Genitourinary and rectal examination

The genitourinary and rectal examination is the bedside assessment of the urinary tract, the male and female external genitalia, and the rectum and anus. It is performed to find infection, inflammation, masses, obstruction, hernias and structural abnormalities, to support or refine a differential diagnosis, and to create a baseline that later clinicians can compare against. It is part of the routine abdominal and systemic examination as well as a focused urological or gynaecological assessment, and many of its signs are only meaningful when the whole patient has been looked at, since renal disease, pregnancy, skin disease and lymphadenopathy can change what a lump or mass means. ^[1][2]

The setting should make the examination possible and keep it dignified. A warm, well-lit room with a couch at your height, adequate drapes, a chaperone, lubricating gel, gloves, a light source and a bedpan or specimen pot within reach. The patient should know what is about to happen, why it is needed, and that they can stop it at any time. A rushed, cold or unexplained intimate examination is one that the patient will refuse and that the examiner will not repeat, and neither outcome helps anyone.

This page covers the external and rectal examination only. Bimanual pelvic examination and colposcopy, ultrasound, cystoscopy and prostatic biopsy belong to other topics and should be learned alongside this one rather than in place of it.

Preparation is where a genitourinary examination succeeds or fails. Introduce yourself by name and role and confirm the patient's identifiers. Explain what you are going to do in plain words, including which body parts will be exposed and examined and whether a finger will be inserted into the anus or vagina. Invite questions, obtain informed consent, and state explicitly that consent can be withdrawn at any moment. ^[3][4]

Offer a chaperone before any intimate examination rather than after you have begun. Explain what the chaperone will do and ask the patient whether they are happy with that person. The chaperone is essential rather than optional for every pelvic or genital examination, and the offer and the patient's response must be recorded in the notes. Many examiners also chaperone a rectal examination performed on a woman by a man, or on any patient where either party prefers one. ^[3][4][5]

A chaperone, where one is used, should usually be a health professional rather than a friend or relative, and should stand where they can see the examination and the patient at the same time. The chaperone witnesses consent, observes professional boundaries, and is available as a second pair of eyes if the patient later wishes to report what happened. ^[3]

Clean your hands before and after the examination. Don gloves before touching mucosa, genitalia or any body fluid, and change gloves between the external examination and the rectal or vaginal part. Warm your hands during the examination and have the patient use the toilet and empty the bladder beforehand, unless the point of the examination is to assess a full bladder or incontinence.

Expose only what you need and cover everything else. Explain each step as it happens: "I am going to look at the outside of your genital area now" is both courtesy and consent. Use good light, a sheet or gown, and a pillow under the head or back when this helps. For the rectal examination ask the patient to remove underwear and provide privacy to undress.

Position follows the part of the examination:

• Male and female external genital examination: supine, with the lower abdomen, genitalia and upper thighs exposed and the rest covered. Draping preserves dignity and keeps the perineum visible.
• Suprapubic assessment: supine with the bladder as full or as empty as the clinical question demands; ask the patient to drink if you need a full bladder, and to void before a prostate or rectal examination.
• Rectal examination: left lateral with the knees drawn up toward the chest and the buttocks at the edge of the couch. Explain this position and make sure the patient is supported and not left reaching for balance.
• Speculum: the patient lies supine, usually with legs bent, feet together and knees apart. Ask the patient to change position if they are uncomfortable; a side-lying position with knees drawn up is an alternative. ^[6]

Privacy and respect are not courtesies added afterwards; they are part of the examination. A patient who feels safe will relax the perineal muscles and tolerate a rectal examination that would otherwise be impossible, and a patient who does not feel safe will not come back.

Work through the genitourinary tract from top to bottom and from outside to inside, so that you do not have to return to a part you have already finished. The order below is the standard sequence used in clinical skills teaching and in most OSCE stations. ^[1][2]

