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2 Patient Evaluation
Fig. 2.8 Pruritis ani
Fig. 2.9 Anal condyloma
Incontinence
Patients complaining of fecal incontinence are
often nervous and shameful. They have delayed
admitting their complaints following months or
years of progressive symptoms. For that reason,
they should be made comfortable and approached
in a comfortable environment and with an empathetic and calm demeanor. In many situations,
incontinence symptoms need to be specically
elicited as many patients will not offer this
information.
Onset, duration, timing, and magnitude of
symptoms such as severity and frequency of episodes are important to understand. Stool frequency and consistency as well as the use of
supplementary ber should be considered.
Patients present with varying degrees of incontinence, from gas only to liquid stool to solid stool.
Patients commonly complain of repeated wiping
29
after a bowel movement while others may describe
complete loss of control with unrecognized passage of solid stool [59]. Characterization of incontinence is aided by the use of validated fecal
incontinence scoring tools such as the Fecal
Incontinence Severity Index (FISI) and the
Cleveland Clinic Florida Fecal Incontinence score
(CCF-FIS)/Wexner score [60]. The use of these
instruments is recommended by the American
Society of Colon and Rectal Surgeons (ASCRS)
to determine the severity of disease, guide appropriate treatment, and to objectively measure
response to treatment [28, 61, 60]. The CCF-FIS/
Wexner score is the most widely cited fecal incontinence score (Google Scholar October 4, 2018).
Distinguishing between active or urge incontinence and passive incontinence is crucial. Active
or urge incontinence is a loss of stool despite conscious efforts whereas passive incontinence
occurs when there is a lack of awareness of loss of
stool. Active incontinence occurs due to EAS dysfunction with intact sensation and can be the
result of a hyposensitive or hypersensitive rectum
and a history of obstetric trauma or prior anorectal
surgery. Passive incontinence results from IAS
dysfunction or dysfunction of the sensory mechanism usually due to neurologic disease, anatomic
damage or fecal impaction leading to overow of
liquid stool [59, 62]. A history of previous gynecologic and anorectal surgery as well as a thorough obstetric history including traumatic tears or
episiotomies should be obtained as a guide for
selecting further diagnostic studies and determining appropriate treatment [29, 63–65].
Constipation
“Constipation” has different meanings to different patients and should be claried and documented by the clinician. Again, objective tools
such as the Bristol Stool Scale to characterize stool and the Rome Criteria to distinguish
true functional bowel disorders from patientreported unacceptable defecation may aid in
patient assessment [9, 66]. Constipation may
be the result of obstructing masses, mechanical or physiologic outlet obstruction, or colonic
inertia, and it is important to distinguish
between these in order to provide appropriate
30
treatment. Obstructing tumors or masses should
be excluded in the work up, and can be associated with bleeding, pain or mucous discharge.
Patients with outlet obstruction may complain
of the urge to defecate but the inability to pass
stool as well as straining or the need to digitize
the anus or vagina or splint on the perineum
[67]. Patients with colonic inertia do not have
the urge to defecate and over time patients
become uncomfortable due to distension and
bloating. These patients ultimately require the
use of various laxatives to defecate [48, 68]. It
should be emphasized that a history of psychiatric illness and both sexual and physical abuse are
commonly encountered in patients who present
with complaints of constipation [22–25]. Recent
changes in diet or medication may also be considered when evaluating a patient with constipation. Additionally, a history of immobility and
endocrine disorders should be obtained [9, 66,
69, 70]. A validated clinical constipation scor-
ing system such as the Cleveland Clinic Florida/
Wexner Constipation Score can be useful in distinguishing between these types of constipation
as well as quantifying severity and documenting
any changes in severity following therapy [71].
Physical Examination
The physical examination should be systematic
and focused, with careful attention to the patient’s
general appearance, abdomen, and nally, the anorectum. It is not uncommon to confuse vaginal or
scrotal complaints with anorectal complaints so
one should be prepared for a genitourinary exam.
The patient should be made comfortable and at
ease during the examination as the most amount
of information can be gained if the patient is able
to tolerate this portion well. Anxiety can be minimized by assuring the patient that the exam is not
prolonged or painful, and informing the patient of
the steps and providing reassurance throughout
[36, 48]. The patient should be allowed to undress
alone, and body areas not being examined should
be covered at all times [36, 48]. Finally, ensure that
a chaperone is in the room during the examination.
