Indications for rectal examination

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• Alimentary problems. All 'acute abdomens', suspected appendicitis, pelvic abscess, peritonitis and lower abdominal pain. Diarrhoea or constipation: mucus or blood in stools. Anal irritation or pain; tenesmus or rectal pain. Bimanual examination of a lower abdominal mass. In ihe search for tumours or transperitoneal metastases either diagnostically or in making a decision about treatment.

• Genitourinary problems. Assessment of the prostate in men with symptoms of prostatism (p. 155) or suspicion of prostatic carcinoma. Dysuria, frequency, haematuria. Epididymo-orehitis and in lieu of vaginal examination in patients where this would be inappropriate.

• Miscellaneous problems. Patients with unexplained backache, lumbosacral nerve root pain, unexplained bone pain or iron-deficiency anaemia. In all cases of pyrexia of unknown origin or unexplained weight loss.

Spasm of the external anal sphincter is commonly due to anxiety, but when associated with local pain, it is likely to be due to an anal fissure and a local anaesthetic suppository should be used before a satisfactory examination can be undertaken.

Examination sequence

□ Position the patienl in the left lateral position with the buttocks at the edge of the couch, the knees drawn up to the chest and the heels clear of the perineum.

□ Reassure the patient and explain that the examination may be uncomfortable but should noi be painful.

□ Lubricate the examining index finger, protected by a suitable glove.

□ Examine the perianal skin in a good light looking for evidence of skin lesions, external haemorrhoids or fistulae.

□ Place Ihe lip of the forefinger on the anal margin and with steady pressure on the sphincter pass the finger gently through the anal canal into the rectum (Fig. 5.22).

□ If anal spasm is encountered, ask the patient to breathe out and relax. If anal spasm is present with anal pain, use local anaesthetic jelly before trying again. Ifpain persists, an examination under general anaesthesia may be necessary.

□ Ask the patienl to squeeze the examining forefinger with the anal sphincter, and note any weakness of sphincter contraction.

□ Palpate around the entire rectum: note any abnormality and examine any mass systematically.

□ Note the percentage of the rectal circumference involved by disease and its distance from the anus.

□ Identify the uterine cervix in women and the prostate in men; assess size, shape, consistency, and note any tenderness elicited.

□ Perform bimanual examination if necessary, using the other hand laid Hat over ihe lower abdomen.

□ Repeat the examination after the patienl has defecated if in doubt about palpable masses.

□ After withdrawal, examine the linger for stool colour and the presence of blood and mucus.

□ Test the stool sample for blood using a 'Haemoecult' test card.

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