Signs

Signs

To examine the rectum the patient is most conveniently posi- tioned in the left lateral or semi-prone (Sims) position. Inspection Visual examination of the anus precedes rectal examination to exclude the presence of anal disease, e.g. fissure or fistula. Evidence of rectal prolapse or abnormal pelvic floor descent can be elicited by asking the patient to strain. Digital examination The index finger used with gentleness and precision remains a valuable test for rectal disease ( Figure 79.2 ). The anal sphincters are assessed for anatomical integrity , resting tone James Marion Sims , 1813–1883, gynaecological surgeon, the State Hospital for Women, New Y ork, NY , USA, introduced this position to give access to the anterior vaginal wall during operations for the closure of vesicovaginal fistula. herniation of the anterior rectal wall into the vagina. Tumours in the lower and middle thirds of the rectum can usually be felt. On removal, the finger should be examined for mucus, pus or blood. It is useful to note the normal, as well as the abnormal, findings on digital examination, e.g. the prostate in the male. Digital findings can be recorded as intraluminal (e.g. blood, pus), intramural (e.g. tumours, granular areas, strictures) or extramural (e.g. enlarged prostate, uterine fibroids). Intramural lesions can be described as fixed, tethered or mobile. Proctoscopy This procedure can be used to inspect the anus, anorectal junction and lower rectum. A lubricated proctoscope is inserted through the anus to provide views of the lower rectum and anal canal ( Figure 79.3 ). Biopsy can be performed of any suspicious areas, provided it is above the sensitive anoderm. Proctoscopy is particularly useful for assessing the presence of haemorrhoids. ). Sigmoidoscopy In the past, the sigmoidoscope was a rigid stainless steel instrument of variable diameter and normally 25 /uni00A0 cm in length, but this has been replaced by disposable plastic instruments. The rectum must be empty for proper inspection. Direct inspection of the rectal mucosa may alert the clinician to inflammation or tumours. This procedure can be performed in the outpatient setting. Flexible sigmoidoscope This is used as a supplement to rigid sigmoidoscopy or when views proximal to the rectum are required ( Figure 79.4 ). The lower bowel needs to be cleaned out with preliminary enemas. In addition to the rectum, the whole sigmoid colon up to the splenic flexure is within visual reach. Flexible sigmoidoscopy

Figure 79.2 Digital rectal examination in the male. Assessment of the anal sphincter complex, lower rectum and prostate. Figure 79.3 Proctoscope for visualisation of the anorectum.

is indicated to investigate underlying causes of fresh rectal bleeding or other bowel symptoms when full visualisation of the colon by colonoscopy is not required. Summary box 79.3 Examination of the rectum /uni25CF /uni25CF /uni25CF /uni25CF

Figure 79.4 Flexible colonoscope. Visual inspection of the Proctoscopy perineum Sigmoidoscopy – rigid and/ or /f_l exible Digital examination