Inspection of the anus may show external hemorrhoids, and internal hemorrhoids after the patient has just been to the closet, external fistulae, ulcerations, pin worms, abscess, fissure, and skin diseases, such as eczema and venereal warts. If the buttocks are separated by the hands and the patient bears down, a fissure may be brought into view.<Callout type="tip" title="Tip">The Sims position is ideal for both visual and digital examination.</Callout> Some points in the diagnosis have been obtained already from the vaginal examination. Tumors can be ruled out by the vaginal touch. The sphincter ani is now everted by a finger in the vagina pressing the rectal wall out through the anus, thus affording an opportunity for study and a search for hemorrhoids, polypi, ulcers, fissures, or fistula?. This procedure cannot, however, be executed in virgins with unstretched perinea, a reasonable amount of injury or elasticity of the perineum being a necessity.<Callout type="warning" title="Warning">Avoid forcing the examination on unprepared patients to prevent injury.</Callout> Before taking up the digital examination let us review a few points in the anatomy and physiology of the rectum. The rectum is about eight inches long, merging above into the sigmoid flexure of the descending colon at the left sacro-iliac articulation, there being no distinct point of separation between the two.<Callout type="important" title="Important">The long axis of the anal canal is nearly horizontal when the patient is in the erect posture and is at approximately a right angle to the main lumen of the rectum.</Callout> The rectum is composed of four coats, — serous, muscular, areolar, and mucous. It is similar in structure to the rest of the large intestine, except that the semilunar folds of the mucous membrane to be found higher up in the bowel are here strongly developed, so that they form shelves projecting into the lumen of the gut.<Callout type="risk" title="Risk">Prolapse and varicosity can occur due to the loose connection between the muscular and mucous coats.</Callout> The reflex contractions of the sphincter prevent healing of a fissure and are a source of pain. They also prevent an ischio-rectal abscess from closing and convert it into a fistula.<Callout type="tip" title="Tip">Thoroughly stretch the sphincter to the point of temporary paralysis before any operative procedure.</Callout> A good light, preferably an electric light and a head mirror, are necessary, just as in cystoscopy. The patient is put in the knee-chest position. Something as to the condition of the anal canal may be learned by the use of the smallest-size Sims vaginal speculum in the anus and some physicians report good results with it.<Callout type="beginner" title="Beginner">The Sims rectal speculum is adapted only for use with the patient anesthetized.</Callout> Two proctoscopes are sufficient for diagnostic purposes. The shorter one, three inches (7.5 centimeters) long by seven-eighths inch (2.3 centimeters) in diameter, is passed first. It is thoroughly anointed and introduced slowly while the patient bears down.<Callout type="gear" title="Gear">Use a Kelly proctoscope for difficult cases or when examining children.</Callout> In introducing the longer proctoscope it is advisable to remove the obturator after the sphincter has been passed and to carry the instrument higher in the rectum by sight. The semilunar valves can be seen and avoided by the advancing edge of the proctoscope.<Callout type="important" title="Important">Remember that the empty rectum is normally contracted, so this state must not be mistaken for stricture.</Callout> The mucous membrane of the rectum is studded by branching vessels and the openings of little glands may be seen. Inflammation is marked by a diffuse velvety injected appearance of the mucosa, together with the disappearance of the normal branching vessels; ulcerations are easily distinguished, polypi may be seen hanging from the rectal wall, or the bleeding surface of a carcinoma may obstruct the lumen of the proctoscope.<Callout type="risk" title="Risk">Stricture due to syphilis or cancer requires a smaller proctoscope.</Callout> Stretching the sphincter and speculum examination of the rectum. In exceptional cases it is necessary to give an anesthetic in order to make a complete diagnosis of rectal disease. In such an event, after the patient is thoroughly anesthetized she is placed in the Sims position; the operator anoints both thumbs and inserts them through the anus.<Callout type="warning" title="Warning">Rapid and forcible stretching can result in rupture of the muscle followed by partial or complete permanent incontinence.</Callout> Thorough stretching of the sphincter is essential for any instrumentation of the rectum except proctoscopy. After the preliminary stretching the sphincter muscle is fixed between the thumb and forefinger of the left hand and successive portions of its periphery are stretched by the thumb and forefinger of the right hand.<Callout type="important" title="Important">The Sims rectal speculum is passed, light is reflected into the rectum by the head mirror, the alligator forceps and pledgets of cotton being used to wipe away discharges and feces.</Callout>
Key Takeaways
- The Sims position is ideal for both visual and digital rectal examinations.
- Thoroughly stretching the sphincter before any operative procedure is essential.
- Use appropriate proctoscopes based on the condition of the patient's rectum.
Practical Tips
- Always ensure the patient is comfortable and prepared during a rectal examination to prevent discomfort or injury.
- Use proper lighting and tools, such as an electric light and head mirror, for clear visualization.
- Be gentle but firm when stretching the sphincter to avoid causing permanent damage.
Warnings & Risks
- Avoid forcing the examination on unprepared patients to prevent injury.
- Rapid and forcible stretching can result in muscle rupture or partial/complete incontinence.
- Incorrect use of proctoscopes may lead to injury or failure.
Modern Application
While many of these techniques are outdated, understanding the anatomy and physiology of the rectum remains crucial for modern survival scenarios. Proper hygiene, recognizing symptoms, and knowing when to seek medical attention can be life-saving in emergency situations.
Frequently Asked Questions
Q: What is the Sims position used for during a rectal examination?
The Sims position is ideal for both visual and digital examinations of the anus. The patient lies on their back with their legs bent at the knees and raised, allowing easy access to the anal area.
Q: Why is it important to stretch the sphincter before a rectal examination?
Stretching the sphincter allows for better visualization and examination of the rectum. It helps in identifying any abnormalities or conditions that may not be visible otherwise, ensuring a thorough diagnosis.
Q: What are some signs of inflammation in the rectum during an examination?
Inflammation in the rectum is marked by a diffuse velvety injected appearance of the mucosa, together with the disappearance of normal branching vessels. Ulcerations and polyps may also be visible.