1. General appearance. Before touching the patient look at the overall impression: colour and anaemia, jaundice (liver disease can coexist with haematuria), the hydration status, mobility, body habitus, and any distress with micturition. Note abdominal distension, ascites or visible ureteric peristalsis in thin patients.
2. Hands and face. Look for stigmata that may belong to renal or systemic disease: anaemia, pigmentation, asterixis, tremor, xanthelasma and clubbing. Check the blood pressure if this is part of a wider assessment.
3. Abdomen and flanks. Inspect the abdomen for scars (renal, ureteric, bladder or gynaecological), hernias, masses, distension, visible veins and pulsation. Palpate all four quadrants systematically, feeling for the kidneys (often not palpable), the bladder, and any mass. In thin people a normal kidney can be felt bimanually. Percuss the renal angles and the bladder.
4. Renal angle (costovertebral angle) tenderness. With the patient sitting or lying, place the flat of one hand over the angle between the lowest rib and the spine, and strike the back of that hand firmly with the other fist, or press deeply into the angle with the thumb. Tenderness here is a sign of renal inflammation or infection, classically pyelonephritis, and corresponds to the fever, chills and flank pain that define that condition. ^[8]
5. Bladder. A bladder that is full or unable to empty is palpable or percussible as a dull, domed swelling arising from the pelvis, in the midline, below the umbilicus, which you cannot get above. Record the height of the swelling in centimetres above the pubic symphysis and note whether it is tender. After the patient voids, repeat the examination: a bladder that remains palpable suggests urinary retention rather than a simply full bladder.
6. Male external genitalia (if applicable). Inspect the pubic hair (distribution and loss), the penis (circumcised or not, the meatus, the glans, discharge or lesions), the scrotum, the perineum and the inguinal regions. Note the lie of the testes. Ask the patient to cough or strain while you inspect the inguinal area. ^[1]
7. Scrotal content. Palpate each testis between the thumb and fingers, noting size, position, consistency, tenderness and whether each is separate from the epididymis. Palpate the epididymis along the posterolateral border of each testis, then the spermatic cord in the inguinal canal. A varicocele feels like a bag of worms and becomes more prominent on standing or straining. A swelling that cannot be got above suggests a hernia entering the scrotum. ^[1]
8. Transillumination and torsion signs. Darken the room and hold a torch behind the swelling. Illumination suggests a fluid-filled mass such as a hydrocele, whereas a solid tumour or a hernia does not transilluminate. A hydrocele is so large that the underlying testis may not be palpable. For suspected torsion, elicit the absent cremasteric reflex by stroking the inner thigh and note the position of the testis and Prehn sign; these are only adjuncts and never outweigh an urgent scrotal ultrasound or surgical exploration. ^[1]
9. Hernia. Standing the patient where possible, inspect both inguinal regions while they cough or strain, then palpate the inguinal canal via the external ring and its medial aspect. A hernia is a swelling that may be reduced, that has a cough impulse, and that you cannot get above once it has entered the scrotum. Record which side, whether it is reducible, and whether there is tenderness suggesting strangulation. ^[1]
10. Female external genitalia (if applicable). Inspect the mons pubis and pubic hair, the labia majora and minora, the clitoris, the urethral meatus, the vestibule, the fourchette and the perineum. Note discharge, swelling, lesions, tears, bruising or atrophy, and ask about pain before you touch. Then gently separate the labia to view the vaginal introitus and ask the patient to bear down, looking for pelvic organ prolapse, stress incontinence or a bulge. ^[6]
11. Speculum overview. The speculum examination (vaginal speculum, usually metal or plastic) is a view of the vagina and cervix, not a full pelvic examination. Explain the procedure, obtain consent in the presence of the chaperone, position the patient comfortably, insert the blades with lubricant, open them to see the cervix, and inspect the vaginal walls, the cervix and its os and any discharge. A small speculum may be more comfortable; some patients prefer to insert it themselves. Record where the cervix sits, its appearance, and any bleeding, discharge or lesions. This examination is usually over in a minute. ^{[6] [3][4]}
12. Rectal (anal) examination. Perform this at the end of the examination so that the patient is not left tensed throughout. Position the patient in left lateral with knees drawn up, separate the buttocks and inspect the perianal area before touching. Palpate the anal sphincter tone, then rotate the examining finger 360 degrees to feel the full circumference of the rectal wall, and in men palpate the prostate anteriorly. Withdraw slowly and inspect the glove for blood, mucus, pus or stool. ^[2]
13. Prostate description. In men, once your finger is in the rectum, sweep it anteriorly over the prostate and describe what you feel: size (a normal gland is about the size of a walnut with a palpable midline sulcus), symmetry, and consistency. Normal prostate is symmetrical and its consistency is similar to that of the tip of the nose. A hard, irregular, nodular, fixed or asymmetrical gland raises the possibility of malignancy; a smooth, boggy, tender enlargement suggests inflammation or infection; a smooth, rubbery, symmetrical enlargement without a prominent median sulcus suggests benign enlargement. ^[2]

