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References
1.
Menees SB, Almario CV, Spiegel BMR, et al. Prevalence of and factors associated with fecal incontinence: results from a population-based survey. Gastroenterology. 2018;154:1672–1681. e3.
2. Rao SS, Bharucha AE, Chiarioni G, et al. Functional anorectal disorders. Gastroenterology. 2016;
150:1430–1442. e4.
3. Bharucha AE, Rao SS. An update on anorectal disorders for gastroenterologists. Gastroenterology.
2014;146:37–45. e2.
4. Read NW, Haynes WG, Bartolo DC, et al. Use of anorectal manometry during rectal infusion of saline to
investigate sphincter function in incontinent patients. Gastroenterology. 1983;85:105–113.
5. Bharucha AE, Fletcher JG, Harper CM, et al. Relationship between symptoms and disordered
continence mechanisms in women with idiopathic faecal incontinence. Gut. 2005;54:546–555.
6. Gourcerol G, Granier S, Bridoux V, et al. Do endoflip assessments of anal sphincter distensibility pro-
vide more information on patients with fecal incontinence than high-resolution anal manometry?
Neurogastroenterol Motil. 2016;28:399–409.
7. Sorensen G, Liao D, Lundby L, et al. Distensibility of the anal canal in patients with idiopathic fecal
incontinence: a study with the functional lumen imaging probe. Neurogastroenterol Motil.
2014;26:255–263.
8. DeLancey JO, Kearney R, Chou Q, et al. The appearance of levator ani muscle abnormalities in mag-
netic resonance images after vaginal delivery. Obstet Gynecol. 2003;101:46–53.
9. Sultan AH, Kamm MA, Hudson CN, et al. Anal-sphincter disruption during vaginal delivery. N Engl
J Med. 1993;329:1905–1911.
10. Graf W, Mellgren A, Matzel KE, et al. Efficacy of dextranomer in stabilised hyaluronic acid for treatment
of faecal incontinence: a randomised, sham-controlled trial. Lancet. 2011;377:997–1003.
11. Hull T, Giese C, Wexner SD, et al. Long-term durability of sacral nerve stimulation therapy for chronic
fecal incontinence. Dis Colon Rectum. 2013;56:234–245.
12. Heymen S, Scarlett Y, Jones K, et al. Randomized controlled trial shows biofeedback to be superior to
pelvic floor exercises for fecal incontinence. Dis Colon Rectum. 2009;52:1730–1737.
13. Kumar L, Emmanuel A. Internal anal sphincter: clinical perspective. Surgeon. 2017;15:211–226.
14. Al-Ali S, Blyth P, Beatty S, et al. Correlation between gross anatomical topography, sectional sheet plas-
tination, microscopic anatomy and endoanal sonography of the anal sphincter complex in human
males. J Anat. 2009;215:212–220.
15. Netter F. In: Kelly P, ed. Atlas of Human Anatomy. 3rd ed. Teteboro, NJ: Icon Learning System; 2003.
Plates
361 & 364.
16. Rattan S. The internal anal sphincter: regulation of smooth muscle tone and relaxation. Neurogas-
troenterol Motil. 2005;17(suppl 1):50–59.
17. Harnett KM, Rieder F, Behar J, et al. Viewpoints on acid-induced inflammatory mediators in esoph-
ageal mucosa. J Neurogastroenterol Motil. 2010;16:374–388.
18. Rattan S. Ca2 +/calmodulin/MLCK pathway initiates, and RhoA/ROCK maintains, the internal anal
sphincter smooth muscle tone. Am J Physiol Gastrointest Liver Physiol. 2017;312:G63–G66.
19. Rattan S, Singh J, Kumar S, et al. Nature of extracellular signal that triggers RhoA/ROCK activation for
the basal internal anal sphincter tone in humans. Am J Physiol Gastrointest Liver Physiol. 2015;308:
G924–G933.
26 ANORECTAL DISORDERS
20. Cobine CA, Hannah EE, Zhu MH, et al. ANO1 in intramuscular interstitial cells of Cajal plays a key role
in the generation of slow waves and tone in the internal anal sphincter. J Physiol. 2017;595:2021–2041.