The exam room should be clean, well-venti-
lated, and well-lit. A sink should be available in
P. A. Suwanabol and J. A. Maykel
Fig. 2.10 Examination room
the room and a toilet at least nearby, preferably
adjoining. A portable light or headlight, lubricant,
and tissue paper should be available. It is helpful
to have enemas and suction available should stool
residue limit visualization. Anoscopes should be
covered from view yet within reach of the examiner (Fig.2.10). It is important to have supplies
such as local anesthetic, syringes, needles and a
scalpel available in the event that small procedures are necessary [72]. Preparation and easy
access to instrumentation are critical; delays
while searching for equipment can be uncomfortable and anxiety-invoking while reecting
disorganization.
Abdominal Examination
The abdominal portion of the exam should be performed while the patient is supine and must
include inspection and palpation of all four quadrants from the xiphoid to pubis with attention to
surgical incisions and areas where pain may be
elicited. Evaluation for abdominal distension,
organomegaly or masses should be performed
2 Patient Evaluation
with attention to stigmata of conditions that may
affect surgical treatment such as underlying liver
or heart failure. Importantly, inguinal lymph node
basins should be examined as these are the primary
draining lymph nodes for both benign and malignant anal pathology.
Anorectal Examination
As this is typically most anxiety-invoking event
for the patient, it is crucial that the physician set
expectations, allay fears, inform the patient of the
steps of the exam, and act with discretion
throughout the visit. Only a relaxed patient will
allow and tolerate a thorough examination. In
addition to having a chaperone to witness the
procedure, a nurse or medical assistant may be
useful to help retract the buttocks and assist in
procedures if necessary. Again, cover portions of
the body that are not being examined.
Consideration of patient positioning is
critical. The most commonly used position is
the left lateral decubitus position (Sims position) with the hips on the edge of the table.
Alternatively, the patient may be in prone
jackknife or lithotomy position but these positions require special tables and may be difcult for patients with certain conditions (late
pregnancy, orthopedic limitations, or recent
abdominal surgery) (Fig. 2.11). No position
is superior to the other and should be chosen
based on examiner and patient comfort with
the goal being to obtain the best visualization
possible. However, from the author’s perspective, the lateral position seems to be better
accepted compared to the awkward prone position. However, at one of the editors prefers the
prone position as it provides better exposure
and allows the examiner to stand. The examiner sits on a stool or stands with illumination
provided by a portable light or head light. The
anorectal examination involves three distinct
components: visual inspection, external palpation, and digital rectal exam.
Visual Inspection
Visual inspection should commence at the
sacrococcygeal region to evaluate for piloni-
31
Fig. 2.11 Patient positioning. Upper gure: Sims; Middle
Figure: Prone Jacknife; Lower Figure: Left lateral
dal disease followed by the overlying skin of
the ischioanal spaces. Evaluate for maceration,
ulceration, drainage sites, lesions and masses.
The buttocks are then parted and the anus is
gently and slowly effaced. The entire perineum
is evaluated for nodules, external hemorrhoids,
skin tags, external stula openings, and scarring followed by inspection of the anal verge
for ssures, ulcers and prolapsing tissue as well
as purulent or bloody discharge. The perineum
and anus are further evaluated for dermatologic
diseases or stigmata of other diseases such as
sentinel piles or lateral ssures characteristic of
anal ssures and Crohn’s disease respectively as
well as lichenication and ulcerations characteristic of pruritis ani and High-grade squamous
intraepithelial lesions or Paget’s disease [73].
The patient should be asked to strain to evaluate for anal masses, rectal prolapse, and perineal
descent as well as evaluating for seepage and
the quality of the perineal body. Visualization
alone should be able to diagnose a signicant
number of anorectal pathology including external hemorrhoids, condyloma, prolapse, or ssures. A patulous anus can be appreciated and
may indicate prolapse or the underlying etiology of fecal incontinence.
32
P. A. Suwanabol and J. A. Maykel
External Palpation
Palpation should follow visual inspection in a
stepwise fashion. First, while evaluating the
sacrococcygeal region and the ischioanal spaces.
Then, once the buttocks are effaced and visual
inspection of the perineum and anal verge are
performed, the perineum should be palpated for
uctuance and induration, as well as for stula
tracts or masses. The anal verge is palpated to
elicit pain or discomfort as well as to characterize
any masses or lesions discovered.
