The anal region is subject to a number of specific diseases. Hemorrhoids (piles) are mucosal prolapse, initially occurring on straining, but in more advanced cases remaining as external lumps. They present with bleeding, perianal lumps, and the complications of thrombosis and strangulation. Rectal prolapse is extrusion of the full thickness of the rectal wall and is usually only seen in patients incapable of controlling their bowel habit. An anal fissure is a longitudinal linear ulcer across the anal margin that causes pain and spasm, and may bleed. Sepsis may present as a perianal abscess: an anal fistula is an inflammatory tract where an abscess, initially in communication with the anal canal, discharges onto the surface, producing a tract between anal mucosa and the perianal skin, usually bypassing muscular control.

A perianal hematoma (external pile) is a thrombosed subcutaneous vein that is an extremely tender lump; it fortunately soon resolves. Other perianal lesions include Crohn’s disease and malignancy of the anal canal. All these perianal lesions can produce discharge, local irritation, inflammation and pruritus (table 11). Anal warts are of venereal origin and also occur around the vulva and glans penis. AIDS sufferers are subject to additional infections, including herpes simplex virus, cytomegalovirus, Mycobacterium avian-intercellulare and candida

Pilonidal disease and hydradenitis supurativum are two other infective conditions occurring in the perineum but not of anorectal origin. The former commences in a congenital midline pit over the sacrum, between the buttocks, infection may progress to abscess formation. Hydradenitis is a chronic suppurative disease of apocrine glands, affecting the groins and extending into the perineum, it may also occur in the axillae.

Table 11 Pruritus ani

Examination of the alimentary tract is completed by examination of the perineum, including rectal, and sometimes vaginal, these examinations are usually undertaken with the subject in the left lateral position.

Rectal examination provides valuable information on pelvic organs.

Explain the importance of the procedure to the patient, who should turn onto their left side, so the pelvis is a true vertical, bringing the buttocks to the edge of the couch and drawing their knees up to their chest: ensure adequate lighting to observe the perineum. Put on a pair of disposable gloves and first lift up the right buttock to expose the anus, the back of the scrotum or the vaginal margins. Note any abnormality of the skin, protrusions from the anal canal or other lesions. Ask the patient to strain down and note any extrusion of skin or mucosa through the anus (figure 64a).

Dip your gloved right index finger into a lubricant and lubricate the anal margin. Tell the subject that you are intending to insert the finger. Rest the pulp of the finger on the anal margin and gently curl the tip into the anus (figure 64b,c). Proceed slowly and note any tenderness or spasm as the finger passes through the anal sphincter. Extreme tenderness and spasm may indicate a fissure and may prevent further examination unless carried out very slowly and very gently. Usually your finger passes easily through the sphincter into the anal canal and the lower rectum. Note any surrounding lumps or nodularity within the anal canal.

Systematically palpate the contents of the pelvis (figure 64d). First feel the hollow of the sacrum and the coccyx, this may be examined between your index finger inside and thumb outside.

Turn your hand anticlockwise round the left side of the pelvis to examine anteriorly (figure 64e). In a normal prostate, the groove between the two lateral lobes is palpable. The seminal vesicles lie above this but are not usually palpable. The tip of your finger, however, is touching the peritoneum of the pouch of Douglas, through the wall of the rectum, and detects abnormalities within the pouch, including the tenderness of pelvic peritonitis.

Rotate your finger to examine the right side of the pelvis and ask the patient to strain down as your finger negotiates the lower rectum to note any abnormality of the wall.

Further information may be obtained by bimanual examination, your left hand palpating the lower abdomen (figure 65).

 

 

 

The vagina lies anterior to the rectum. The rounded firm cervix with a central canal can be felt through the rectal wall. Lean over the patient and rest your left hand over the suprapubic region to examine the pelvis bimanually, when it may be possible to assess the shape and size of the uterus, and any associated abnormalities.

Note any tenderness in the fornices, suggesting pelvic inflammatory disease. The ovaries lie on the lateral wall and are not usually palpable but may become so in the presence of an ovarian cyst or other pathology.

Note the presence of fecal material in the rectum and, on removal of your finger, note the consistency of this material and the presence of any blood or mucus on the glove, before disposing of it. Clean the anus with toilet paper then ask the patient to return to the supine position.

Abnormal findings may lead to further examination by proctoscopy, sigmoidoscopy or colonoscopy.

Vaginal disorders include venereal and non-venereal infection and the late sequelae of child-birth – cystoceles, rectoceles and procidentia.

Vaginal examination should only be undertaken with prior consent, with a chaperone and with full privacy; it is usually in an obstetric or gynecological clinic; it does not form part of a routine abdominal examination.

The examination may be carried out in the left lateral position, but is usually in the supine position, with bent knees and abducted hips. The patient should empty her bladder before the examination.

Initial examination is of the vulva and introitus (figure 66); a good light is essential. Examine the anatomy, hair distribution, skin condition, swellings, discharge, bleeding and organ prolapse, at rest and on straining.

Gloved right ring and middle fingers palpating and fixing cervix; for uterus to be palpated by the abdominal hand

Digital examination must be unhurried and gentle, and wearing surgical gloves; explain to the patient what you are going to do at each stage, and develop a set and reliable routine. Initially insert a single digit and a second only if accommodated.

A bivalved speculum is usually introduced, having excluded any obstruction and determined the size of instrument required. Observe the shape and colour of the cervix, and any discharge. Note any cervical abnormality and take a swab and smear. In the latter, know the details of the package you are going to use, read and follow the full instructions, have all the apparatus you need laid out ahead of time and ensure the required patient details are on the specimen.

Bimanual examination provides information on the cervix, uterus and adnexia (the fallopian tubes and ovaries). The normal cervix is firm to palpation (the consistency of the cartilage of your nose), but it softens in pregnancy to the consistency of your lip. Determine whether the uterus is ante- or retroverted (figure 67; it may be difficult to palpate if

the latter. Note the size, shape, consistency and other abnormalities, including associated discomfort.

The adnexia are normally impalpable, except in very thin individuals (figure 68). If palpable, determine the shape and size and features of any mass, and tenderness. The final part of the examination is palpation of the pouch of Douglas, to identify any intraperitoneal abnormality, as with a rectal examination.

Pain and tenderness must be kept to a minimum in the examination, but they are an important physical sign of pelvic inflammatory disease and some disorders of pregnancy. Your technique must be gentle enough to differentiate between discomfort from the examination and existing pathology.

On completion of the examination, provide the patient with appropriate tissues and privacy to rearrange her clothing.

Pain and tenderness must be kept to a minimum in the examination, but they are an important physical sign of pelvic inflammatory disease and some disorders of pregnancy. Your technique must be gentle enough to differentiate between discomfort from the examination and existing pathology.

On completion of the examination, provide the patient with appropriate tissues and privacy to rearrange her clothing.

1. Symphysis pubis

2. Emptied bladder

3. Anteverted uterus

4. Rectum

5. First coccygeal vertebra

1. Normal ovary: not palpable, but the subject’s left hand (with its side resting on the anterior superior iliac spine) indicates the normal ovarian position

2. Abnormal ovary may be palpable bimanually: gloved fingers placed in the fornix of vagina, the other hand palpating the abdomen