21. Bharucha AE. Pelvic floor: anatomy and function. Neurogastroenterol Motil. 2006;18:507–519.
22. Raizada V, Mittal RK. Pelvic floor anatomy and applied physiology. Gastroenterol Clin North Am.
2008;37:493–509. vii.
23. Yamato S, Rattan S. Role of alpha adrenoceptors in opossum internal anal sphincter. J Clin Invest.
1990;86:424–429.
24. Rathi S, Kazerounian S, Banwait K, et al. Functional and molecular characterization of beta-
adrenoceptors in the internal anal sphincter. J Pharmacol Exp Ther. 2003;305:615–624.
25. Li F, De Godoy M, Rattan S. Role of adenylate and guanylate cyclases in beta1-, beta2-, and beta3-
adrenoceptor-mediated relaxation of internal anal sphincter smooth muscle. J Pharmacol Exp Ther.
2004;308:1111–1120.
26. Rattan S, Shah R. Influence of sacral nerves on the internal anal sphincter of the opossum. Am
J Physiol. 1987;253:G345–G350.
27. Rattan S, Thatikunta P. Role of nitric oxide in sympathetic neurotransmission in opossum internal anal
sphincter. Gastroenterology. 1993;105:827–836.
28. Santorini J. Septemdecim Tabulae. 1715.
29. Shafik A. A new concept of the anatomy of the anal sphincter mechanism and the physiology of def-
ecation. The external anal sphincter: a triple-loop system. Invest Urol. 1975;12:412–419.
30. Fritsch H, Brenner E, Lienemann A, et al. Anal sphincter complex: reinterpreted morphology and its
clinical relevance. Dis Colon Rectum. 2002;45:188–194.
31. Hussain SM, Stoker J, Lameris JS. Anal sphincter complex: endoanal MR imaging of normal anatomy.
Radiology. 1995;197:671 – 677.
32. Liu J, Guaderrama N, Nager CW, et al. Functional correlates of anal canal anatomy: puborectalis mus-
cle and anal canal pressure. Am J Gastroenterol. 2006;101:1092–1097.
33. Thompson P. The Myology of the Pelvic Floor. Newton, MA: McCorquoddale; 1899.
34. Hsu Y, Fenner DE, Weadock WJ, et al. Magnetic resonance imaging and 3-dimensional analysis of
external anal sphincter anatomy. Obstet Gynecol. 2005;106:1259–1265.
35. Mittal RK, Bhargava V, Sheean G, et al. Purse-string morphology of external anal sphincter revealed by
novel imaging techniques. Am J Physiol Gastrointest Liver Physiol.
2014;306:G505–G514.
36. Bo K, Lilleas F, Talseth T, et al. Dynamic MRI of the pelvic floor muscles in an upright sitting position.
Neurourol Urodyn. 2001;20:167–174.
37. Zijta FM, Froeling M, Nederveen AJ, et al. Diffusion tensor imaging and fiber tractography for the visu-
alization of the female pelvic floor. Clin Anat. 2013;26:110 –114.
38. Zijta FM, Froeling M, van der Paardt MP, et al. Feasibility of diffusion tensor imaging (DTI) with fibre
tractography of the normal female pelvic floor. Eur Radiol. 2011;21:1243–1249.
39. Sappey P. Traite d’Anatomie Descriptive. 2nd ed. 1739.
40. Holl M. Handbuch des Anatomie. Jena: Fischer; 1897.
41. Lawson JO. Pelvic anatomy. I. Pelvic floor muscles. Ann R Coll Surg Engl. 1974;54:244–252.
42. Guaderrama NM, Nager CW, Liu J, et al. The vaginal pressure profile. NeurourolUrodyn.
2005;24:243–247.
43. Guaderrama NM, Liu J, Nager CW, et al. Evidence for the inner vation of pelvic floor muscles by the
pudendal nerve. Obstet Gynecol. 2005;106:774–781.
