You are on page 1of 57

Anorectal Examination

By

Dr Hemant D Toshikhane MS(AY.) PROF & HOD DEPT OF SHALAYATANTRA KLEU SHRI BMK AYURVEDA MAHAVIDAYALAYA SHAHAPUR, BELGAUM drhemantt@gmail.com

COMMON PROBLEMS
Per rectal bleeding,

Pain,
Constipation,

Mass in or out side of the anal canal


Anemia

Common conditions
Haemorrhoids, Fissure in ano, Fistula in ano,

Anal polyp,
Proctitis, Pilonidal sinus, Rectal prolapse, Neoplasia of anal canal and rectum.

Rectal Anatomy

Common ailments- Structures Elderly ailments

Anal canal - Haemorrhoids, Fissure in ano, Fistula in ano, Incontinence, Stricture and Anal growth

Rectum - Proctitis, Fistulous communication, Rectal prolapse and Carcinoma


Perineum- Perianal abscess, Gluteal sinus, Pilonidal sinus

History
Principal symptoms of rectal and anal conditions:
Bleeding Pain Tenesmus Change in bowel habit Change in the stool Discharge pruritis

DIAGNOSTIC APPROACH
History (Prashna) Physical examination (Darshana, Sparshana)

Investigations

Age

History

Hemorrhoids common all ages but are uncommon below the age of 20 years. Perianal haematomata occurs at all ages

Fissure-in-ano-(acute) quite common in children


Anorectal abscess common between the ages of 20 and 50 years. Pilonidal sinus rare before puberty and in people over 40 years.

History - Bleeding
Can be fresh or altered
Example of altered is melaena Black tarry stool

Recognizable blood may appear in four ways:


Mixed with feces On the surface of the feces Separate from the feces: after/unrelated to defecation On the toilet paper after cleaning

History
Sex Hemorrhoids-

common in both sexs


Perianal haematomataoccurs at all ages Fissure-in-ano-

common in men
Anorectal abscessmore common in men Pilonidal sinus-

more common in men


Prolapse of rectummore common in women

History - Bleeding
Diagnosis of anal conditions which present with rectal bleeding

Bleeding but No pain:


Blood mixed with stool = ca of colon Blood streaked on stool = ca of rectum Blood after defecation = hemorrhoids Blood and mucus = colitis

Bleeding + pain = fissure or carcinoma of anal canal


The most common causes of rectal bleeding in patients who visit primary care physicians are hemorrhoids, fissures and polyps.

History Anal pain


A nagging, aching discomfo rt careful

history focusing on the nature of the pain and its relationship to defecation The pattern of pain helps differentiate anal fissure from hemorrhoids and other conditions. (hemorrhoids and rectal cancer are usually not painful)

Anorectal pain that begins gradually and becomes excruciating over a few days with localized are of tenderness is more likely to be

abscess.
made worse by defecation could be due to

piles.

An occasional, severe, cramp-like pain deep in the anal canal, that often occur at night, lasting about half an hour
proctalgia fugax. Proctalgia fugax pain is excruciating and may be accompanied by sweating, pallor and tachycardia. Patients experience urgency to defecate, yet pass no stool.

A knife-like pain when you have your bowels open, and which may last for 1015 minutes afterwards. often described like 'passing glass'. In addition to the pain, some bright red blood on the toilet paper is noticed. Anal fissure.

History Anal pain


Diagnosis of anal conditions which present with pain
Pain alone
Fissure ( pain after defection) Proctalgia fugax (pain spontaneously at night) Anorectal abscess

Pain with bleeding


Fissure

Pain with a lump


Perianal haematoma Anorectal abscess

Pain, lump and bleeding


Prolapsed hemorrhoids/rectum Carcinoma of the anal canal

Anorectal examination
One of the most important examinations in a patient with abdominal disease. Still its the least popular segment of the entire physical examination.
Should not be omitted from your examination, especially in middle-aged and older patient, why?
risks missing an asymptomatic carcinooma

Can be done in numerous positions:


Left Lateral (Sims) position. The usual position when the patient is in bed. Turn patient on to left side with pelvis vertical. Ask patients to draw knees up to chest with buttocks on the side of the couch The Knee-elbow position. Patient kneeling on couch, resting on elbows, of particular use when palpating the prostate and seminal The Dorsal Position. This position with the patient lying on the back with right leg flexed is useful when the patient is in severe pain, and movement is contra-indicated. Enables assessment of rectovesical pouch in abdominal emergencies. Lithotomy. best position for examination but not always available.

