Digital anorectal exam - DARE

A digital anorectal exam, or DARE, is a physical examination of the anus, anal canal, and lower rectum. A healthcare professional inspects the area and gently inserts a lubricated, gloved finger to feel for changes.

The exam may identify a lump, thickened tissue, tenderness, an ulcer, or bleeding. It can help investigate symptoms and may be included in anal cancer screening for some people at higher risk.

DARE is similar to a digital rectal examination. The term DARE places particular emphasis on carefully checking the anus and anal canal, where anal cancers can develop.

The examination does not provide a numerical result. It also cannot confirm cancer by itself. If an area feels or looks unusual, further examination and sometimes a biopsy are needed. A biopsy removes a small tissue sample for laboratory testing.

DARE may be offered to investigate:

• Bleeding from the anus or rectum
• A new lump, swelling, or area of thickening
• Persistent anal pain, pressure, itching, or discharge
• A sore that is not healing
• Changes in bowel control or the shape of bowel movements
• A feeling that the rectum is not empty after a bowel movement

These symptoms have many possible causes. Haemorrhoids, small tears called anal fissures, infections, inflammation, and skin conditions are more common explanations than cancer. The examination helps determine what further testing, if any, is appropriate.

DARE may also be part of screening for anal cancer in selected higher-risk groups, including some people living with HIV. Screening policies differ between countries and services. They may take account of age, immune health, previous anal or genital precancer, and local access to anoscopy.

DARE is mainly intended to find changes large enough to see or feel. It is not a reliable test for microscopic or flat precancerous cells.

You may be offered DARE if you have ongoing or unexplained anorectal symptoms. It can be performed regardless of your sex or gender.

Some guidelines recommend regular assessment of anal symptoms and DARE for people living with HIV. Other people who may be considered for screening include those with previous anal precancer or cancer, certain HPV-related genital cancers, or long-term immune suppression. The recommended approach is not the same everywhere.

Having a risk factor does not mean you have cancer. It means that screening may be worth discussing in the context of your age, health history, preferences, and local guidance.

Tell the healthcare professional if you have severe pain, recent anorectal surgery, trauma, or a condition that makes internal examination difficult. The exam can be stopped or postponed. It should only proceed with your consent.

You do not need to fast, change your diet, or use a laxative or enema. You may eat, drink coffee, and take your usual medicines unless you have been given separate instructions for another procedure.

Using the toilet beforehand may make you more comfortable, but it is not medically required.

Before the appointment, mention any:

• Current bleeding, pain, sores, or discharge
• Previous anal, rectal, pelvic, or prostate surgery
• Haemorrhoids, fissures, inflammatory bowel disease, or radiation treatment
• Medicines that increase bleeding, such as anticoagulants like warfarin or apixaban
• Past trauma or anxiety related to intimate examinations

You can ask what the examination will involve before agreeing. You may request a chaperone where that service is available. You can also ask to change position or stop at any point.

You will be given privacy to undress from the waist down and will usually be covered with a sheet. You may lie on your side with your knees bent. Other positions are sometimes used if they are more comfortable or allow a better examination.

The healthcare professional first looks at the skin around the anus for lumps, sores, warts, irritation, bleeding, or other visible changes. They may gently feel the surrounding area.

They then apply lubricant to a gloved finger and slowly insert it through the anus. You may be asked to relax or bear down as if having a bowel movement. The finger is moved carefully around the anal canal and lower rectum to check for lumps, thickening, tenderness, narrowing, or irregular tissue.

You may feel pressure or an urge to open your bowels. The internal part usually lasts less than a minute, although a careful examination may take longer. The entire appointment commonly takes 5 to 10 minutes.

Results are usually discussed immediately.

A normal result means no concerning change was seen or felt within the area examined. It does not rule out every anal or rectal condition. Small, flat, early, or higher abnormalities may not be reachable or noticeable by touch.

