What position do you place the patient in to assess perineum?

September 23, 2025 •

4 min read

Proper patient positioning is critical for a safe and accurate medical examination, with different positions offering distinct benefits depending on the assessment type. Understanding what position do you place the patient in to assess perineum is essential for ensuring both effective diagnosis and patient comfort.

Quick Summary

Assessing the perineum often involves placing the patient in the lithotomy, Sims', or knee-chest position, with the choice depending on the specific examination and patient needs. Proper positioning is crucial for visibility, patient dignity, and effective diagnosis.

Key Points

Lithotomy Position: Used for pelvic exams and childbirth, involves the patient lying on their back with feet in stirrups, providing optimal view of the female perineum.
Sims' Position: A side-lying position where the patient's upper leg is bent, ideal for rectal exams and immobile patients, as it relieves pressure on the sacrum.
Knee-Chest Position: An alternative prone position that offers the best visualization for anorectal exams, though some patients may find it uncomfortable.
Trauma-Informed Care: Always explain the procedure, use respectful language, and obtain consent to ensure patient dignity and comfort during a sensitive examination.
Consider Patient Needs: Factors like obesity, limited mobility, or specific areas of concern may require alternative positions or modifications, emphasizing a personalized approach.
Prioritize Comfort and Safety: Use proper draping and padding in all positions to protect patient privacy, prevent nerve injury, and minimize discomfort during the procedure.

Why Proper Positioning is Essential

Accurate assessment of the perineum is vital for diagnosing a wide range of conditions, from skin infections and lesions to pelvic floor issues and hemorrhoids. The perineum is the area between the anus and the scrotum or vulva. Proper positioning is not just a clinical requirement for visualization; it is also a fundamental aspect of patient-centered care, ensuring comfort, safety, and respect for privacy. Different medical procedures and patient limitations necessitate various positioning techniques, all designed to provide the examiner with the best access while minimizing patient discomfort or risk.

The Primary Positions for Perineal Assessment

Several standard positions are utilized in medical practice for perineal examination. The choice depends on the patient's sex, the specific area being examined (e.g., vaginal vs. rectal), and the patient's physical limitations.

The Lithotomy Position

This is one of the most common positions used for female pelvic and perineal examinations, as well as during childbirth.

How to position: The patient lies on their back (supine) with their hips and knees flexed. Their feet are placed in stirrups, and their buttocks are moved to the edge of the examination table.
When to use: This position provides excellent visualization of the female genitalia and anterior perineum. It is also used for procedures involving the bladder and rectum.
Considerations: Proper padding is crucial to prevent nerve compression and pressure injuries. Draping should be used to minimize unnecessary exposure and protect patient dignity.

The Sims' (Lateral Decubitus) Position

Also known as the left lateral Sims' position, this is a side-lying posture commonly used for rectal exams and with patients who cannot tolerate the lithotomy position.

How to position: The patient lies on their left side, with their left leg straight and their right hip and knee bent and brought up towards the chest.
When to use: The Sims' position is ideal for administering enemas, performing rectal examinations, or assessing the perineum in patients with mobility restrictions.
Considerations: This position relieves pressure on the sacrum and hips, making it more comfortable for some patients. It provides good access to the rectal area.

The Knee-Chest (Proctologic) Position

This position offers superior access for examining the rectum and posterior perineum, and is the preferred position for procedures like anoscopy.

How to position: The patient kneels on the examination table and then leans forward, resting their upper body and face on the table. The buttocks are raised, and the knees are pulled up towards the chest.
When to use: This is specifically designed for proctologic and rectal exams, offering the best visualization of the anorectum.
Considerations: Some patients may find this position embarrassing or difficult to hold. The examiner should be sensitive and provide clear instructions and reassurance.