44. Jung SA, Pretorius DH, Padda BS, et al. Vaginal high-pressure zone assessed by dynamic 3-dimensional
ultrasound images of the pelvic floor. Am J Obstet Gynecol. 2007;197:52. e1-7.
Chapter 2 • Anorectal Anatomy and Function 27
45. Raizada V, Bhargava V, Jung SA, et al. Dynamic assessment of the vaginal high-pressure zone using
high-definition manometry, 3-dimensional ultrasound, and magnetic resonance imaging of the pelvic
floor muscles. Am J Obstet Gynecol. 2010;203:172. e1-8.
46. Tuttle L, Ali Z, Schwartz J, et al. Length tension measurement of the anal sphincter muscle assessed by
functional luminal imaging probe (FLIP). Am J Physiol. 2018; [in press].
47. Kim YS, Weinstein M, Raizada V, et al. Anatomical disruption and length-tension dysfunction of anal
sphincter complex muscles in women with fecal incontinence. Dis Colon Rectum. 2013;56:1282–1289.
48. Rajasekaran MR, Sohn D, Salehi M, et al. Role of puborectalis muscle in the genesis of urethral pres-
sure. J Urol. 2012;188:1382–1388.
49. Percy JP, Neill ME, Swash M, et al. Electrophysiological study of motor nerve supply of pelvic floor.
Lancet. 1981;1:16–17.
50. Gordon AM, Huxley AF, Julian FJ. The variation in isometric tension with sarcomere length in verte-
brate muscle fibres. J Physiol. 1966;184:170–192.
51. Huxley AF, Simmons RM. Proposed mechanism of force generation in striated muscle. Nature.
1971;233:533–538.
52. Rajasekaran MR, Jiang Y, Bhargava V, et al. Length-tension relationship of the external anal sphincter
muscle: implications for the anal canal function. Am J Physiol Gastrointest Liver Physiol. 2008;295:
G367–G373.
53. Mittal RK, Sheean G, Padda BS, et al. The external anal sphincter operates at short sarcomere length in
humans. Neurogastroenterol Motil. 2011;23. 643–e258.
54. Mittal RK, Sheean G, Padda BS, et al. Length tension function of puborectalis muscle: implications
for the treatment of fecal incontinence and pelvic floor disorders. J Neurogastroenterol Motil.
2014;20:539–546.
55. Rajasekaran MR, Jiang Y, Bhargava V, et al. Sustained improvement in the anal sphincter function
following surgical plication of rabbit external anal sphincter muscle. Dis Colon Rectum.
2011;54:1373–1380.
56. Timor-Tritsch IE, Monteagudo A, Porges RF, et al. The use of a 15-7-MHz ‘smallparts’ linear transducer
to evaluate the anal sphincter in female patients. Ultrasound Obstet Gynecol. 2005;25:206–209.
57. Lee TH, Bharucha AE. How to perform and interpret a high-resolution anorectal manometry test.
J Neurogastroenterol Motil. 2016;22:46–59.
58. Chakraborty S, Feuerhak KJ, Zinsmeister AR, et al. Reproducibility of high-definition (3D) manometry
and its agreement with high-resolution (2D) manometry in women with fecal incontinence. Neuro-
gastroenterol Motil. 2017;29.
59. Raizada V, Bhargava V, Karsten A, et al. Functional morphology of anal sphincter complex unveiled by
high definition anal manometery and three dimensional ultrasound imaging. Neurogastroenterol
Motil. 2011;23:1013–1019.
e460.
60. Coss-Adame E, Rao SS, Valestin J, et al. Accuracy and reproducibility of high-definition anorectal
manometry and pressure topography analyses in healthy subjects. Clin Gastroenterol Hepatol.
2015;13:1143–1150. e1.
61. Cheeney G, Remes-Troche JM, Attaluri A, et al. Investigation of anal motor characteristics of the sen-
sorimotor response (SMR) using 3-D anorectal pressure topography. Am J Physiol Gastrointest Liver
Physiol. 2011;300:G236–G240.