An abnormal result means the examiner found something that needs explanation. This does not automatically mean cancer. Possible causes include haemorrhoids, scar tissue, an anal fissure, inflammation, an abscess, warts, rectal prolapse, or a benign growth.

Depending on the finding, the next test may be anoscopy. This uses a short tube to look inside the anal canal. High-resolution anoscopy uses magnification to identify areas that may contain abnormal cells.

A suspicious lump or sore generally requires a biopsy to establish what it is. Imaging such as MRI or CT may be arranged only if the examination and other tests suggest it is needed.

DARE is based on what can be seen and felt, so there is no laboratory number to alter. Food, coffee, exercise, time of day, pregnancy, and most medicines do not directly change the result.

The examination can still be misleading because of:

• Stool that limits contact with the rectal wall
• Pain or muscle spasm that prevents a complete examination
• Haemorrhoids, fissures, warts, or scar tissue that feel irregular
• Recent surgery, radiotherapy, inflammation, or infection
• A lesion that is small, flat, soft, or beyond the finger’s reach
• Differences in examiner training and experience

Recent use of an enema or suppository may cause temporary irritation. Tell the examiner if you have used one, but routine bowel preparation is not recommended for DARE.

There is no single well-established figure for how often DARE finds or misses anal cancer. Accuracy changes with the size, position, and texture of the abnormality, as well as the examiner’s experience.

DARE is better at finding a firm lump or clear area of thickening than a small or flat lesion. It may therefore say that nothing concerning was felt even when abnormal cells are present. This is why it should not be used as the only test when symptoms continue or when a screening programme recommends anal cytology or high-resolution anoscopy.

The exam can also identify a change that feels concerning but is not cancer. Haemorrhoids, inflammation, scar tissue, and benign growths can produce an abnormal examination. A biopsy is the test that determines whether suspicious tissue contains cancer cells.

Anoscopy is better for directly viewing the anal canal. High-resolution anoscopy is generally the more appropriate test for locating anal precancer after an abnormal screening result. Colonoscopy examines farther into the bowel but is not a replacement for a focused anal examination.

DARE is generally low risk. It may cause brief discomfort or pressure, and minor bleeding can occur if tissue is already irritated or fragile.

Significant injury is uncommon. Tell the examiner immediately if you feel sharp or severe pain so the examination can be stopped.

If the examination is normal and your symptoms settle, no further testing may be needed. Screening follow-up, when applicable, is based on the programme you attend and your individual risk factors.

Arrange routine follow-up if symptoms continue, return, or change despite a normal examination. Persistent bleeding, a new lump, ongoing pain, discharge, or altered bowel habits may require anoscopy, imaging, or referral to a colorectal specialist.

Seek prompt medical assessment for worsening anal pain with fever, swelling, or pus, as this may indicate an infection or abscess.

Seek emergency care for heavy or continuing bleeding, fainting, severe weakness, or black, tar-like stools. These are not expected effects of DARE and may indicate bleeding elsewhere in the digestive tract.

Can I drink coffee before a DARE?

Yes. Coffee does not affect the examination, and fasting is not needed.

Does the time of day matter?

No. The examination can be performed at any time. You may prefer an appointment when you are less likely to feel rushed or anxious.

Can I exercise beforehand?

Yes. Exercise does not alter what the examiner can see or feel. If exercise worsens your pain or bleeding, tell the healthcare professional.

Do I need an enema or bowel preparation?

No. Routine bowel preparation is unnecessary and may irritate the area. Using the toilet beforehand is optional.

Will the examination hurt?

You may feel pressure or mild discomfort, but severe pain is not expected. Existing fissures, inflammation, or an abscess can make the exam more painful. Ask the examiner to stop if needed.

Can I have the exam during my period?

Usually, yes. Menstruation does not prevent DARE, although blood may make it harder to identify the source of rectal bleeding. Tell the examiner that you are menstruating.