Digital Rectal Examination
Prior to inserting the nger, apply gentle pressure
to the anus to deliver a warning to the patient and
to initiate sphincter relaxation. Gently and slowly
insert a well-lubricated nger to assess for tenderness or discomfort of both the anal canal and
perianal skin, scarring or stricturing, induration,
mucosal abnormalities or masses, rectoceles and
evaluation of stool presence and consistency. The
nger should be slowly and carefully rotated 360
degrees to evaluate the entire circumference of
the anal canal. Sphincter tone at rest and with
voluntary squeeze, and the ability of the puborectalis to relax as indicated by descent coupled with
posterior movement while bearing down should
also be evaluated which provides information
about defecatory function [74–77]. Bearing down
may also allow an intrarectal mass to reach the
examiner’s nger. Additional maneuvers should
include rm palpation of the puborectalis and
levators as well as a bimanual exam of the coccyx
in patients who complain of pain indicative of
levator ani syndrome and coccyxdynia respectively. The presacral region posterior to the rectum can be palpated for masses. Thickness of
perineal body and laxity of rectal wall should be
assessed particularly in patients who complain of
incontinence and defecation difculties [78].
Once the examining nger is removed, any evidence of blood or purulence is noted as well as
stool consistency. When a painful diagnosis such
as an anal ssure is discovered on inspection, this
portion of the exam should be deferred since it is
unlikely to provide additional information in the
acute setting. If a patient will not tolerate a digital
rectal examination then the evaluation should be
done with the assistance of sedation, either com-
bined with endoscopy or, when indicated, in the
operating room [79].
Diagnostic Studies
The clinician should have a good sense of the
diagnosis following the history and physical
examination. In certain situations, additional
diagnostic studies need be performed to conrm
the diagnosis, gather additional data, and aid in
preoperative planning.
Anoscopy
Anoscopy is the most widely used tool when
evaluating patients with anorectal complaints. It
is inexpensive, simple, and an important adjunct
to the examination. In fact, anoscopic examination should be performed for every patient with
anorectal complaints unless limited by pain, such
as patients with anal ssure or abscess. Often
these patients are also unable to tolerate a digital
exam. Evaluation of the distal rectum, anal canal,
and anoderm can be performed using a tapered
anoscope with a diameter no larger than
20–30 mm (Fig. 2.12) [59, 80]. Anoscopy is
always preceded by digital rectal exam, which
allows relaxation of the sphincter, and verbal
consent from the patient. The well-lubricated
scope and its obturator are gently inserted with
constant gradual pressure. The use of 2% lidocaine jelly is rarely needed. However, a smaller
scope may be necessary if stenosis is encountered. The obturator is removed and inspection of
all quadrants of the anal canal is performed.
Rather than simply rotating the scope while in the
anal canal, the obturator must be reinserted into
the scope prior to rotation to prevent sliding of
mucosa when moving from one quadrant to the
next. Alternatively, the anoscope can be repeatedly withdrawn and reinserted at a different orientation. These maneuvers also help to prevent
discomfort and tearing in the anoderm [48, 59].
Internal hemorrhoids, friable mucosa, ssures,
abscesses and stulas, condyloma, hypertrophied
anal papilla, proctitis, and masses are evaluated
and biopsies and cultures are taken if necessary.
2 Patient Evaluation
Fig. 2.12 Anoscopes
33
To detect internal hemorrhoidal, mucosal, or rectal prolapse, the patient may be asked to strain
upon withdrawal of the scope [59, 81–83].
Anoscopy does not require bowel preparation
and patient sedation is not necessary. Again, it is
not recommended that anoscopy be performed in
patients with known anal ssures or in patients
who demonstrate signicant discomfort during
the digital rectal exam.
Proctoscopy
Further evaluation of the anorectum up to the distal sigmoid colon can be performed with proctoscopy and is considered the most accurate method
to determine the exact location of a rectal lesion
when compared to exible endoscopy [84].
Similar to anoscopy, sedation is not necessary,
however, enemas are generally required to clear
the rectum of solid stool. The standard proctoscope is equipped with a light source and is
25 cm long. The outside diameter measures
19 mm although smaller diameter scopes are
available if needed (11 and 15mm) [83, 84].
