Rectal examination is an important part of the abdominal examination and genitourinary examination. It is important in examining for gastrointestinal disease but also for the detection of disease in other pelvic organs. It is an intimate physical examination which should be conducted correctly for detection of disease and patient comfort. Findings should be accurately and correctly recorded.
The rectum begins at the termination of the sigmoid colon about 12 cm from the anal verge. Two muscle bundles, known as the internal and external anal sphincters, participate in defecation. The internal anal sphincter is an enlargement of the circular smooth muscle of the colon and functions involuntarily. The external anal sphincter consists of striated muscle bands under the voluntary control of the puborectalis muscle. The rectum has the same innervation as the bladder; the hypogastric nerves innervate the internal anal sphincter, and the internal pudendal nerve (S3–S4) operates the external anal sphincter. Because of the common innervation, dysuria is a common complaint associated with rectal disorders.
An important landmark both anatomically and clinically is the pectinate line where the anus and rectum merge, approximately 3 to 4 cm from the skin. It serves as a demarcation for venous and lymphatic drainage and for the nerve supply. Above the pectinate line, the veins drain into the portal and caval systems, sympathetic nerves are present (pain is absent), and lymph drains to the superior rectal and iliac nodes. Below the pectinate line, the veins drain into the caval system alone, innervation is through somatic nerves (pain is present), and lymph drains into the inguinal nodes.
The rectum functions to permit defecation in a voluntary fashion. Peristalsis propels the stool from the sigmoid colon into the rectum. Increased intraluminal pressure causes involuntary relaxation of the internal anal sphincter followed by reflex contraction of the external anal sphincter, preventing incontinence while providing awareness of imminent defecation. The external anal sphincter then relaxes in a voluntary fashion, expelling the feces. Studies suggest that the evacuative process is facilitated by larger fecal bulk, providing an impetus for encouraging patients to consume diets high in fiber and bulk.
Indications
This is an intimate and sometimes uncomfortable examination which is most often done when disease (usually gastrointestinal or genitourinary disease) is suspected or already identified. It may also be done as part of a screening examination when there is no suspicion or expectation of disease but the examination is performed as part of a thorough screening process. It is important in all cases to explain the reasons for the examination (see below) and to get verbal consent. Examples of indications for examination include:
· Assessment of the prostate (particularly symptoms of outflow obstruction).
· When there has been rectal bleeding (prior to proctoscopy, sigmoidoscopy and colonoscopy).
· Constipation.
· Change of bowel habit.
· Problems with urinary or faecal continence.
· In exceptional circumstances to detect uterus and cervix (when vaginal examination is not possible).
Minicase
History
A 70 years old man came to the hospital with a primary complaint difficult to urinate and a feeling of not completely after urination since 3 weeks ago. Patients also feel the frequent of urinate is more often than usual. On examination the vital signs looked good. On physical examination there was no anogenital injury, no pain, no hemorrhoid, rectal touche positive prostate enlargement both lobes symmetrical, chewy, no nodule, the upper limit is not palpable, flat median sulcus, crepitation not exist. Laboratory results within normal limits. Radiology Examination withlower abdominal ultrasound impression suspicious prostatic hypertrophy
Diagnosis
Benigna Hipertrofi Prostat
Procedure
Preparing for the examination
The reasons for performing the procedure should be explained to the patient. The procedure itself should be explained to the patient. Warn patients that:
o The examination may be uncomfortable but should not be painful.
o They may experience a feeling of rectal fullness and the desire to defaecate.
o A chaperone should be offered.
Equipment:
o Suitable gloves
o Lubricant
o Lighting
o Suitable soft tissues
Position the patient comfortably
The clinical situation and experience of the examiner will often dictate which of several methods to employ in performing the rectal examination. In the lithotomy position, the patient is supine with the legs drawn in toward the trunk and the knees allowed to fall out to the side. This position is customarily used when examining the pelvic organs in women and may offer a better examination of the anterior rectum.
The lateral decubitus, or Sim's position, provides optimal examination when the patient is too ill or otherwise unable to assume other positions. The patient lies on the left side with the buttocks near the edge of the examining table or bedside with the right knee and hip in slight flexion.
The proctologic (knee–chest or prone jackknife) position is the preferred position in which to examine the perineum and rectum properly. In this position, the patient can easily undergo further studies such as anoscopy and sigmoidoscopy because of easier access to the anorectum. Regardless of the position used, the rectal examination involves both inspection and palpation.
Detail of The Procedures
Examination findings
The findings are described by convention according to the clock face in the lithotomy position. 12 o'clock is anterior and 6 o'clock posterior.
References :
Bagio, Aji. Penegakan Diagnosa pada Pasien dengan Kasus Benigna Hipertrofi Prostat. www.fkumyecase.net Last Updated 29 Sep 2010.
Draper, Richard. Rectal Examination. www.patient.co.uk Last Updated 6 Jan 2010.
McFarlane, Michael J. The Rectal Examination. www.ncbi.nlm.nih.gov
Student’s Manual Book Gastroenterohepatology System. Medical Faculty of Hasanuddin University.Makassar. 2010.
The rectum begins at the termination of the sigmoid colon about 12 cm from the anal verge. Two muscle bundles, known as the internal and external anal sphincters, participate in defecation. The internal anal sphincter is an enlargement of the circular smooth muscle of the colon and functions involuntarily. The external anal sphincter consists of striated muscle bands under the voluntary control of the puborectalis muscle. The rectum has the same innervation as the bladder; the hypogastric nerves innervate the internal anal sphincter, and the internal pudendal nerve (S3–S4) operates the external anal sphincter. Because of the common innervation, dysuria is a common complaint associated with rectal disorders.
