Most GPs of a certain vintage would have heard the old adage “if you don’t put your finger in, you put your foot in.” It refers of course to the digital rectal examination and its importance as part of a thorough physical examination especially when symptoms indicate some potential pathology in that area. However it would be fair to say that most doctors, let alone patients are not particularly enthusiastic about this particular test. Indeed you could almost hear the collective sigh of relief when the authoritative guidelines suggested regular DRE was not useful as a means of screening for prostate cancer. The downside of this change in recommendation and general avoidance behaviour is that one can become deskilled in this examination, potentially missing an opportunity to diagnose a variety of conditions from prostate abnormalities to cancer. In the latest MJA, Dr Christopher Pokorny from the South Western Sydney Medical School at UNSW gives a synopsis of indications for DRE and a run through of the appropriate technique. “About 25% of colorectal cancers occur in the rectum and up to half can be palpated, but accuracy depends on training, experience, examination technique and the length of the examining finger,” Dr Pokorny writes. His list of indications for the procedure include the more obvious symptoms such as PR bleeding or mucus, change in bowel habit and prostatic symptoms but also a history of faecal urgency, difficult defaecation, faecal incontinence and anorectal pain (with the caveat that DRE should be avoided if there is an obvious anal fissure). Placing the patient in the left lateral position for the procedure is recommended with the patient drawing their knees to their chest and assuming that the patient is safe from falling off the examination couch. Assessment is made of the skin around the anus – looking for fissures, fistulae, skin tags, skin diseases such as warts or psoriasis, abscesses and haemorrhoids. The well-lubricated, gloved finger is then gently inserted, rotated in a clockwise direction into the rectum. Dr Pokorny suggests a systematic examination of the rectal mucosa anteriorly, posteriorly and laterally for masses that should be described as soft, hard, irregular or smooth. Prostatic abnormalities in men and ovarian or uterine abnormalities in women may be noted being careful not to confuse a palpable cervix in a woman with a mass. Finally, the doctor needs to check for any blood, including malaena on the glove. Dr Pokorny does concede the value of this examination is limited by the body habitus of the patient, and the length of the examiner’s fingers. Nonetheless, it is unwise to miss this diagnostic opportunity in general practice. “DRE is an often neglected but important part of the physical examination and should be performed whenever symptoms suggest anorectal or prostatic pathology,” he concludes. MJA doi:10.5694/mja17.00373