Why Does My OBGYN Do a Rectal Exam?

A rectal exam during an OB-GYN visit is not routine for every patient. When your provider does include one, the purpose is almost always to evaluate a specific concern that cannot be fully assessed through a vaginal exam alone. The thin wall separating the vagina from the rectum means structures on the rectal side, including ligaments, the anal sphincter, and potential growths or endometriosis nodules, are sometimes best felt from behind. Whether you are dealing with unexplained pelvic pain, symptoms after childbirth, or a suspected prolapse, the rectal component gives your provider information the vaginal exam misses.

What the Exam Actually Reveals

The vagina and rectum sit remarkably close together. They are separated by a thin layer of tissue called the rectovaginal septum, which in women who have not given birth averages only about two centimeters in length.¹ Because this wall is so thin, a finger placed in the rectum while another is in the vagina (a bimanual rectovaginal exam) lets the provider feel tissue in the space between the two, the uterosacral ligaments behind the uterus, and the back wall of the cervix. These are areas where endometriosis nodules, masses, or abnormal bulging from prolapse tend to hide from a standard vaginal-only exam.

The rectal exam also allows direct assessment of the anal sphincter muscle itself, which matters after vaginal deliveries and in patients reporting bowel leakage. In short, the exam is not about the rectum per se. It is about reaching structures that sit behind or below the vaginal canal and cannot be adequately evaluated any other way during a physical exam.

It Is Not Part of Every Well-Woman Visit

If you have been told the rectal exam is a standard part of an annual pelvic exam, that information is outdated. A critical review of the available literature found no evidence supporting the routine rectovaginal exam during well-woman visits. The review concluded that providers should limit the exam to patients who have specific rectovaginal or pelvic complaints.² In other words, if you are asymptomatic and coming in for a standard checkup or Pap smear, there is no good evidence that a rectal exam adds anything useful.

This is an important distinction because many patients feel blindsided when a rectal exam happens during what they expected to be a straightforward visit. If your provider includes one, they should be able to tell you what specific symptom or finding prompted it. If they cannot, you are within your rights to ask.

Checking for Deep Endometriosis

One of the most common clinical reasons for a rectal exam at the OB-GYN is suspicion of deep infiltrating endometriosis. This is a form of endometriosis where tissue grows into the wall of organs like the bowel, bladder, or the ligaments supporting the uterus. These nodules can cause severe pain during periods, intercourse, or bowel movements, and they often cannot be felt through a vaginal exam alone because they sit behind or below the cervix.

Physical examination, which includes the rectovaginal approach, has a pooled sensitivity of about 71% and specificity of about 69% for detecting deep infiltrating endometriosis.³ That means the exam catches roughly seven out of ten cases and correctly rules it out in about seven out of ten unaffected patients. For endometriosis in the uterosacral ligaments specifically, one study found physical examination had a sensitivity of about 74%.⁴

Those numbers are decent for a screening tool that requires nothing more than a provider’s hands. The exam has a useful profile as a first step: when the provider feels a nodule, it is very likely real (high positive predictive value), though a negative exam does not reliably rule endometriosis out. One study found rectovaginal examination had a positive predictive value near 89% but a negative predictive value of only about 32%.⁵ So if your provider feels something abnormal, take it seriously. But if they do not, that alone does not mean endometriosis is absent, especially if your symptoms are persistent.

Evaluating Prolapse and Rectocele

The posterior wall of the vagina is where a rectocele forms: a bulge where the rectum pushes forward into the vaginal space. It is also where an enterocele can develop, which involves the small intestine pressing down into the same area. These conditions feel similar to the patient (a sense of pressure or a bulge) but require different treatments, so getting the diagnosis right matters.

A clinical assessment of the posterior compartment needs to distinguish between a true rectocele, an enterocele, perineal hypermobility, and a deficient perineum. Proper differential diagnosis allows for appropriate treatment decisions and involves a combination of medical history, physical exam, and sometimes imaging.⁶ The rectal exam is a key part of the physical assessment here because it lets the provider feel whether the rectum is actually bulging forward (true rectocele) or whether the defect is in the perineal body or involves bowel from above (enterocele). These distinctions are difficult or impossible to make with only a vaginal exam.