Digital rectal examination on its own has limited positive predictive value, of roughly 5 to 30 percent when the prostate-specific antigen is 4 nanograms per millilitre or less. A suspicious finding should therefore be followed by imaging and, where indicated, biopsy, rather than treated as a diagnosis. ^[7] Guidelines also build digital rectal examination into follow-up: the NICE active surveillance protocol includes a digital rectal examination at 12 months. ^[9] 14. Document everything immediately. Write a short, structured entry while the patient is still present, including consent, chaperone, position, exposure, each region inspected and palpated, the negative findings that matter, and any limitations. The entry of a normal examination is not "normal examination" but a list of what was seen and felt. ^[3]

The following table gathers the signs from the steps above with the way to elicit each one and a short interpretation. Every sign is a poor test on its own; it becomes useful when it is grouped into a pattern and matched with the history. ^[1][2][6][8]

Presentation is a separate skill, and it is where many students lose marks despite having examined thoroughly. Findings must be given in a fixed order, positive and important findings first, negatives chosen because they change the differential, and a one-line summary and differential at the end. ^[1][2]

1. The patient and the general appearance. "A 62-year-old man, comfortable at rest, with no respiratory or abdominal distress, and no palpable bladder."
2. The most important positive finding first. "The clinically important findings are on the right side of the scrotum" or "the prostate is enlarged."
3. The other positives in examination order: hands and face, abdomen and flanks, renal angles, bladder, external genitalia, scrotal contents, perineum, rectal findings and prostate, then the glove inspection.
4. The chosen negatives. State only those that change the diagnosis: "There is no renal angle tenderness, no suprapubic mass, no scrotal swelling on the left, and the penis and perineum are normal." Do not read out every negative you looked for.
5. Investigations to hand or about to be done: "He has no haematuria on dipstick, and urine microscopy is pending" or "Peak flow is not applicable here; a scrotal ultrasound is being arranged."
6. A one-sentence summary and a differential. "In summary, this is a right-sided hydrocele" or "In summary, a smooth, rubbery prostate enlargement consistent with benign obstruction, with malignancy still a possibility to be excluded."

• Speak in the past tense and use numbers rather than impressions: "the pulse was regular" becomes relevant only if you measured it; "about the size of a walnut" is better than "big".
• Use the standard terms (hydrocele, varicocele, bluish bulging vessels, stony dull?) rather than private descriptions such as "bag of grapes" in the final statement, even if you used them to yourself while examining.
• State both sides when you have compared them: "the left testis felt normal, the right was swollen and transilluminated."
• Separate finding from diagnosis. Say "a smooth rubbery prostate, estimated walnut-sized with loss of the median sulcus" rather than "benign prostatic hyperplasia", and only name the diagnosis in the final summary.
• Lead with what is abnormal. The examiner knows you started at the hands.
• Finish by returning dignity to the patient before you present: cover them, thank them, and then speak.

Write briefly and in the order you examined, using short lines rather than prose:

• Consent obtained; chaperone (nurse) present; left lateral for rectal.
• Abdomen: soft, no masses; bladder not palpable; renal angles not tender.
• External genitalia: normal penis and meatus; scrotum symmetrical; both testes descended, smooth, non-tender; epididymides normal; no hydrocele or varicocele; no hernia with cough impulse.
• Rectum: normal sphincter tone; no masses or tenderness; prostate smooth, rubbery, symmetrical, about walnut-sized, median sulcus palpable; no hard or irregular areas.
• Glove: no blood or mucus.
• Summary: normal genitourinary and rectal examination.

A normal entry of this shape is what the next clinician needs in order to know that everything was looked at, not a single word "normal".

All patient details below are invented and illustrative. They are not real patient records.

Normal examination, spoken. "This 24-year-old man had a normal general appearance and no stigmata of systemic disease. His abdomen was soft with no masses and neither renal angle was tender. The bladder was not palpable or percussible. The external genitalia were normal: circumcised with a central meatus, no discharge or lesions, both testes descended, smooth and non-tender, with normal epididymides, no hydrocele or varicocele, and no hernia on coughing. The perineum and perianal area were normal. On rectal examination in the left lateral position, anal tone was intact and I felt no masses or tenderness. The prostate was smooth, symmetrical, rubbery and about walnut-sized, with a palpable median sulcus, and there were no hard or nodular areas. The glove was clean on withdrawal. In summary, this is a normal genitourinary and rectal examination, and no further urological action is required."

Scrotal swelling (hydrocele), spoken. "The findings of note were in the scrotum. On inspection there was a smooth, painless swelling of the right hemiscrotum that transilluminated brightly in a darkened room. The right testis itself could not be palpated separately through the swelling, and the examiner could not get above the mass. There was no cough impulse and no bag-of-worms feeling to suggest a varicocele. The left testis was normal. In summary: a right-sided hydrocele, which has not been distinguished from a hernia entering the scrotum; an ultrasound of the scrotum would confirm the fluid collection and the position and state of the testis."

