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Proctological Examination

Groups Safety First Product Data Urethral Insertion Rectum & Anus Circumcision Miscellaneous This group [ Proctological Examination ] [ The KleenSpec Sigmoidoscope ] [ Enema Tank ] [ Flow Meter ] [ Vaginal Specula in Rectum ] [ A Lab Visit ]

from a Welch Allyn publication of an unknown date Text prepared by  George  D. Vaughn, M. D. Medical College of Virginia, Richmond Editor's Notes Several sections of the original publication dealing with pathology have been removed because they were not out of the scope of this page. The definitions are the editors. If you engage in rectal play you are strongly urged to read and study this document especially the precautions. Consider how you can adapt the various steps suggested in the Examination section to your play.  Chase Union offers a variety of instruments to perform these examinations. Introduction According to the American Cancer Society, 15% of rectal cancer is now cured but as much as 75% can be cured. This difference can be made up by early detection. It is obvious that early detection can only be accomplished by the general practitioner including the proctological examination as part of his routine. The purpose of this instruction booklet is to aid the general practitioner in using this important diagnostic procedure. The anal canal, rectum and lower colon, unlike many parts of the body, may be directly viewed. When a patient presents himself with an ano-rectal complaint, it is the duty of every physician to make a thorough and complete examination. This examination has been considered by many, physician and patient alike, to be an embarrassing and repulsive procedure, yet there is no excuse for carelessness or its omission. Existing pathology is overlooked more often through failure of examination than through lack of knowledge of the ano-rectal and colonic areas. Two false ideas that are common among doctors today are that a cursory digital exploration constitutes an adequate examination and that expensive, complicated equipment is necessary to perform the examination. Neither of these is true. Digital examination is a necessary and valuable aid in proctologic examinations but in many instances only locates the grossest of pathology. In addition to a sensitive finger the physician needs some sort of an endoscopic instrument. There are many such instruments available, but probably the type most useful is one which carries its own light, thus being readily available for the general practitioner in his routine practice. Patient History It is imperative that an accurate history be taken. This need not be long and involved but should cover certain salient points, such as bowel habit, bleeding, protrusion, pain, swelling, itching and discharge. Examination For the sake of completeness the following order is suggested: (A) Palpation  This portion of the examination is frequently overlooked but in reality is a valuable adjunct in arriving at a correct diagnosis. Areas of induration, fluctuation and pain on superficial or deep pressure should be noted. Subcutaneous fistulous tracts may be found in this manner. (B) Digital Digital examination should always precede anoscopy. The patient is best placed in the lateral Sims position on a flat table with his right hand retracting the right buttock as an aid to the examiner. The patient should be reassured at this point that the examination will be uncomfortable but should not be painful. With the right index finger sheathed in a rubber glove and the left hand retracting the left buttock, the examining finger is gently inserted into the anal canal. Any unusual change in tone of the sphincter muscle is noted first. The finger is then swept over the complete circumference of the anal canal and lower rectum, noting any areas of induration or swelling, loss of continuity of the sphincter muscles, or unusual masses that may be encountered. Internal hemorrhoids can rarely be felt. The finger is then advanced as far as possible seeking any other pathology that may be present. The coccyx, cervix and prostate are readily palpable through the rectal wall. If there is a mass or induration in the rectovaginal wall, a bimanual examination is indicated and the involved area can be palpated between the two examining fingers. (C) Anoscopy Anoscopic examination is best accomplished by placing the patient in the lateral Sims position with the patient retracting the right buttock with his right hand and the examiner using his left hand to retract the left buttock. With the patient remaining in the Sims position, the tip of the anoscope should be well covered with a water soluble lubricant, and the instrument firmly but gently pressed into the anal canal while being slowly rotated. (Figure 1) It is usually best to pass the scope its full depth before the obturator is removed, and the examination carried out as it is slowly withdrawn. ((Figure 2) (D) Sigmoidoscopic Click on picture for full size in new window. Sigmoidoscopic examination is a means of diagnosis that is available to every physician. Observance of a few simple rules of procedure and caution will enable any examiner to complete a satisfactory examination. The type of instrument best suited for this procedure is approximately ten inches long and one half to one inch in diameter. It should be equipped with distal illumination with a removable magnifying lens in the proximal end. As well as magnifying all structures under observation, this window has the advantage of closing the instrument so that air may be used to balloon the bowel, and thus allow it to be advanced under direct vision. A sigmoidoscope of small caliber is frequently helpful in examining a patient with a particularly painful anal canal or in passing through a stricture of the anus or rectum. A sigmoidoscope with a built-in smoke removal tube greatly facilitates visibility when smoke is created in using electrical cutting instruments. Preparation of the Patent It is recommended that ten minutes prior to examination the patient be given an enema. (There are disposable enema containers that are economical, easy to use, painless to the patient and entirely practical in accomplishing the objective desired.) Position of the Patient It is important that the patient be placed in a comfortable, and as nearly relaxed position as possible. Inverted  Position This is the position most commonly used by proctologists, principally because of its convenience. The inverted position consists basically of placing the patient in a "jack-knife" attitude over a table that is constructed in such a manner that it will break in the center. Sims Position This position is seldom used for a sigmoidoscopy although it may be indicated in very obese or seriously ill patients. Knee-Chest Position This position is by far the most satisfactory for the physician whose type of practice does not warrant the use of one of the specially constructed inversion tables. The patient is