Tip
Effect
Avoid anticipations about negative scenarios
It reduces anxiety and fear
Explain the patient every step of the visit
It reduces the fear of pain
Do not fully undress the patient
It reduces the embarrassment
Talk to the patient “face to face and eye to eye”
It strengthens the relationship of mutual trust
Provide the patient information brochures
It allows the patient to better understand his condition
2 Where to Visit a Coloproctology Patient
A coloproctology clinic should have some specific characteristics and, above all, should have some essential equipment . A room too small and packed with all the equipment (Fig. 11.1a) or, conversely, any aspecific general surgery office (Fig. 11.1b) is not suitable. Everything a colorectal surgeon should have is clearly described elsewhere in this book; however, specific examination tables, instrumentation for the anoscopy and proctoscopy, fistula probes, and, if possible, an ultrasound scanner equipped with an endoanal/endorectal probe could be particularly useful (Fig. 11.2) (García-Olmo and Pascual Migueláñez 2010).
Fig. 11.1
Where to visit a coloproctology patient: a room small and too packed with instruments (a) or a generic general surgery (b) office is not ideal
Fig. 11.2
Where to visit a coloproctology patient: a specific table, anoscopy/proctoscopy, probes, and, if possible, an endoanal scanner are needed
With regard to the positioning the patient for proctologic examination, some practical considerations are needed. To obtain a correct lithotomy or prone (jackknife) positions, specific examination beds are needed; however, they are not always possible to have in an outpatient clinic, mostly due to their costs; on the other hand, the knee-chest position could result very embarrassing for the patient. On the contrary, the left lateral Sims’ position could be obtained easily and quickly on any medical bed and is usually well tolerated by the patient. In a specifically designed study, a questionnaire about medical positioning was administered to 178 patients evaluated for a coloproctological disease: in about two thirds of the cases, the Sims’ position was the preferred choice (Gebbensleben et al. 2009). However, the same research group stated that the knee-chest position may allow a better and detailed patient evaluation (Kuehn et al. 2009).
In our opinion, the Sims’ position is comfortable for both the patient and the coloproctologist and could fit the in-office diagnostic necessity in the majority of patients; however, if any doubt should arise, different position should be suggested.
3 How to Perform a Coloproctologic Examination
Today, the diagnostic value of the complete abdominal examination is more limited than in the past mainly because the more frequent use of imaging tests and screening campaigns have made the diagnosis of colorectal diseases increasingly accurate and early. Furthermore, studies have shown that a complete abdominal examination may fail in the correct diagnosis also in acute clinical conditions or in cases of malignancies (Laurell et al. 2006; Gans et al. 2015). In fact, it is increasingly rare today to diagnose a colorectal cancer, by detecting a marked hepatomegaly, an abdominal mass, or malignant ascites during the physical examination. Nevertheless, a careful and targeted abdominal examination could be very useful: with the abdominal inspection, the presence of existing abdominal scars (Pfannenstiel, median laparotomy, etc.) or abdominal hernias (umbilical or incisional hernia) should be detected. In this way, it will be possible to better plan any abdominal surgery with regard to the choice of the surgical incision, the positioning of trocars, or the choice of the type and position of a potential stoma.
On the other hand, the complete proctologic clinical examination provides, first, a careful inspection of the perineal area and, then, the digital rectal examination (Table 11.2) (Talley 2008). Following the patient’s correct positioning, the buttocks are moved gently, and it is therefore possible to observe the perianal skin and anal mucosa, searching for the presence of lumps or swellings (Fig. 11.3), openings of an anal fistula (Fig. 11.4), the features of a hidradenitis suppurativa (Fig. 11.5), perineal scars, and skin tags (Fig. 11.6). Then, the patient is asked to strain and to observe hemorrhoidal piles prolapse (radial lines on the prolapsing tissue) or a true rectal prolapse (concentric lines) (Fig. 11.7). Finally, it is also possible to evaluate the neuromuscular integrity of the perianal region eliciting a reflex, the so-called anal wink (see below in the section on Fecal Incontinence).