Enlarged prostate (benign pattern), spoken. "This 68-year-old man had a soft, non-tender abdomen with no masses, and neither kidney was palpable and no bladder could be felt above the pubis. The external genitalia and scrotum were normal. On rectal examination there was normal anal tone and no rectal masses or tenderness. The prostate was clearly enlarged, smooth, firm and rubbery, and symmetrical, with the median sulcus lost to palpation. There were no hard, irregular, nodular or fixed areas and no tenderness. The glove was clean. In summary: a smooth, symmetrical prostate enlargement consistent with benign prostatic obstruction, with malignancy not excluded on physical examination alone; I would want a serum prostate-specific antigen and, as indicated, a urinary flow assessment and renal function before finalising management."

Rectal findings (haemorrhoids), spoken. "On inspection of the perianal region there were bluish, bulging vessels covered by mucosa that became visible when the patient coughed, consistent with internal haemorrhoids, and the anal verge was tender. On palpation the anal sphincter had normal tone and I felt no rectal mass or hard stool, and the prostate examination was normal. The glove on withdrawal showed a little fresh red blood. In summary: symptomatic internal haemorrhoids with a small amount of rectal bleeding; the alternatives include an anal fissure and a more proximal source, which would need endoscopic assessment if bleeding persists or if alarm symptoms are present." ^[2]

• Performing a genital or rectal examination without consent and without recording the consent and chaperone. This is a professional failure as much as a clinical one.
• Skipping the renal angle and bladder because the complaint is genital or rectal. Upper and lower urinary tract disease is often co-present.
• Examining through clothing or in poor light. Scrotal swelling, rashes and haemorrhoids are easy to miss.
• Forgetting to ask the patient to cough or strain, so that a hernia, varicocele or prolapse is missed.
• Failing to transilluminate a scrotal swelling, and so not doubling the diagnostic yield in one minute.
• Relying on Prehn sign or the cremasteric reflex to exclude testicular torsion. They are supportive only; a tender, high-riding testis in a young man is torsion until imaging or exploration says otherwise.
• Treating "a varicocele feels like a bag of worms" as a diagnosis rather than as a description. Always state the side and the change with standing or straining.
• Palpating the prostate without describing both sides, symmetry and consistency, or calling an enlargement "benign" before a biopsy or imaging has excluded cancer.
• Forcing a rectal examination in a patient with a painful anal fissure, which is both cruel and uninformative. If it is too painful, say so and arrange an appropriate examination under anaesthesia.
• Leaving the patient exposed between stages, or not providing privacy to undress and redress. This destroys trust and the examination's validity.
• Presenting the prostate as a diagnosis instead of as a set of signs, and omitting the glove inspection, which is the one finding that most changes the differential.
• Writing "normal examination" without listing what was seen and palpated, so the next clinician cannot tell whether the examination was done at all.

• The genitourinary and rectal examination is consented, chaperoned, ordered and documented as a complete sequence, not a list of tricks.
• Exposure, hand hygiene, appropriate position and a chaperone are part of the examination and must be recorded as such.
• Work from the kidneys down to the rectum: renal angles, bladder, external genitalia, scrotal signs, speculum (in women) and then rectal examination.
• Consent and chaperone are essential, particularly for pelvic and genital examination, and the offer and response are documented. ^[4][5]
• Renal angle tenderness suggests renal inflammation or infection, typically pyelonephritis. ^[8]
• A full or non-emptying bladder presents as a midline domed swelling above the pubis that you cannot get above.
• Transillumination separates a fluid-filled scrotal swelling such as a hydrocele from a solid mass or hernia. ^[1]
• Varicocele feels like a bag of worms and increases with standing or straining. ^[1]
• Testicular torsion is a surgical emergency; reflex and Prehn sign are adjuncts only. ^[1]
• A normal prostate is about walnut-sized with a palpable median sulcus, and symmetrical with consistency like the tip of the nose. ^[2]
• Hard, irregular, nodular or fixed areas in the prostate raise concern for malignancy; smooth boggy tenderness suggests inflammation. ^[2][7]
• Internal haemorrhoids are bluish, bulging, mucosa-covered vessels that may appear on coughing and are usually painless. ^[2]
• Documentation must state what was inspected and palpated, the relevant negatives and a summary with a differential.
• Presentation leads with the most important finding, states only the negatives that matter, and ends with a one-line summary and differential.