flexible sigmoidoscopy, but no prostate MRI because the gland is already hard and asymmetrical on palpation; urology referral can be made after the PSA result. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a routine urology appointment in four weeks and a PSA test, and reassure him that the rectal bleeding is likely from haemorrhoids.

A Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then start an alpha blocker for the urinary symptoms and a bulk-forming laxative, with a plan to repeat the digital rectal examination after the urinary symptoms improve; the rectal bleeding can be managed as haemorrhoids.
B Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him, record the findings and chaperone, then summarise and plan blood tests including PSA, a stool test, bowel assessment, a prostate MRI and urology referral. ✓
C Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then request a PSA and a prostate MRI, refer to urology after the PSA result is available, and arrange bowel assessment after the bleeding has settled.
D Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a PSA and a flexible sigmoidoscopy, but no prostate MRI because the gland is already hard and asymmetrical on palpation; urology referral can be made after the PSA result.
E Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a routine urology appointment in four weeks and a PSA test, and reassure him that the rectal bleeding is likely from haemorrhoids.

The answer is B: Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him, record the findings and chaperone, then summarise and plan blood tests including PSA, a stool test, bowel assessment, a prostate MRI and urology referral.

Explanation

Why B is correct

See Palpation of the Rectal Walls. Option B is correct. A rectal examination does not end when you take your finger out. You help the patient to clean up and dress in privacy, dispose of gloves and equipment as clinical waste, wash your hands, thank him, and document the indication, the findings and the chaperone (the person who was present as a witness and support). You then summarise and plan. NICE advises that a prostate that is hard and nodular on examination should prompt urgent referral to a urological cancer specialist, and assessment of suspected prostate cancer includes a PSA (prostate-specific antigen) blood test. His rectal bleeding must not be forgotten, because a digital rectal examination and further tests are needed to exclude serious underlying pathology such as bowel cancer, so the plan covers the bowel as well. Memory aid: care, clean, record, plan for both problems.

Closing: help the patient to clean up and dress in privacy, dispose of gloves as clinical waste, wash your hands and thank the patient.
Documentation: the indication, the findings and the chaperone.
Prostate: a hard and nodular prostate should prompt urgent referral to a urological cancer specialist, and a PSA blood test is part of the assessment.
Bleeding: needs examination and further tests to exclude serious pathology such as bowel cancer, so the plan covers both problems.

Why the other options are incorrect

A. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then start an alpha blocker for the urinary symptoms and a bulk-forming laxative, with a plan to repeat the digital rectal examination after the urinary symptoms improve; the rectal bleeding can be managed as haemorrhoids.: Starting an alpha blocker and laxative and repeating the examination treats the symptoms as benign prostatic enlargement and haemorrhoids without excluding the hard, asymmetrical prostate, which needs urgent urology referral and cancer assessment.
C. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then request a PSA and a prostate MRI, refer to urology after the PSA result is available, and arrange bowel assessment after the bleeding has settled.: Urgent urology referral for a hard, asymmetrical prostate should not wait for the PSA result, and bowel assessment is indicated for the first episode of rectal bleeding rather than being deferred until bleeding settles.
D. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a PSA and a flexible sigmoidoscopy, but no prostate MRI because the gland is already hard and asymmetrical on palpation; urology referral can be made after the PSA result.: A hard, asymmetrical prostate needs urgent urology referral and prostate MRI as part of the suspected cancer pathway, not delayed referral based on the PSA result.
E. Help him clean up and dress in privacy, dispose of gloves and equipment safely, wash your hands, thank him and record the findings and chaperone, then arrange a routine urology appointment in four weeks and a PSA test, and reassure him that the rectal bleeding is likely from haemorrhoids.: A hard, asymmetrical prostate should prompt an urgent referral to urology rather than a four-week routine appointment, and rectal bleeding at this age needs prompt bowel assessment instead of being attributed to haemorrhoids.

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1
A 57-year-old man has agreed to a digital rectal examination after an explanation, with a chaperone present. Before you insert your finger, he says, "I do not want this examination. Please stop." He has capacity to decide and there is no emergency. What is the best immediate response?
2
When starting to insert the examining finger during a digital rectal examination, which technique is most appropriate?

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