Rectal examinations are a routine yet often underutilized component of physical assessment across a wide range of clinical settings. While they are frequently associated with prostate evaluation, particularly in men, their scope is much broader and extends to the detection of multiple anorectal conditions.
Despite their importance, many clinicians report limited training or discomfort with performing rectal exams, which can contribute to underuse and misinterpretation of findings, some of the most common of which include hemorrhoids, anal fissures, perianal abscesses, fistulas, and skin tags. Beyond these, rectal exams can also reveal more serious conditions such as anal cancer or precancerous lesions related to human papillomavirus (HPV).
For further insight into her session at GHAPP and some of the key takeaways for NPs and PAs, the editorial team of HCPLive Gastroenterology spoke with Stewart for the following Q&A:
HCPLive: What are the goals of and take home messages from this session?
Stewart: My fun titled topic is “Everything Anal: What’s Going on Back There?”
I think in school for many of us NPs and PAs were taught how to do a very basic rectal exam, which usually focuses on the prostate. But that’s not our goal of a rectal exam in practice, right? So in practice, we need to distinguish between hemorrhoids, fissures, abscesses, fistula, HPV, and anal cancer without anyone ever really teaching us how to do this exam.
My talk is about all of the different kinds of common anal rectal conditions that you see and how to clinically examine for them, what you need specifically to do on your exam, what you’re looking for. It also includes a lot of pictures so people can really see what they might see in clinic. The goal is for participants to really leave that talk feeling much more confident about a rectal exam, which is a really key piece of our job as NPs and PAs.
HCPLive: What are the most common misconceptions or misdiagnoses you see when it comes to rectal exams?
Stewart: So I would say in general, less so from GI APPs, but certainly from my colleagues who work in urgent care and primary care, if you don’t do a lot of rectal exams, it can be hard to understand the pathology of what you’re looking for. I see many skin tags that are treated as active hemorrhoids, and you can put all the steroid cream you want on a skin tag, but it’s not going to change or go away. So a component of my talk is the difference between the two.
Anal fissures are also often really commonly misdiagnosed or missed on exam. You can see them, but you really have to get into all the nooks and crannies of that perianal skin in order to see them. There’s a lot of really good clinical pearls, if you will, in what you’re looking for and what you’re going to see on exam.
HCPLive: Are there any other key takeaways you would like to highlight?
Stewart: I think just some other things that sometimes GIs don’t recognize as often is HPV. So looking for condylomas or pre-cancerous changes from HPV, as they also specialize in anal HPV, but also herpes lesions are often misdiagnosed as fissures too. So I also have some information about that, and really kind of the clinical picture of how that presents for people as well.
References
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Villanueva Herrero JA, Abdussalam A, Kasi A. Rectal Exam. StatPearls. February 18, 2023. Accessed September 15, 2025.
https://www.ncbi.nlm.nih.gov/books/NBK537356/