The anus and rectum may be examined with the patient in one of several positions. For most purposes, the side-lying position is satisfactory and allows good views of the perianal and sacrococcygeal areas. This is the position described below. The lithotomy position may help you to reach a cancer high in the rectum. It also permits a bimanual examination, enabling you to delineate a pelvic mass. Some clinicians prefer to examine a patient while he stands with his hips flexed and his upper body resting across the examining table.
No matter how you position the patient, your examining finger cannot reach the full length of the rectum. If a rectosigmoid cancer is suspected or screening is warranted, inspection by sigmoidoscopy is necessary.
Ask the patient to lie on his left side with his buttocks close to the edge of the examining table near you. Flexing the patient's hips and knees, especially in the top leg, stabilizes his position and improves visibility. Drape the patient appropriately and adjust the light for the best view. Glove your hands and spread the buttocks apart.
■ Inspect the sacrococcygeal and perianal areas for lumps, ulcers, inflammation, rashes, or excoriations. Adult perianal skin is normally more pigmented and somewhat coarser than the skin over the buttocks. Palpate any abnormal areas, noting lumps or tenderness.
■ Examine the anus and rectum. Lubricate your gloved index finger, explain to the patient what you are going to do, and tell him that the examination may make him feel as if he were moving his bowels but that he will not do so. Ask him to strain down. Inspect the anus, noting any lesions.
As the patient strains, place the pad of your lubricated and gloved index finger over the anus. As the sphincter relaxes, gently insert your fingertip into the anal canal, in a direction pointing toward the umbilicus.
Anal and perianal lesions include hemorrhoids, venereal warts, herpes, syphilitic chancre, and carcinoma. A perianal abscess produces a painful, tender, indurated, and reddened mass. Pruritus ani causes swollen, thickened, fissured skin with excoriations.
Soft, pliable tags of redundant skin at the anal margin are common. Though sometimes due to past anal surgery or previously thrombosed hemorrhoids, they are often unexplained.
See Table 13-1, Abnormalities of the Anus, Surrounding Skin, and Rectum (pp._-_).
MEDIAN SECTIONS—VIEW FROM THE PATIENT'S RIGHT SIDE. PATIENT LYING ON HIS
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