After Childbirth and Anal Sphincter Injuries

Vaginal delivery can tear the anal sphincter, the ring of muscle that controls bowel continence. This type of injury, called an obstetric anal sphincter injury, affects roughly 3% of first-time mothers who deliver vaginally and about 1% of those who have delivered before.⁷ Recognizing the injury immediately matters because proper surgical repair at the time of delivery can prevent long-term incontinence.

A rectal exam right after delivery is the standard way to check whether the sphincter has been damaged. The provider inserts a finger into the rectum and asks you to squeeze, feeling whether the muscle ring is intact and functional. Some tears extend into the rectal lining itself and would be missed entirely without this check. Among women who do sustain these injuries, the majority are asymptomatic at one year, and most of those who do have symptoms report only incontinence of gas rather than stool.⁷ But that good prognosis depends heavily on the injury being found and repaired correctly in the first place.

If you are months or years postpartum and mention bowel leakage, difficulty controlling gas, or urgency to your OB-GYN, a rectal exam may be performed at a follow-up visit to assess the sphincter’s current function. These symptoms are underreported because of embarrassment, and they are undertreated in part because providers do not always ask.⁸ If your provider brings up a rectal exam in this context, it is because this is one of the few situations where the physical exam directly changes the treatment plan.

Pelvic Floor Problems That Go Unreported

Pelvic floor disorders are common enough that roughly one in nine women with these problems will eventually need surgery. The disorders include anal incontinence, chronic constipation, and defecatory dysfunction (the feeling that you cannot fully empty your bowels). Despite how widespread they are, patients are reluctant to bring them up because of embarrassment, and providers are sometimes reluctant to pursue them because treatment options can feel limited.⁸

This creates a frustrating gap where people suffer in silence for years. If you mention any of these symptoms to your OB-GYN, a rectal exam is one of the first steps in working out what is going on. The exam can reveal reduced sphincter tone, a rectocele, or other structural issues that point toward specific treatments like pelvic floor physical therapy, pessary use, or surgical repair. It is worth understanding that the exam serves a real diagnostic purpose in these cases, not a bureaucratic one.

How Imaging Compares to the Hands-On Exam

Given how uncomfortable many patients find the rectovaginal exam, you might wonder why providers do not skip straight to ultrasound or MRI. In many cases they eventually do, but the physical exam serves as the first filter that decides whether imaging is warranted.

For deep infiltrating endometriosis, transvaginal ultrasound significantly outperforms physical examination. Across pooled studies, transvaginal ultrasound showed a sensitivity of about 76% and a specificity of 94%, compared to the physical exam’s 71% sensitivity and 69% specificity.³ MRI performed similarly well, with about 82% sensitivity and 87% specificity. At specific sites like the rectosigmoid, one study found transvaginal ultrasound had a sensitivity of 98% and specificity of 100%, vastly outperforming the physical exam’s 72% sensitivity and 54% specificity at that same location.⁹

So imaging is clearly superior when it comes to pinpointing endometriosis lesions and mapping their extent before surgery. The physical exam still has a role, though, because it is immediate, requires no equipment, and can be done during the same visit where the patient reports symptoms. It also picks up on things like tenderness, tissue texture, and mobility that do not show up on a scan. In practice, a provider who feels a suspicious nodule on rectal exam will order imaging to confirm and map it; the hands-on exam speeds up the process rather than replacing the scan.

For prolapse, ultrasound has a complementary role. It helps distinguish a true rectocele from other causes of posterior wall descent, providing detail about whether the problem involves the rectovaginal septum itself or perineal hypermobility.⁶ But the initial clinical exam, including the rectal component, is still where the assessment begins because the provider needs to see and feel the bulge during straining to understand its severity and character.

What You Can Expect and What You Can Ask For

The experience of a rectal exam is, at best, uncomfortable and at worst genuinely distressing, especially for patients with a history of trauma. Research consistently shows that people who have experienced sexual assault report increased anxiety, pain, embarrassment, and sometimes retraumatization during pelvic exams.¹⁰ This makes it especially important for providers to explain why the rectal exam is being done before they do it, and to give you the opportunity to decline or postpone.

Current best practice calls for providers to obtain explicit consent not just for the pelvic exam itself but also for any additional components, including students being present during the exam and the use of a chaperone.¹¹ You have every right to ask what is being done, why, and to set limits. If your provider cannot explain the clinical indication for a rectal exam, that is a conversation worth having before the exam proceeds.