A Comparison of Perineal Assessment Positions


Position	Primary Use Case	Patient Population	Best for	Considerations
Lithotomy	Female pelvic/perineal exam, childbirth, urology	All patients who can tolerate it	Female genitalia, anterior perineum	Use padding to prevent nerve injury; requires specific table setup
Sims'	Rectal exam, enema administration	Immobile, elderly, or bedridden patients	Rectal area, posterior perineum	More comfortable than knee-chest for many patients
Knee-Chest	Proctologic exam, anoscopy	Patients requiring deep rectal access	Rectum, anus, posterior perineum	Can be uncomfortable or embarrassing; offers optimal visualization
Standing/Leaning	Male prostate and rectal exam	Ambulatory male patients	Prostate, perianal area	Requires patient cooperation; less stability than table-based positions

Key Considerations for Proper Positioning

Proper patient positioning extends beyond simply moving the body; it involves a holistic, patient-centered approach.

Trauma-Informed Care

Healthcare professionals should always approach perineal assessments with sensitivity, especially given the potential for patient vulnerability and prior trauma. This involves:

Explaining every step of the procedure and obtaining verbal consent.
Using respectful, non-triggering language.
Offering a chaperone to be present during the exam.
Ensuring the patient feels in control and can stop the procedure at any time.

Patient Dignity and Privacy

Maintaining privacy is paramount. Effective draping techniques and ensuring curtains or doors are closed create a respectful environment. A medical provider should only expose the necessary area for the shortest possible time.

Adaptations for Patient Needs

Medical providers must be flexible and adapt to the patient's individual needs. For instance, a patient with severe obesity may be better examined in the lateral decubitus position, which has been shown to improve visualization of the cervix. Similarly, patients with joint issues or limited mobility may require alternative positioning or assistive devices.

Procedural Steps for Assessment

Regardless of the position chosen, the process of a perineal assessment follows a general protocol.

Preparation: Gather all necessary supplies, including gloves, adequate lighting, and a drape.
Explanation and Consent: Explain the procedure to the patient and secure their verbal consent.
Positioning: Assist the patient into the chosen position, ensuring they are stable and comfortable.
Draping: Cover the patient, exposing only the perineal area.
Inspection: Inspect the perineum for skin changes, discharge, lesions, hemorrhoids, or other abnormalities.
Palpation: Gently palpate any identified abnormalities to assess consistency, tenderness, and size.
Conclusion: Cover the patient and provide post-procedural care, then document the findings.

Conclusion

While the lithotomy, Sims', and knee-chest positions are the most common options, healthcare providers must understand the nuances of each to determine the most appropriate choice for the patient and the specific assessment required. The ultimate goal of a perineal examination is not just to gather clinical information, but to do so with the utmost respect for the patient's dignity, comfort, and safety. A personalized approach, guided by a thorough understanding of positioning techniques, ensures the best possible outcome for both the patient and the provider.

For more detailed information on examination techniques, including the rectal examination, you can consult sources such as the NCBI Bookshelf article on Clinical Methods: The Rectal Examination, which provides comprehensive procedural guidance and discusses various positions (https://www.ncbi.nlm.nih.gov/books/NBK424/).

Frequently Asked Questions

For male patients, assessing the perineum can be done in a variety of positions. For a prostate or rectal exam, the patient may be asked to stand and lean over an examination table or assume the Sims' (side-lying) position.

Yes, the Sims' position is a very effective and common way to assess the perineum, particularly for rectal or perianal examinations. It is especially useful for patients who are bedridden, elderly, or have mobility issues.

The lithotomy position is the most common position for a standard pelvic exam in females. In this position, the patient lies on their back with feet supported by stirrups, allowing the healthcare provider clear access to the perineal and pelvic areas.

The knee-chest position, while providing optimal access for anorectal exams, can be uncomfortable for many patients. Healthcare providers should always ensure the patient's comfort and dignity and provide clear communication and reassurance throughout the process.

For patients with limited mobility, the Sims' (side-lying) position is often the best choice, as it is easier to assume and hold than the lithotomy or knee-chest positions. Proper padding and support should be used to maximize comfort and prevent pressure injuries.

The lithotomy position involves the patient lying on their back with knees flexed and supported, typically for gynecological and pelvic exams. The Sims' position is a side-lying position with one leg bent, used primarily for rectal exams or patients with limited mobility.

For a perianal exam, the proctologic (knee-chest) position provides the best visualization of the anal and rectal areas. However, the Sims' position is also a common and often more comfortable alternative for inspecting the perianal region.