In either the prone jackknife position or left
lateral decubitus position, the perineum and anus
are inspected followed by digital rectal examination and nally, gentle insertion of both the proctoscope and its obturator aimed posteriorly toward
the sacrum initially. Once the proctoscope is
inserted beyond the sphincter complex, the obturator is removed and the rectum is insufated to
visualize the area of interest. The trajectory of the
rectum changes from posterior to anterior, and the
examiner must follow the course of the rectum
while insufating the lumen. Generally the proctoscope can be inserted no more than 20cm due to
tight angulation at the rectosigmoid junction and
the likelihood of producing crampy visceral discomfort [85]. Insertion is performed slowly under
direct visualization. The proctoscope is then withdrawn in a sweeping fashion to atten the rectal
valves and allow full evaluation of all walls of the
rectum. The anal canal is visualized but is generally better evaluated with a slotted anoscope.
Suction can be used through the proctoscope to
clear any residual stool or mucous. Prior to complete withdrawal of the proctoscope, the window
is opened to allow release of any retained air.
Proctoscopy is used to assess a variety of anorectal diseases including proctitis and ulcers, and
is most commonly used to rule out malignancy
and evaluate rectal cancer location (distance from
anal verge, anterior/posterior location). While not
commonly performed in the ofce setting, biopsies and polypectomies can be performed, foreign bodies can be removed and topical therapies
such as formalin can be applied for patients with
radiation proctitis [59].
34
P. A. Suwanabol and J. A. Maykel
Although incredibly rare (0.005–0.01% incidence and the result of inexperience or over
aggressiveness), great care must be taken to prevent perforation from using the proctoscope,
and concern should be heightened in patients
who become ill following the procedure [81,
82]. Additionally, anal tears and subsequent
bleeding may occur from performing proctoscopy [82, 83]. The most common presenting
symptoms include pain (33%) and discomfort
(13%) [86].
Flexible Sigmoidoscopy
Flexible endoscopic evaluation allows a greater
length of intestine to be evaluated with better
magnication, optics and patient tolerance [87,
88]. A exible sigmoidoscope is 60cm in length
and typically allows visualization up to the
splenic exure [89, 90]. Two Fleets enemas the
day of the procedure are used to prepare for sigmoidoscopy, which may be performed without
any sedation, depending on patient comfort.
However, proper training is required and the procedure must be performed by a technician comfortable and experienced with the endoscopic
equipment [83]. Additional advantages to using
exible sigmoidoscopy include a lower cost and
easier maintenance when compared to colonoscopy, and can be performed at the bedside in an
acute or an intensive care unit setting [59].
Potential complications of exible endoscopy are
rare and include abdominal distension and discomfort, bradycardia, subcutaneous or mediastinal emphysema, perforation (0.01%), and
bleeding following biopsy or polyp removal [82,
83, 91].
Endoluminal Ultrasound
Ultrasound of the anus and rectum is a valuable
diagnostic tool for both benign and malignant
diseases. Endoanal ultrasound (EAUS) allows
detailed evaluation of anal sphincter anatomy and
any abnormalities related to fecal incontinence
with sensitivity and specicity of locating a
sphincter defect approaching 100% [92]. In addition, endoanal ultrasound can be used to identify
and characterize abscesses and stulas, and to
evaluate patients with anal pain or perianal
Crohn’s disease [59]. Endorectal ultrasound
(ERUS) is most commonly utilized for staging of
rectal cancer, and has become a critical component in determining both tumor depth as well as
regional lymph node status with T stage accuracy
ranging from 63 to 93% and N stage accuracy
ranging from 50 to 83% [93].
Endorectal ultrasound in 2D and 3D modes
utilizing a 1850 rotating probe and 10–16MHz
transducer (BK Medical Systems Inc., Peabody,
MA, USA) is performed by placing the patient
in the left lateral decubitus position. Fleets
enemas are used for bowel preparation and no
sedation is required. A digital rectal exam and
proctoscopy are performed. The proctoscope is
left in place so that the handheld probe is
inserted through the proctoscope to the level of
interest. The proctoscope is withdrawn creating space for the latex balloon to ll and the
entire rectum and anal canal are evaluated,
with specic focus on the lesion of interest.
The main advantages of ERUS are that it is
fast, inexpensive and does not require sedation
or ionizing radiation. However, ERUS is operator-dependent making reliability and accuracy
a real concern [2].
Computed Tomography
Computed tomography (CT) is commonly used
to evaluate diseases of the colon and rectum.