28 ANORECTAL DISORDERS
3
How to Examine the Anorectal
Region
Satish S.C. Rao
DIV I S I ON O F GA STR O E N TER O L O GY A N D HEPA T O L O GY, M E DI C A L COLL E G E OF G E O R GIA ,
AUGU S T A UNIV E R S IT Y , AU GUS T A , GA , U N I T ED S T ATE S
3.1 Introduction
Fecal incontinence (FI) and dyssynergic defecation, along with other anorectal disorders
such as anal fissure, hemorrhoids, rectocele, and rectal prolapse, are common problems
that affect one-third of the US population.
1
In addition to a meticulous history, one should
perform a detailed physical examination including a neurological examination and, importantly, a digital rectal examination (DRE) to evaluate the perineum and anorectum.
2,3
Unfortunately, DRE is not routinely performed in clinical practice, except for perhaps as
a cursory exam prior to colonoscopy or sometimes to check for occult blood.
4
This problem
is further compounded by a lack of knowledge, and of training, on how to perform a
comprehensive DRE.
In one survey of 256 final-year medical students, 17% had never performed a DRE, and
48% were unsure of their findings.
5
Furthermore, other studies have shown that DRE is significantly underutilized. In a comprehensive survey of 652 faculty, fellows, medical residents, and medical students across four centers, on average 41 DREs were performed
annually.
4
Whilst most students felt they were inadequately trained, most physicians
reported a lack of confidence in performing DRE or making a diagnosis.
4
The reasons for
not performing a DRE included concerns such as “patient’s modesty,” “too invasive,” “limited value,” “convenience,” and “gender/chaperone” issues. Thus both training and utilization of DRE remains a challenge, which underscores the urgent need for training healthcare
providers at all levels. It is also important to educate trainees and peers regarding the potential benefits of a meticulous DRE. In one study of medical students training with a manikin
model significantly enhanced confidence for performing DRE,
6
suggesting that simulation
models can augment the learning ability, and provide an excellent means of learning.
3.2 DRE Protocol
In order to perform a proper and accurate DRE, a good set-up is needed.
Anorectal Disorders.
https://doi.org/10.1016/B978-0-12-815346-8.00003-5
© 2019 Elsevier Inc. All rights reserved.
29
DRE evaluation requires a good light source to illuminate the perineum, latex free
gloves, gauze, lubricating jelly, 2% lidocaine jelly, q tip, occult blood testing kit, and lighted
proctoscope (
Figs. 3.1 and 3.2).
DRE consists of four basic steps (
Table 3.1):
1. Inspection of the anus and perianal skin;
2. Assessment of perineal sensation and the anocutaneous reflex;
3. Digital palpation; and
4. Maneuvers to assess anorectal function.
FIG. 3.1 Figure shows proper patient position (left lateral) and light arrangement. With permission from Am J
Gasteroenterol, Elsevier.
FIG. 3.2 This figure shows the equipment needed to perform a comprehensive digital rectal examination. With
permission from Am J Gasteroenterol, Elsevier.
30 ANORECTAL DISORDERS
Table 3.1 Components of the Digital Rectal Examination, Technique, Expected
Findings, and Grading of Responses
Exam Component Technique Findings and Grading of Response(s)
I. Inspection of the
anus and surrounding
tissue
Place patient in the left lateral position with
hips flexed to 90 degrees. Inspect perineum
under good light
Skin excoriation, skin tags, anal fissure, scars
or external hemorrhoids, gaping anus,
prolapsed hemorrhoids or rectum,
condyloma
II. Testing of perineal
sensation and the
anocutaneous reflex
Stroke the skin around the anus in a
centripetal fashion (toward anus), in all four
quadrants, by using a stick with a cotton bud
Normal: Brisk contraction of the perianal skin,
the anoderm, and the external anal sphincter
Impaired: No response with the soft cotton
bud, but anal contractile response seen with
the opposite (wooden) end
Absent: No response with either end
III. Digital palpation Slowly advance a lubricated and gloved index
finger into the rectum and feel the mucosa
and surrounding muscle, bone, uterus,
prostate, and pelvic structures
Tenderness, mass, stricture, or stool and the
consistency of the stool (BSFS)
Examine prostate for nodules, mass,
tenderness
Evaluate for retroverted uterus, rectocele
IV. Maneuvers to
assess anorectal
function and
dysfunction
Resting tone Assess strength of resting sphincter tone Normal, weak (decreased), or increased
Squeeze maneuver Ask the patient to squeeze and hold as long
as possible (up to 30 s)
Normal, weak (decreased), or increased
Sphincter defects Palpate anal sphincter muscle for defects
during rest or squeeze maneuver
Describe as present or absent and degree of
sphincter loss using a clock or in quadrants
Push and bearing
down maneuver
In addition to the finger in the rectum, place
the other hand over the patient’s abdomen.
