Rectal Case: Examination

                                                                Ano-Rectal Case: Examination

[A] Preparation

·         Adequate privacy and uncover the patient from the waist to the middle of the thighs

·         Patient in the left lateral position with the neck and shoulders rounded so that the chin rests on the chest, hips flexed to 90° or more, but knees flexed to slightly less than 90

·         Positions

Ø  Left lateral(Sim’s)- DRE, proctoscopy

Ø  Dorsal-patient too ill, bimanual, pelvic swelling, recto-vesical, recto-uterine

Ø  Knee elbow- prostate, seminal vesicles

Ø  Right lateral- Ca at pelvirectal junction when it tends to fall downwards & towards anus

Ø  Lithotomy-lesion high in rectum, bimanual 

·         Explain the nature of examination

[B] Inspection

·         Lift up the uppermost buttock with your left hand àsee the anus, peri-anal skin and perineum

·         Look for:

■ Skin rashes and excoriation

■ faecal soiling, blood or mucus

■ scarring, or the opening of a fistula

■ lumps and bumps (e.g. polyps, papillomata,condylomata, a peri-anal haematoma, prolapsed piles, or even a carcinoma),

■ Ulcers, especially fissures

[B] Palpation

·         place fingers on either side of the anus àgently stretch the anal orifice ( to see if there is any  spasm associated with a fissure)

·         If there is spasm or a fissureà DRE should not be done

Digital Rectal examination

·         Place the pulp of your gloved right index finger on the centre of the anus, with the finger parallel to

·         the skin of the perineum and in the mid-line àpress gently into the anal canalà at the same time press backwards against the skin of the posterior wall of the anal canal  àAs the finger goes through the anal canal, note the tone of the sphincter, any pain or tenderness and any thickening or masses àTurn your finger round so that the pulp feels forwards and can detect any masses outside the rectum in the peritoneal pouch between the rectum and the bladder or uterus

·         Bimanual examination

Place your left hand on the abdomen and feel bimanually à gives much better idea of the size, shape and nature of any pelvic mass

·   Look for

o   Intralumen-hard faeces, intussception, ballooning, mass

o   Intramural-induration, ulcer, growth, stricture, mucous membrane mobility

o   Extramural

§  Anterior (male) -prostate, seminal vesicle, base of bladder, rectovesical pouch

§  Ant (female) -uterus, cervix, vagina, pouch of douglus

§  Lateral (Both) -ischiorectal fossa, lat walls of pelvis, lower end of uterus

§  Lateral (female)-ovarian cyst, fallopian tube, salpingitis

§  Posterior -coccyx, sacrum

o   Look examining finger for blood, mucous, faeces

1. The cervix and uterus

·         Bimanual palpation àdefine the shape and size of the uterus and any adnexal masses.

·         Do not call the hard mass that you can feel in the anterior rectal wall a carcinoma until you are sure that it is neither the cervix nor a tampon

2. The prostate and seminal vesicles

·         Normal prostate -firm, rubbery, bilobed and 2–3 cm across, Its surface should be smooth,with a shallow central sulcus, and the rectal mucosa should move freely over it

·         BPH -enlargement of the whole gland( bulges backwards into the rectum) ,central sulcus is usually present unless the gland is very large

·         Carcinoma of the prostate - an irregular, hard enlargement which is often unilateral associated with ‘winging’ of the prostate(lateral thickening of prostate)

[C] Proctoscopy

·         Short illuminated tube,employed to inspect the anal canal

·         It should really be called an anoscope, but is always called a proctoscope(misnomer)

·         Technique of proctoscopy

■ Position the patient as for DRE

■ No bowel preparation is necessary

■ Make sure there is no painful external pathology

■ Insert the instrument in the direction of the anal canal, pointing at the patient’s umbilicus

■ Remove the obturator and inspect the anal canal as you withdraw the instrument