Anorectal examination
Things never to be forgotten

Explain necessity of procedure and reassure the patient Explain the procedure Tell the patient that is usually uncomfortable but not painfull Get informed consent Ensure adequate privacy

Expose the patient from waist to knee and explain the position of examination.
Equipment: plastic glove + lubricating jelly + good light

Anorectal examination
External inspection:
Piles. Skin tags (normal, Crohn's, hemorhoids). Rectal prolapse. Anal fissure. Fistula. Anal warts. Carcinoma. Signs of incontinence, diarrhea. Ask pt. to strain. Rectal prolapse upon straining. Hemorrhoid prolapse. Incontinence. Ask if straining is painful

External inspection (straining):

Learning Objectives
List the uses of DRE in patient care

Describe the communication skills relevant to performance of the DRE


Name 3 issues that will affect patient comfort during the exam Describe the technical skills necessary to competently perform the exam

List and explain the common physical findings of the prostate exam

Reasons to Perform the DRE


Colorectal Cancer Screening
Prostate Cancer Screening Part of a comprehensive physical exam Other rectal pathology (hemorrhoids)

Skills Checklist
Communication skills

Explaining procedures
Showing sensitivity to patient needs or responding to discomfort Talking the patient though the exam Sharing exam findings with the patient

Skills Checklist
Technical skills Positioning the patient Performing the exam Explaining exam results Arranging appropriate follow up

Qualitative Research Data


Patient: The doctor talked to me while he was doing the rectal exam and told me what he was doing, what he was finding, so that was good. So he was kind of walking me through it while he did it.

Qualitative Research Data


Patient: The way she used the bedsheet to cover me up, that was fine. She covered me up with this, so basically I was exposed only for the few seconds of the exam. That was a nice touch.

Technical Skills: Positioning the Patient


Carefully assess the patients strength and mobility before positioning him Common positions for the DRE
Modified lithotomy (patient on back, knees flexed) Sims position (for bedridden patients) Left lateral position Standing, hips flexed w/upper body on table

Ask the patient if he feels stable and comfortable before proceeding

Explaining Screening Exam Results, 2


If the DRE yields suspicious results: Explain your findings to the patient Negotiate a follow up plan for the patient
Colonoscopy
PSA and possible biopsy

Address patient concerns

Anorectal examination
Palpation
Lubricate index finger. Insert finger slowly, assessing external sphincter tone as enter. Male:

palpate prostate [anterior of rectum] Hard nodule (prostate cancer). Tender (prostatitis).

Female: Palpate cervix [anterior of rectum] Mass in pouch of Douglas .

Rotate finger, palpating along left, posterior, right walls. Withdraw finger.

Wipe lubricant off pt.


Ask if was significant pain during examination.

Anorectal examination
Inspect withdrawn fingertip for: Blood, melaena Stool color Pus Mucous. Other examination would be systemically preformed and depends on the case you have e.g swelling such as anorectal abscess or ulcers.

PROCTOSCOPIC EXAMINATION
Internal Hemorrhoids Hypertrophied Anal papillae Congestion

Bleeding points
Foreign body

The Dreaded Digital Rectal Examination

It still brings tears to my eyes!!!

PROBING
Advisable only after proper inspection and palpation. Should be done following the Goodsalls rule to avoid faulty direction. A malleable copper probe is passed into the fistula, hold it in position & forefinger of the other hand is inserted into the anal canal. Feel the tip of the probe emerging through the internal opening into the anal canal.