Ask the patient to push and bear down as if
to defecate and assess changes in abdominal
muscle tightening, perineal descent and
contraction or relaxation of anal sphincter
and puborectalis
(i) Abdominal push effort: Normal, weak
(decreased), excessive
(ii) Anal relaxation: Normal, impaired,
paradoxical contraction
(iii) Puborectalis relaxation: Normal, impaired,
paradoxical contraction
(iv) Perineal descent: Normal, excessive,
absent
(v) Rectal mucosal intussusception/prolapse:
Presence or absence
Anorectal pain
assessment
Palpate coccyx (bidigital), and palpate
levator-ani muscle in all four quadrants
Presence or absence of tenderness over
coccyx and/or levator-ani muscle. If present,
grade intensity on a scale of 0–10, and
whether sensation(s) experienced at home is
reproducible
Modify with permission from Am J Gastroenterol.
Chapter 3 • How to Examine the Anorectal Region 31
Body posit ion: The patient should be asked to lie in the left lateral position with the hips
flexed to 90 degrees (Fig. 3.1). At the outset, the examiner should exercise considerable
sensitivity, and spend time to explain the procedu re and allay any fears and anxiety associated with the procedure. Most patients are apprehensive about this procedure.
3.2.1 Inspection
The anus and surrounding tissue should be inspec ted using a bright light to check for skin
excoriation, skin tags, anal fissure, gaping anus, prolapsed rectum, stool staining, skin and
mucosal abnormalities (condyloma, etc.), scars, or hemorrhoids. Next, the anal mucosa
should be gently and carefully parted to examine and identify an anal fissure that may
be located usually posteriorly. If present, 2% lidocaine gel should be applied first and
one should wait for 5 min before finger insertion.
3.2.2 Assessment of Perineal Sensation and Anocutaneous Reflex
This is assessed with a cotton bud and by stroking the perianal skin toward the anus in
each of four quadrants. The normal anocutaneous reflex consists of a brisk contraction
of the anoderm and the external anal sphincter. This reflex examines the integrity between
the sensory nerves—S
2
, S3,S4neurons—and the motor innervat ion of anal sphincter. If
there is no response with the soft cotton bud the examiner should use the opposite
(wooden) end. If a response is evok ed with the wooden end but not the cotton end, then
it is categorized as impaired response, whereas if there is no response with either end it is
designated as absent, both of which suggest an underlying neuronal injury.
7
3.2.3 Digital Palpation
At this step the lubricated, gloved index finger is carefully advanced into the rectum. First
assess for any tenderness, spasm, mass, stricture, or stool. If stool is present, its amount,
consistency (Bristol stool scale), location, and the patient’s awareness of stool should be
noted. A lack of awareness of stool in the rectum suggests rectal hyposensitivity. In contrast, the presence of hard, compacted stool indicates long-standing stasis and/or fecal
impaction. In men, the prostate should be palpated for its size, contour, consistency,
nodularity, mass or tenderness by gently rotating the index finger anteriorly. Likewise,
in women, anteriorly a retroverted uterus, tenderness or m ass may be felt (
Fig. 3.3).
3.2.4 Maneuvers to Assess Anorectal Function
The next step is to assess the resting sphincter tone, the length of anal canal, and the
acuteness of the anorectal angle. The resting sphincter tone is categorized as normal, weak
(decreased), or increased. Next, the subject is asked to squeeze the anus and hold for 30 s.