An important landmark both anatomically and clinically is the pectinate line where the anus and rectum merge, approximately 3 to 4 cm from the skin. It serves as a demarcation for venous and lymphatic drainage and for the nerve supply. Above the pectinate line, the veins drain into the portal and caval systems, sympathetic nerves are present (pain is absent), and lymph drains to the superior rectal and iliac nodes. Below the pectinate line, the veins drain into the caval system alone, innervation is through somatic nerves (pain is present), and lymph drains into the inguinal nodes.
The rectum functions to permit defecation in a voluntary fashion. Peristalsis propels the stool from the sigmoid colon into the rectum. Increased intraluminal pressure causes involuntary relaxation of the internal anal sphincter followed by reflex contraction of the external anal sphincter, preventing incontinence while providing awareness of imminent defecation. The external anal sphincter then relaxes in a voluntary fashion, expelling the feces. Studies suggest that the evacuative process is facilitated by larger fecal bulk, providing an impetus for encouraging patients to consume diets high in fiber and bulk.
Indications
This is an intimate and sometimes uncomfortable examination which is most often done when disease (usually gastrointestinal or genitourinary disease) is suspected or already identified. It may also be done as part of a screening examination when there is no suspicion or expectation of disease but the examination is performed as part of a thorough screening process. It is important in all cases to explain the reasons for the examination (see below) and to get verbal consent. Examples of indications for examination include:
· Assessment of the prostate (particularly symptoms of outflow obstruction).
· When there has been rectal bleeding (prior to proctoscopy, sigmoidoscopy and colonoscopy).
· Constipation.
· Change of bowel habit.
· Problems with urinary or faecal continence.
· In exceptional circumstances to detect uterus and cervix (when vaginal examination is not possible).
Minicase
History
A 70 years old man came to the hospital with a primary complaint difficult to urinate and a feeling of not completely after urination since 3 weeks ago. Patients also feel the frequent of urinate is more often than usual. On examination the vital signs looked good. On physical examination there was no anogenital injury, no pain, no hemorrhoid, rectal touche positive prostate enlargement both lobes symmetrical, chewy, no nodule, the upper limit is not palpable, flat median sulcus, crepitation not exist. Laboratory results within normal limits. Radiology Examination withlower abdominal ultrasound impression suspicious prostatic hypertrophy
Diagnosis
Benigna Hipertrofi Prostat
Procedure
Preparing for the examination
The reasons for performing the procedure should be explained to the patient. The procedure itself should be explained to the patient. Warn patients that:
o The examination may be uncomfortable but should not be painful.
o They may experience a feeling of rectal fullness and the desire to defaecate.
o A chaperone should be offered.
Equipment:
o Suitable gloves
o Lubricant
o Lighting
o Suitable soft tissues
Position the patient comfortably
The clinical situation and experience of the examiner will often dictate which of several methods to employ in performing the rectal examination. In the lithotomy position, the patient is supine with the legs drawn in toward the trunk and the knees allowed to fall out to the side. This position is customarily used when examining the pelvic organs in women and may offer a better examination of the anterior rectum.
The lateral decubitus, or Sim's position, provides optimal examination when the patient is too ill or otherwise unable to assume other positions. The patient lies on the left side with the buttocks near the edge of the examining table or bedside with the right knee and hip in slight flexion.
The proctologic (knee–chest or prone jackknife) position is the preferred position in which to examine the perineum and rectum properly. In this position, the patient can easily undergo further studies such as anoscopy and sigmoidoscopy because of easier access to the anorectum. Regardless of the position used, the rectal examination involves both inspection and palpation.
Detail of The Procedures
- The examination is started from anal inspection under shiny illumination
- Observe anal tone when relaxation and volunter contraction.
- The patient is asked to strain abdominal muscles just like when defecating for examining the perineal descencus, haemoroid prolaps or other prominent lesions (rectal prolaps and tumor)
- The right index finger that use handscoen and lubricated with K-Y jelly, is contacted slowly to the anal.
- Press anal gently until sphincter is opened and the finger can be put into the anal directly
- Evaluate the rectal ampula
- Palpate the mucous and rectal filler
- Pay attention to the prostate and cervices and also several lesions outside the rectum
Examination findings
The findings are described by convention according to the clock face in the lithotomy position. 12 o'clock is anterior and 6 o'clock posterior.
- External inspection may reveal:
- Skin disease. For example, natal cleft dermatitis in seborrhoeic eczema
- Skin tags
- Pilonidal sinus
- Genital warts
- Anal fissures
- Anal fistula
- External haemorrhoids
- Rectal prolapse
- Skin discolouration with Crohn's disease
- External thrombosed piles
- Internal examination may reveal:
- Simple piles (but best examined at proctoscopy)
- Rectal carcinoma
- Rectal polyps
- Tenderness (with, for example, acute appendicitis)
- Diseases of the prostate gland
- Malignant or inflammatory conditions of the peritoneum (felt anteriorly)
References :
Bagio, Aji. Penegakan Diagnosa pada Pasien dengan Kasus Benigna Hipertrofi Prostat. www.fkumyecase.net Last Updated 29 Sep 2010.
Draper, Richard. Rectal Examination. www.patient.co.uk Last Updated 6 Jan 2010.
McFarlane, Michael J. The Rectal Examination. www.ncbi.nlm.nih.gov
Student’s Manual Book Gastroenterohepatology System. Medical Faculty of Hasanuddin University.Makassar. 2010.