Acute Ano-rectal Conditions

ANORECTAL ABSCESS
An anorectal abscess is a collection of pus in the anal or rectal region Causes: Infection of an anal fissure (cleft or slit), sexually transmitted infections, and blocked anal glands are common causes of anorectal abscesses Abscesses may occur in an area that is easily accessible for drainage, or higher in the rectum. Deep rectal abscesses may be caused by intestinal disorders such as Crohn's disease or diverticulitis.

ANORECTAL ABSCESS
High risk groups include diabetics, immunocompromised patients, people who engage in receptive anal sex, and patients with inflammatory bowel disease. The male to female ratio is approx. 2:1 The most common organisms * E.coli (60%) * Staph. aureus (23%)

Common sites of anorectal abscesses

ANORECTAL ABSCESS
Symptoms and signs :
( the most common symptom) * Swelling (95% of patients) * Discharge (12% of patients) * Fever(18% of patients ) * Constipation (may occur) * Rigors ,sweating and tachycardia Complications: systemic infection, ,recurrence , scarring and anal fistula formation
* Pain

TESTS : Rectal examination , Proctosigmoidoscopy Treatment :


* Urgent

incision and drainage( the treatment of choice) * Antibiotics

Rectal prolapse
Rectal prolapse is the abnormal movement of the rectal mucosa down to or through the anal opening.

Mucosal prolapse

Complete rectal prolapse

Rectal prolapse
Mucosal prolapse is more often seen in children below 3 yrs of age following an attack of diarrhoea or whooping cough , and if it occurs in adult is usually associated with haemrrhoids. Complete rectal prolapse is seen more commonly in elderly women who have a habit of excessive straining during defecation.
Rectal prolapse is often associated with other conditions such as: * Pinworms(Enterobiasis) * Cystic fibrosis * Malnutrition and malabsorption (Celiac disease) * Constipation * Prior trauma to the anus or pelvic area

Proctitis
An inflammation of the rectum causing discomfort, bleeding, and occasionally, a discharge of mucus or pus, And the anus may also be involved. Causes:

* Sexually-transmitted diseases(gonorrhea, herpes, Syphilis ,chlamydia, and


lymphogranuloma venereum. * Non-sexually transmitted infections( Beta-hemolytic streptococcus , Amoebic dysentry, Bilharzial dysentry) *Autoimmune diseases (Ulcerative colitis and crohns disease) * Tuberculous proctitis * AIDS *Radiation Proctitis * noxious agents

Proctitis
Symptoms: pain, discomfort rectal bleeding rectal discharge, pus stools, bloody constipation Tenesmus

*Tests: proctoscopy sigmoidoscopy rectal culture

Proctitis
Treatment: treatment of the underlying cause usually cures the problem. Proctitis caused by infection is treated with antibiotics specific for the causative organism. Corticosteroid or mesalamine suppositories may relieve symptoms in Crohn's disease or ulcerative colitis.

Benign tumours of the rectum (POLYPS)


A polyp is a lesion that projects into the lumen Polyps are commonly found in vascular organs Polyps bleed easily The rectum and sigmoid colon are common sites of polyps Symptoms and signs of polyps * passage of blood and mucus PR * Rarely obstruction or intussusception

Types of Polyps
Juvenile Polyps
Commonest form of polyps in children Are red pedunculated spheres lesions Can occur throughout large bowel but are most common in the rectum Usually present before 12 years Present with Prolapsing lump or rectal bleeding Have little malignant potential Treated by local endoscopic resection

Adenomatous Polyps
Are pedunculated lesions Mainly occur in the rectum and sigmoid colon Are often asymptomatic but may produce anaemia from chronic occult bleeding May give rise to crampy pain May secrete mucus Have malignant potential Treated by colonoscopic polypectomy

Villous Papillomas
Are flat, sessile lesions within the rectum Secrete copious amount of mucus producing spurious diarrhoea Present with hypokalemia Significant risk of malignant change Treated by transanal excision of complete lesion If lesion is extensive, mucosal proctectomy and coloanal anastomosis should be done

ISCHIORECTAL ABSCESS

THANK YOU ALL

You might also like