32 ANORECTAL DISORDERS
The squeeze anal tone is also categorized as normal, weak (decreased), or increased.
Repeat once more to ensure that the patient has understood the command. Also, feel
for any anal sphincter defect(s) and categorize this as present or absent, and estimate
its size and location using a clock face (e.g., anterior defect between 10 o’clock and 1
o’clock).
Afterwards assess the bearing down or push effort. First, place the left hand on the
patient’s abdomen and ask the subject to push and bear down as if to defecate. The ability
to generate a good push effort is assessed by simultaneously feeling the abdominal muscles with the left hand on the belly. The ability to relax the puborectalis and external anal
sphincter tone and the degree of perineal descent are assessed by the finger in the rectum.
Repeat once more as patient’s may not have fully understood the examiner’s request or are
too shy to comply. A normal response consists of contraction of the abdominal muscles
together with relaxation of the anal sphincter and puborectalis muscle, and descent of the
perineum. The presence of two or more of the following findings during a DRE suggests a
bedside diagnosis of dyssynergia: (1) inability to contract the abdominal muscles,
(2) inability to relax the anal sphincter and /or puborectalis, (3) paradoxical contraction
of the anal sphincter or puborectalis, or (4) absence of perineal descent. An outward bulge
and excessive movement of the perineums that exceeds 3 cm is usually defined clinically
as excessive perineal descent.
8
3.2.5 Maneuvers for the Assessment of Anorectal Pain, Rectocele, and
Rectal Mucosal Intussusception
In patients with anorectal pain further assessment of anorectal structures should be performed. First, carefully palpate the puborectalis/levator-ani muscle in each of the four
quadrants by gently stroking the muscle and recording the presence and intensity of
FIG. 3.3 This cartoon shows the anatomical structures usually assessed during a digital rectal examination.
Reproduced with permission from Am J Gasteroenterol, Elsevier.
Chapter 3 • How to Examine the Anorectal Region 33
pain/discomfort on a scale of 0–10 as reported by the patient. Additionally, palpate the
anterior and posterior rectal wall for any rectal wall, vaginal wall, or prostate tenderness.
Next, advance the finger posteriorly, above the puborectalis muscle, and palpate the coccyx, both internally with the right index finger and externally with the left index finger, i.e.,
perform bidigital palpation and gently move the coccyx. If pain is evoked during this
maneuver it suggests coccygodynia.
Finally, rotate the finger and let it rest anteriorly, and ask the patient to push or bear
down. If the tip of the finger dips into an indentation of the anterior rectal wall when
the subject is bearing down, most likely a rectocele is present. Also during the push effort,
the presence of rectal mucosal intussusception or rectal prolapse can be detected as a
bulge felt at the tip of the finger.
3.3 Clinical Utility of DRE
The usefulness and accuracy of DRE has been assessed in several studies but there are
discrepant results in the literature. In one study of 66 FI patients, DRE findings somewhat
correlated with the resting sphincter pressure (r ¼ 0.56; P <.001) or maximum squeeze
pressure (r ¼ 0.72; P <.001).
9
However, another study of 280 patients who had several
anorectal disorders showed that the sensitivity, specificity, and positive predictive value
of DRE were very low.
10
Likewise, the positive predictive value of detecting a low sphincter
tone was 66.7 % and a low squeeze tone was 81%.
11
In another study of 64 patients, the
agreement between DRE and resting or squeeze pressure was 0.41 and 0.52, respectively.
12
Recently, in 41 patients with FI there was poor agreement for resting pressure but moderate agreement for squeeze pressure compared with high-resolution anal manometry.
13
A DRE scoring system (DRESS) for the resting and squeeze tone has been proposed using a
scale of 0–5.
14
In 303 patients, DRE versus anorectal manometry (ARM) showed a positive
correlation coefficient of 0.82 for resting and 0.81 for squeeze pressure. Another study
compared sphincter defects between DRE and ultrasound; whilst there was good correlation for large defects (150–270 degrees), there was modest correlation (61%) for defects
between 90 and 150 degrees, and poor correlation (37%) for those <90degrees.
