| Exam component | Technique | Findings and grading of response(s) |
| I. Inspection of the anus and surrounding tissue | ||
| Place patient in the left lateral position with hips flexed to 90°. Inspect perineum under good light. | Skin excoriation, skin tags, anal fissure, scars or hemorrhoids | |
| II. Testing of perineal sensation and the anocutaneous reflex | ||
| Stroke the skin around the anus in a centripetal fashion, in all four quadrants, by using a stick with a cotton bud | Normal: Brisk contraction of the perianal skin, the anoderm and the external anal sphincter Impaired: No response with the soft cotton bud, but anal contractile response seen with the opposite (wooden) end Absent: No response with either end | |
| III. Digital palpation and maneuvers to assess anorectal function | ||
| Digital palpation | Slowly advance a lubricated and gloved index finger into the rectum and feel the mucosa and surrounding muscle, bone, uterus, prostate and pelvic structures | Tenderness, mass, stricture, or stool and the consistency of the stool |
| Resting tone | Assess strength of resting sphincter tone | Normal, weak (decreased), or increased |
| Squeeze maneuver | Ask the patient to squeeze and hold as long as possible (up to 30 seconds) | Normal, weak (decreased), or increased |
| Pushing and bearing down maneuver | In addition to the finger in the rectum, place a hand over the patient's abdomen to assess the push effort. Ask the patient to push and bear down as if to defecate. |
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