Rectal examination – preparation and course. Changes in the anus area

Proven content

Rectal examination is a very important part of the physical examination and should not be omitted for no apparent reason (approximately 30% of colorectal cancers lie within 20 cm of the anal canal and at least some of them can be found on a rectal examination).

Per rectum examination – preparation for the examination

Rectal examination is not pleasant, but explaining the purpose of the examination to the patient and carrying it out in conditions that ensure intimacy favor its acceptance by the examined person. If the test is performed on a woman, the examiner should ask a nurse or a student to be present during the test.

Immediately before the rectum, the patient should be asked to relax and warned about the possibility of feeling the pressure on the stool during the examination, as well as the urge to urinate during the palpation of the prostate gland in men. The anal area must be properly lit. If there is a large amount of stool in the rectal void, the examination should be resumed after passing the stool.

The course of the per rectum examination

1. A right-handed (left-handed) person examines the patient lying on the left (right) side.
2. During the rectal examination, the patient should lie on a flat couch with the legs bent at the hip and knee joints and the spine as flexed as possible. The buttocks are placed on the edge of the couch. The examination can also be performed in the knee-elbow position. It is also possible to perform the examination in the supine position with the lower limbs bent at the hip and knee joints, and the feet placed on the surface of the couch.
3. The subject is covered with a sheet.
4. The examiner uses disposable gloves, applying petroleum jelly or lignocaine ointment at room temperature to the index finger.

What is a Rectal Examination?

The rectal examination consists of viewing the rectal area and the actual examination by right. After lifting the right buttock with the left hand, the area of ​​the anus is examined. The color and surface area of ​​the skin around the anus are assessed. For rectal examination, the index finger of the right hand is placed on the front edge of the anus, and then gently pressed, the finger is inserted into the anus. The subject may be asked to breathe into the lungs and hold the breath for a short time in order to facilitate the insertion of the finger. A request to tighten the anus allows the tension of the external anal sphincter to be assessed, and the command to press the stool allows for the diagnosis of rectal prolapse.

Rectal examination begins with an assessment of the diameter of the anal canal and the mucosal surface area that lines the canal. The presence of a fissure, anal canal inflammation or internal varicose thrombosis may make the examination impossible due to the great soreness. In this case, you can administer an analgesic suppository before the examination or perform a short-term intravenous sedoanalgesia test (participation of an anesthesiologist!).

Anal canal stricture, sometimes to a diameter that makes it impossible to insert a finger, occurs in anal cancer, post-surgical fibrosis, and in the course of inflammatory bowel disease (especially Crohn’s disease).

Changes in the anus area

In skin vitiligo, discoloration of this area of ​​the body is often found. Discoloration is typical, among others. for the Peutz-Jeghers syndrome. Redness and superficial epidermal defects (blemishes) are typical of chronic irritation in this area, which occurs in patients with diarrheal syndromes. Other pathological changes in this area include:

1. rectal varices (external hemorrhoids with or without evidence of thrombosis),
2. condylomas (hard and uneven ridges) and perianal fistulas, which may be part of inflammatory bowel disease, especially Crohn’s disease (Fig. 32).

Gently squeezing the area around the mouth allows you to evaluate the purulent, fecal or serous content flowing out of the fistula. Scars can result from surgery or the spontaneous healing of fistulas. Anal ulceration occurs in patients with syphilis and gonorrhea.

Rectal examination and hemorrhoids

Haemorrhoids (hemorrhoids) are dilated upper and lower rectal veins, which under physiological conditions form vascular cushions in the anal area. The haemorrhoids that occur in everyone are divided into internal and external. The latter are formed below the comb line and are covered with multilayered flat epithelium.

Check out the treatment of hemorrhoids

Thrombosis of external haemorrhoids can cause severe pain and bleeding. Internal haemorrhoids bulge above the crest line at 2, 6 and 10 o’clock in the supine position. These changes are structurally similar to arteriovenous malformations (they contain blood with a high degree of oxygenation). Their degree of advancement should be assessed according to the following scale:

1. grade 1 – slight;
2. grade 2 – falling out and self-draining;
3. grade 3 – falling out and draining only with a finger;
4. grade 4 – irreducible with or without complications of thrombosis. Unlike haemorrhoids, haemorrhoids are compressible, tortuous veins that run from the anal canal towards the rectum. Anal varices are a symptom of portal hypertension (they occur in about half of patients with liver cirrhosis).

Rectal examination and rectal bubble

Within the rectal void, rectal examination involves rotating the finger along the long axis of the anal canal while palpating the entire cup and adjacent structures such as the sacrum, prostate, uterus, bladder, and Douglas Bay. The cup of the rectum in a healthy person is usually empty (does not contain stool). Retention of stools suggests constipation, and loose stools are indicative of diarrhea. The rectal mucosa should be smooth and soft.

During the rectal examination, we help ourselves with the other hand, placing it on the edge of the right iliac plate in order to stabilize the patient’s position. After you feel an exophytic lesion in the rectum, it may be helpful to place your other hand flat on the skin of the middle abdomen and apply pressure to push the pelvic organs down.

The rectal examination should distinguish between small rectal nodules and polyps and lumps in the stool that allow them to crumble and separate from the rectal wall. Anal cancer is a hard infiltrate that cannot be moved against the surface. It usually covers part or all of the circumference of the rectum in a ring shape, taking the shape of a funnel tapering towards the head. In the case of malignant stricture of the proximal part of the rectum, the distal part of the rectum may be dilated (Hohenegg’s symptom).

In front of the rectal bulb is the prostate gland in men. The prostate gland is assessed for its size, surface area, firmness and soreness. There are two lobes separated by an interlobar groove, the surface of the gland is smooth, its consistency is cohesive, and the pressure does not cause pain.

In women, the cervix or the uterine body in retroflexion is examined at this site. A tampon inserted into the vagina may be mistaken for a tumor of the cervix. Douglas Bay, located between the anterior wall of the rectum and the posterior wall of the uterus or bladder, is a site of fluid accumulation and an abscess or neoplastic infiltration. In inflammation of the appendix, intense pressure soreness of the rectal wall located closest to the appendix is ​​observed.

At the end of the test, the patient should be rubbed on lignin and the glove surface of the examining finger should be inspected for stool color and signs of blood, pus, mucus, or parasites. If rectal bleeding is suspected, the stool obtained during the examination may be sent for occult blood testing.

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