15
Similarly,
DRE had good sensitivity (90%) but poor specificity (28%) for discriminating between
small and large sphincter defects.
16
Finally, one study showed that trainees lack adequate
DRE skills for recognizing resting and squeeze tone in FI despite coaching and may need
longer-term mentorship.
17
Thus DRE is not always reliable in FI, is prone to interobserver differences, and may be
influenced by many factors, including the size of the examiner’s finger, techniqu e, experience, and cooperation of the patient. Recent studies, however, show improved correlations when performed by single or well-trained examiners.
14,18
However, with regards to the assessment of patients with chronic constipation and
presence of dyssynergic defecation, DRE findings appear to be clinically useful. In one
study, the diagnostic yield of DRE was compared with ARM, balloon expulsion test, and
colonic transit study in a prospective study of 209 patients.
19
The sensitivity and
34 ANORECTAL DISORDERS
specificity of DRE for identifying dyssynergia were 75% and 87%, respectively, and the
positive predictive value was 97%. DRE also identified normal resting and squeeze pressure in 86% and 82% of dyssynergic subjects. Another study of 207 dyssynergic patients
confirmed these findings with similar positive predictive value but a lower specificity.
13
With regards to the presence of rectocele, moderate agreement was found for DRE when
compared to radiological imaging.
20
Thus DRE appears to be a reliable bedside tool for
identifying dyssynergia and rectocele, and for facilitating the selection of patients for further confirmatory physiologic testing.
13–15,19
3.4 Conclusion
In summary, DRE appears to be a useful tool for the assessment of common anorectal
disorders. Medical students, residents, and gastroenterology fellows should be trained
to perform DRE and encouraged to perform this evaluation in their routine practice. It
can reveal significant findings that can guide management, including the selection of
appropriate diagnostic tests. A normal DRE will mostly exclude significant anorectal dysfunction. Recent meticulous and comparative studies have provided new evidence for its
clinical utility when compared to objective anorectal tests. However, it must be emphasized that there is a steep learning curve for all practitioners and only through repeated
practice can one become adept with this technique.
References
1.
Rao SS, Bharucha AE, Chiarioni G, et al. Anorectal disorders. Gastroenterology. 2016;150:1430–1442.
2. Schey R, Cromwell J, Rao SSC. Medical and surgical management of pelvic floor disorders affecting
defecation. Am J Gastroenterol. 2012;107:1624–1633.
3. Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol.
2008;103:820–822.
4. Wong RK, Drossman DA, Bharucha AE, et al. The digital rectal examination: a multicenter survey of
physicians’ and students’ perceptions and practice patterns. Am J Gastroenterol. 2012;107:1157–1163.
5. Lawrentschuk N, Bolton DM. Experience and attitudes of final-year medical students to digital rectal
examination. MJA. 2004;181:323–325.
6. Kaplan AG, Abdelshehid CS, Alipanah N, et al. Genitourinary exam skills training curriculum for med-
ical students: a follow-up study of comfort and skill utilization. J Endourol. 2012;26:1350–1355.
7. Rao SS, American College of Gastroenterology Practice Parameters C. Diagnosis and management of
fecal incontinence. American College of Gastroenterology Practice Parameters Committee. Am J
Gastroenterol. 2004;99:1585–1604.
8. Harewood GC, Coulie B, Camilleri M, et al. Descending perineum syndrome: audit of clinical and
laboratory features and outcome of pelvic floor retraining. Am J Gastroenterol. 1999;94:126–130.
9. Hallan RI, Marzouk DEMM, Waldron DJ, et al. Comparison of digital and manometric assessment of
anal-sphincter function. BJS. 1989;76:973–975.
10. Herbst F, Teleky B. Alteration of maximum anal resting pressure by digital rectal examination prior to
Manometry—analysis of agreement between repeat measurements. Int J Colorectal Dis.
1994;9:207–210.
Chapter 3 • How to Examine the Anorectal Region 35
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