The question of chaperones during rectal and pelvic exams is worth understanding. Research has found that male providers are much more likely to use chaperones during pelvic exams on female patients, while female providers are significantly less likely to use them for pelvic, breast, or rectal exams.¹² Interestingly, a qualitative study of patient preferences during anorectal exams found that most patients did not mind a chaperone if that person was actively assisting with the exam, but when a chaperone was explicitly offered as an observer, every patient declined.¹³ This suggests that patients may feel more comfortable when everyone in the room has a clear functional role, rather than someone standing by solely as a witness.

Questions Worth Asking Before the Exam

If your OB-GYN tells you a rectal exam is needed, a few straightforward questions can help you understand the situation and feel more in control:

What are you looking for? The answer should be specific: endometriosis nodules, sphincter integrity, a rectocele, or something else. “It’s just part of the exam” is not an adequate answer given that the evidence does not support routine use.
Could imaging find this instead? In some cases, particularly for endometriosis mapping, a transvaginal ultrasound or MRI may provide more detailed information. Your provider might still want to start with a physical exam, but it is fair to discuss alternatives.
Can I have a moment? Providers should be willing to pause, explain what they are about to do, and give you time to prepare. You can also ask for the exam to stop at any time.

The exam itself typically takes under a minute. The provider wears a lubricated glove and inserts one finger into the rectum, often while another finger remains in the vagina. You may be asked to bear down or squeeze, which helps the provider feel for prolapse or sphincter function. There should be no sharp pain; pressure and an urge to bear down are normal, but stabbing pain is not, and you should speak up if you feel it.

When the Exam Finds Something Unexpected

Occasionally a rectal exam turns up a finding the provider was not specifically looking for. A nodule felt during a bimanual exam could be an endometriosis implant, but it could also be a rectal polyp, a cyst, or rarely something more concerning. In these cases, the physical exam finding typically leads to imaging or referral rather than a diagnosis on the spot. The provider might order a transvaginal ultrasound, an MRI, or refer you to a colorectal specialist depending on what they felt and where.

For patients with known endometriosis who are being evaluated for surgery, the physical exam findings get combined with imaging results to plan the procedure. Ultrasound tends to be better at identifying nodules in certain locations like the rectovaginal space, while MRI performs better for lesions near the bladder or ureters.⁵ The physical exam adds context that imaging alone cannot provide: how tender a nodule is, whether the uterus moves freely or is fixed in place, and whether specific maneuvers reproduce the patient’s pain. These details shape both the surgical approach and the conversation about what to expect from treatment.

If a rectal exam reveals reduced anal sphincter tone in a patient who has not recently given birth, this can prompt further evaluation with anorectal manometry or endoanal ultrasound. These specialized tests quantify how well the sphincter is functioning and can identify old tears that were never repaired. The rectal exam at the OB-GYN, in this sense, sometimes functions as the gateway to a subspecialty workup the patient did not know they needed.

1
PubMed. Observations on the anatomy of the rectovaginal pouch and septum
2
PubMed. An evidence-based review of the rectovaginal examination during well-woman visits
3
PubMed Central. Comparison of physical examination, ultrasound techniques and magnetic resonance imaging for the diagnosis of deep infiltrating endometriosis: A systematic review and meta-analysis of diagnostic accuracy studies
4
PubMed. Diagnostic accuracy of physical examination, transvaginal sonography, rectal endoscopic sonography, and magnetic resonance imaging to diagnose deep infiltrating endometriosis
5
Indonesian Journal of Obstetrics and Gynecology. Rectovaginal Examination, Transvaginal Ultrasonography, and Magnetic Resonance Imaging as Diagnostic Tools for Identifying Deep Infiltrating Endometriosis Nodules
6
Ginekologia Polska. Rectocele
7
BMJ. Obstetric anal sphincter injury
8
Obstetrics and Gynecology Clinics of North America. Evaluation and Management of Posterior Compartment Disorders: Anorectal Incontinence, Constipation, and Defecatory Dysfunction
9
Human Reproduction. Comparison between clinical examination, transvaginal sonography and magnetic resonance imaging for the diagnosis of deep endometriosis
10
The Journal for Nurse Practitioners. Fostering Patient-Centered Trauma-Informed Care: Insights From a First-time Pelvic Examination
11
PubMed. Consent in Pelvic Care
12
PubMed Central. Chaperone use by residents during pelvic, breast, testicular, and rectal exams
13
PubMed. “That’s what sets you at ease:” A qualitative analysis of patient preferences during anorectal exams