8.11: Assessment of the Rectum and Anus

Evaluating the rectum and anus plays a crucial role in conducting a thorough physical examination of the gastrointestinal system. Although it may be uncomfortable and often embarrassing for the patient, it holds immense diagnostic value, particularly in detecting gastrointestinal diseases and abnormalities. This guide will explain how to perform this assessment using inspection and palpation methods.

Rectal Inspection

Begin by inspecting the perianal and anal areas for color, texture, rashes, scars, erythema, fissures, and hemorrhoids. Look for any masses or unusual areas. If any are found, palpate these with a gloved hand.

Ensure proper lighting and water-soluble lubrication, gloves, and drapes are on hand. Inform the patient about the procedure and ensure their comfort. Position options for the rectal examination encompass left lateral with hips and knees flexed, knee-chest, or standing with hips flexed and upper body supported by the examination table. Typically, patients find the right side position most comfortable with knees brought up to the chest.

Carefully spread the patient's buttocks and visually inspect until the patient has relaxed the external sphincter control. Ask the patient to bear down. It allows the appearance of fistulas, fissures, rectal prolapse, polyps, and internal hemorrhoids.

Rectal Palpation

For the digital examination of the rectum, place a gloved, lubricated index finger against the anus. Instruct the patient to gently bear down (Valsalva maneuver). Once the sphincter relaxes, insert the finger pointing towards the umbilicus. Encourage deep breathing and relaxation in the patient. Palpate all rectal surfaces thoroughly by inserting the finger as far as possible, checking for nodules, tenderness, or any irregularities.

The tone of the sphincter should be noted, as well as any nodules or irregularities of the anal ring. Use the gloved finger to remove a stool sample and check it for occult blood.

Findings

Normal findings include a smooth, soft, and uniform texture without pain or discomfort. Abnormal findings can indicate various conditions:

1. Fissure: An ulceration in the anal canal, possibly caused by straining or irritation.
2. Hemorrhoids: Thrombosed veins in the rectum and anus (internal or external), potentially due to portal hypertension, chronic constipation, prolonged sitting or standing, or pregnancy.
3. Mass: A firm nodular edge could indicate tumors or cancer.
4. Melena: Abnormal, black, tarry stool containing digested blood, which may suggest cancer or bleeding in the upper GI tract from ulcers or varices.
5. Pilonidal cyst: An opening of a sinus tract or cyst in the midline just above the coccyx, likely congenital.
6. Steatorrhea: Fatty, frothy, foul-smelling stool, potentially indicating chronic pancreatitis, biliary obstruction, or malabsorption problems.
7. Tenesmus: Painful and ineffective straining, possibly suggesting inflammatory bowel disease, irritable bowel syndrome, or diarrhea from a GI infection.

Remember, this examination requires sensitivity and professionalism. Always ensure the patient's comfort and privacy during the procedure.

Rectum and anus assessments are performed through inspection and palpation techniques.

Ensure proper lighting and have water-soluble lubrication, gloves, and drapes on hand.

Explain the procedure and ensure the patient's comfort.

During a rectal examination, patients can assume positions like knee-chest, left lateral with hips and knees flexed, or standing with hips flexed.

Begin by inspecting the perianal and anal areas for color, texture, rashes, scars, erythema, fissures, and hemorrhoids.

Gently separate the patient's buttocks and visually examine until the patient has relaxed external sphincter control.

Ask the patient to bear down to check the appearance of fistulas, fissures, rectal prolapse, polyps, and internal hemorrhoids.

Perform a digital rectal examination by gently placing a gloved, lubricated finger against the anus, asking the patient to bear down.

Insert the finger towards the umbilicus as the sphincter relaxes, palpate all surfaces, checking for nodules or irregularities.

Note the sphincter tone and check for any nodules or irregularities in the anal ring.