Table 11.2
A complete proctologic physical examination
Phase | What to observe |
|---|---|
Inspection: (a) At rest, with the buttocks moved | Perineal scars, skin tags, openings, lumps, swellings, dermatological problems, warts, fissures |
(b) Straining | Rectal or hemorrhoidal prolapse, perineal descent, prolapsing polyps |
(c) “Anal wink” reflex | Contraction of the sphincter complex |
Digital rectal examination: (a) Evaluation of anal pressures | Resting anal pressure, squeeze pressure, sphincter complex relaxation |
(b) Evaluation of the anal and rectal mucosa | Indurations, fibrosis, thickening, ulcerations, protrusions, irregularities, evocated pain |
(c) Evaluation of the secretions on the finger | Blood, pus, serum, mucus, feces color |
Fig. 11.3
Anal lumps or swellings: hemorrhoidal thrombosis (a, b), anal cancer (c)
Fig. 11.4
Complex anterior anal fistula in a male patient: no external anal opening is indentified near the anal verge (a); a large orifice is located very far from the anal verge, near to the scrotum (b)
Fig. 11.5
Features of a hidradenitis suppurativa
Fig. 11.6
Fistulized pilonidal disease: an orifice is close to the anal verge; an anal fistula should be excluded (a); recurrent pilonidal disease and a recurrent anal fistula in a patient submitted to multiple failed fistulotomies (b)
Fig. 11.7
Difference between hemorrhoidal and rectal prolapse: concentric (a) or radial (b) lines on the prolapsing tissue
After a gel lubrication of the finger and the perianal skin (Fig. 11.8), the digital rectal examination should ensure:
Evaluation of the resting anal pressures, squeeze anal pressure, and relaxation of the sphincter anorectal complex. At this stage, it may already be possible to make the diagnosis by correlations between different information already acquired; for example, the palpation of a discontinuity of the internal anal sphincter covered by a non-ulcerated anal mucosa, together with a low resting pressure, could be related to a previous anal surgery described by the patient; the presence of an anterior perineal scar in a woman with low squeeze pressure may be related to a history of difficult vaginal delivery occurred many years before; an absent or incomplete relaxation at the straining, together with the absence of a rectocele or a rectal intussusception, may suggest the clinician a functional, rather than anatomic, constipation.
Evaluation of the anal and rectal mucosa to assess the presence of induration, fibrosis, thickening, ulceration, protrusions, and irregularities.
Evaluation of the finger after his removal, to assess the presence of blood, pus, mucus, and serum secretions and to observe the feces color.
Fig. 11.8
Generous gel lubrication of the finger and of the perineal skin before a digital rectal examination
A colorectal surgeon or endoscopist should never forget to evaluate the prostate in a male patient: any alteration of gland consistency, irregularity, the size, and the presence of nodules should be reported to the patient, and a urological examination should be recommended (Deshpande et al. 2009). In women it is useful to know the status of their menstrual cycle before performing a digital rectal examination: mainly in the immediate proximity of menstruation, the uterine cervix could be distinctly palpated, which should therefore not be considered a malignancy.
4 Literature Evidence on the Role of the Clinical Examination
A detailed description of clinical findings associated to each colorectal disease is given in another chapter. In this section, the available literature on the role of the clinical examination in some common proctologic disease is summarized, trying to report its potentials, but also its limitations.
Anal Fissure. This condition can be usually diagnosed, thanks to a simple anal inspection and careful digital examination of the anal canal (Fig. 11.9). From the literature, however, it emerges as the physical examination could be imprecise in the evaluation of the sphincter tone. In a study by Jones et al., 40 patients affected by anal fissure were prospectively evaluated by digital anal canal examination and anorectal manometry. A comparison between the clinical and manometric assessment of maximum resting pressure showed that in only 15 out of 35 patients considered to be affected by sphincter hypertone, the diagnosis of anal fissure was confirmed after the physiology testing, so the specificity for hypertone was only 16 % (Jones et al. 2005). Moreover, a larger number of patients than it normally is assumed had a normal or low resting pressure; this could have a very important value in the planning of fissure management, in particular concerning decision-making process toward surgery because in these patients the risk of postoperative fecal incontinence is not negligible. Similarly, other findings showed that the reliability of digital anal canal examination in the identification of sphincter tone was low (Eckardt and Kanzler 1993). For these reasons, performing an anorectal manometry in a patient that should undergo an anal sphincterotomy could be of great interest.Related posts:
Anal Surgery: Organ and Function Preservation
Signs and Symptoms in Coloproctology: Data Collection and Scores
Diagnostic Algorithm for Constipation and Obstructed Defecation
Surgical Anatomy of the Colon, Rectum, and Anus
Topographic Anatomy of the Colon and Rectum: Tips and Tricks in Laparoscopic and Robotic Surgery
Pathologic Evaluation of Colo-Recto-Anal Samples: Procedures and Clinical Significance
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