Using a combination of oral and rectal contrast to
opacity the bowel as well as intravenous contrast
to further delineate intraabdominal anatomy,
high-resolution images are captured [94–96].
Despite signicant advances in diagnostic capability in detecting diseases such as diverticulitis
and colorectal malignancies, rectal and pelvic
oor structures demonstrate poor resolution and
CT is limited in evaluating anoperineal sepsis
[48]. Additionally, radiation exposure and use of
iodinated contrast agents may limit the use of CT
in some patient populations.
2 Patient Evaluation
35
Magnetic Resonance Imaging
Magnetic resonance imaging (MRI) has proven
to be benecial in evaluating complex stulas
and sphincter anatomy in patients with fecal
incontinence as it provides higher resolution of
pelvic structures due to smaller viewing elds
dedicated to the area of interest. Additionally,
MRI is able to characterize ischioanal and perirectal abscesses and stulas better than digital
rectal exam and CT respectively [97, 98].
Similarly, MRI has evolved as the preferred
method of staging rectal malignancies with similar sensitivities for T and N stage as ERUS as
well as clearer determination of lateral/circumferential margin status [99]. Beyond ner tissue
detail, benets of MRI over CT are the ability to
avoid the use of iodinated contrast agents and
ionizing radiation [100, 101].
Physiologic Testing
Reecting the complexity of normal anorectal
function, multiple tests are necessary to complete
a comprehensive evaluation of pelvic oor disorders [102, 103]. Commonly used tests include
anorectal manometry, balloon expulsion, neurophysiologic testing including pudendal nerve terminal motor latency (PNTML) and
electromyography (EMG), anatomic assessment
with EAUS and MRI, perineometry, defecography studies, and gastrointestinal transit studies. It
should be reiterated that each of these test should
be performed to complement and provide additional data beyond the thorough history and physical with the goal of instituting an appropriate
management plan [59, 104].
Anorectal manometry measures the intraluminal pressures of the anal canal and the distal rectum to reect internal and external sphincter
function, and is most frequently used to evaluate
fecal incontinence. Anorectal manometry can
evaluate functional outlet obstruction by measuring changes in pressure during attempted defecation, Hirschsprung’s disease by the absence of
the recto-anal inhibitory reex (RAIR), and
sacral reex arc damage [105–108]. It is particu-
larly valuable when evaluating baseline function
prior to performing any anorectal or pelvic oor
procedures that may impact continence [28]. A
frequently used adjunct to anal manometry is the
balloon expulsion test, which evaluates the ability of the rectum to expel a balloon and diagnose
obstructed defectation. Neurophysiologic testing
includes PNTML and EMG. PNTML measures
the integrity of motor innervation of the pelvic
oor. It is useful in patients with fecal incontinence, constipation, and rectal prolapse. PNTML
is performed by placing a St. Mark’s electrode on
the examiner’s nger and inserting it into the rectum to stimulate the pudendal nerve. Any abnormal latency period is considered to be pudendal
neuropathy. EMG evaluates appropriate EAS
relaxation and contraction as well as potential
nerve injury [109, 110]. Perineometry measures
perineal descent in patients with fecal incontinence. Defecography studies with dynamic uoroscopy and dynamic MR evaluate the function
of the pelvic oor during rectal evacuation and
anorectal anatomic abnormalities such as cystocele, enterocele, rectocele, and rectal prolapse
and intussusception [111–113]. Finally, gastrointestinal transit studies including the colonic
marker study use radiopaque markers and serial
plain radiographs for up to 5days to assess gastrointestinal motility in patients with constipation. Greater than 20% retention of the radiopaque
markers is considered abnormal but distribution
pattern can distinguish slow transit constipation
from pelvic outlet dysfunction [114–116].
Summary
A focused but thorough history and careful and
directed physical examination should accurately
diagnose the majority of anorectal complaints.
The patient should be made to feel at ease
throughout the process, including the discussion
and the anorectal examination. The use of diagnostic studies is thoughtfully considered in relation to the patient’s presenting symptoms and
exam, and should be used to conrm the presumed diagnosis, gather additional information
and aid in preoperative planning.
36
P. A. Suwanabol and J. A. Maykel
Acknowledgments This chapter was written by Patricia
L.Roberts, MD in the previous edition of this textbook.
The authors would like to acknowledge W.Brian Sweeney,
MD for providing photographs and Paul Trombley for creating the medical illustrations.
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