told to kneel on the table with the knees about 6 inches apart, and to place his left shoulder and left side of his face on the table in front of him. The thighs should be perpendicular to the table and the back allowed to sag so that it is concave. "Sims" Procedure The sigmoidoscope should be slightly warmed and well coated with a water soluble lubricant. A. First Step. With the buttocks separated and the obturator in place the sigmoidoscope is pressed firmly against the anal aperture and directed toward the umbilicus (Fig. A). When it is felt that the tip is well inside the sphincter (approximately 6 cm.), the obturator is withdrawn and the lens put in place. From this point on, the sigmoidoscope should be advanced only under direct vision . Should the examiner encounter enema water or very soft feces, there is now available a specially designed suction tube that may be attached either to an electric or faucet suction pump. The removal of this extraneous material will greatly facilitate clear visualization of the bowel wall. B. Second Step. The proximal end of the instrument is then lowered so that the distal end follows along the hollow of the sacrum. (Fig. B) The valves of Houston (usually three in number) are encountered in this area and by manipulating the tip of the sigmoidoscope the superior faces of these valves should be thoroughly inspected. It is sometimes necessary to partially inflate the bowel in this region in order to clearly view all parts. C. Third Step. Upon advancing the instrument past the valves of Houston the tip is again directed anteriorly in order to clear the sacral promontory. At this level the tip of the instrument is in the sigmoid colon which may be recognized by the presence of mucosal folds or rugae. (Fig. C) The height to which the sigmoidoscope may he passed depends upon the flexibility of the bowel and the dexterity of the examiner. At no time must undue pressure be applied in order to reach a higher level. Frequently, a better inspection of the bowel wall may be carried out as the instrument is slowly withdrawn. Any pathologic process that is found should be accurately measured by noting its distance from the anal aperture by means of the calibrated scale on the outside of the sigmoidoscope. (When the doctor finds it necessary to use short-wave diathermy or an electrosurgical machine providing a cutting current in the treatment of a condition, he will find it to be a great aid to use a sigmoidoscope constructed with a build -in smoke tube. The smoke tube makes it possible for the doctor to use the cautery without interruption due to the smoke obscuring visibility.) Precautions in Sigmoidoscopy The sigmoidoscope should never be introduced without first performing a digital examination. In the event that a stenosis or painful lesion is encountered, an instrument of smaller caliber should be available. After the sphincter muscles have been passed, the sigmoidoscope should never be advance except under direct visualization. (If a bolus of feces or any seepage obscures adequate visibility, it can be easily removed by on of two methods. First, by the introduction through the sigmoidoscope of a wad of gauze with the aid of alligator forceps. Second, and by far the easiest and most practical method is to introduce a jet of water through the sigmoidoscope into the area where visibility is impaired in order to soften the feces and then to remove the same by use of a suction tube. This latter technique is now becoming generally recognized as standard procedure with every sigmoidoscopic examination.) The mucosal folds must not be forced out of the way but should be gently teased and with the aid of air pressure be passed without trauma. Rupture of the bowel by improper use of the sigmoidoscope will result in serious and often disastrous consequences. Shorter length rectal instruments, usually known as proctoscopes, are generally used in the treatment of conditions beyond the sphincter muscle but yet not more than six inches within the rectal cavity. Pathological conditions in this area may be treated through the longer sigmoidoscope but most doctors find it to be a convenience to do so through the shorter length instrument. Infant proctoscopes are available for use in pediatrics but are more commonly used in adults where painful lesions may be encountered. In such cases the infant proctoscope will not only minimize any distress to the patient but will many times prevent irritation to the troubled area. One should never rely on x-rays for rectal lesions as these lesions are frequently difficult to demonstrate by this method. (E) Abdominal Examination The inguinal regions should be carefully palpated for tender or swollen lymph nodes. The presence of such nodes may indicate gross infection or metastasis from lesions in the anal canal. The abdominal viscera must be examined, particularly, for nodular enlargement of the liver or palpable masses located along the course of the large bowel. Biopsy The removal of tissue for microscopic examination is the most reliable method of identifying a specific pathology. Its greatest field of usefulness is in positively recognizing and grading a suspected malignant growth and it is advocated routinely in these conditions. Technique: The biopsy is usually performed with the patient in the knee-chest position. The sigmoidoscope is gently introduced until the suspected area is plainly in view. The area is cleansed with a cotton swab and the biopsy forceps introduced through the instrument. A generous portion of the suspected pathology is removed and placed in a fixing solution of formalin. (This may be done with a minimum of discomfort to the patient and without any local anesthetic.) It is important to remove one portion from the edge of the suspected area and another from the center. If a specific organism is suspected, the portion removed should be placed in a suitable culture medium. Conclusion Anal, rectal, and colonic diseases do not make good "after-dinner conversation," consequently, in most instances, the patient has allowed his condition to assume gross proportions before seeking the advice of his physician. Therefore, a correct diagnosis is readily obtained if the physician will only take the time and trouble to make a complete and thorough examination. It is still thought by many that a great deal of dexterity and special training are necessary to insert the anoscope and sigmoidoscope. This is a fallacy that should be quickly discarded. The routine use of these instruments by the practicing physician is a simple technique and will uncover early and unsuspected pathologic areas and gain for himself the satisfaction of a complete examination, well done. Over a period of many years, physicians have added to their armamentarium of diagnostic instruments they would not dare be without. The anoscope and sigmoidoscope must now be accepted as valuable diagnostic aids in any thorough physical examination.

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