Transcription
The Perianal &Digital Rectal ExamWilliam D. Chey, MDProfessor of MedicineDirector, GI Physiology LabDirector, MI Bowel Control Program1
Digital Rectal Exam:Clear Indications A digital rectal examination should be performed inEVERY patient with:– GI bleeding/Rectal bleeding– Chronic constipation– Fecal incontinence– Anorectal painCash BD, et al. J Fam Pract. 2007;56(suppl):S1-S8.2
Constipation: Utility of Rectal Exam Visual inspection of perineal area:– Fissures / hemorrhoids / masses / skin tags Excoriation of perineal skin:– Fecal soiling Stroking of perineal skin:– Absence of reflex contraction indicativeof external anal sphincter neuropathy Hard stool in rectum:– Fecal impaction Assessment for dyssynergia Assessment for fecal incontinence Assessment for levator or coccygeal painLacy, MedGenMed 2005; 7: 19Rao, Gastroenterol Clin North Am 2007; 36: 687–7113
Normal Anorectal PhysiologyAt RestDefecationAnorectalAngle 90 Used with permission from Lembo A, Camilleri Sphincterrelaxes Pelvic floordescendsAngle moreObtuse4
Digital Rectal Exam:Findings in Dyssynergia During simulated defecation, failure of:– The pelvic floor to descend during observation– The anal sphincter to relax– The puborectalis to relax– The anorectal angle to become more obtuse– The abdominal wall musculature to contract– A sensation of your index finger being pushed out of the rectumTalley NJ, et al. Am J Gastroenterol 2008.5
Digital Exam for DyssynergiaDuring simulateddefecationPuborectalisrelaxesAngle widensAnal canalrelaxesPerineumdescends6
Digital Exam for ContinencePosition 1SymphysispubisInternalanalsphincterCheck anal toneat restPuborectalisExternal analsphincter (EAS)7
Digital Exam for ContinencePosition 1SymphysispubisInternalanalsphincterCheck anal toneat restAsk patient tosqueezePuborectalisExternal analsphincter (EAS)8
Digital Exam for ContinencePosition 2SymphysispubisInternalanalsphincterInsert fingerdeeper and feelpuborectalismusclePuborectalisExternal analsphincter (EAS)9
Digital Exam for ContinencePosition sert fingerdeeper and feelpuborectalismuscleAsk patient tosqueezeExternal analsphincter (EAS)10
Digital Exam - Coccygodynia Squeeze coccyxbetween forefingerand thumb Tendernesssuggestsdiagnosis11
Digital Rectal Exam: Findings in Dyssynergia Talley NJ, et al. Am J Gastroenterol 2008. 6 Angle widens Puborectalis relaxes Anal canal relaxes Perineum descends During simulated defecation Digital Exam for Dyssynergia . 7 Position 1 Check anal tone at rest Digital Exam for Continence Internal anal sphincter
