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Anorectal Procedures
Patients with anorectal disorders frequently seek care in the emergency department (ED). The condition may be isolated or the anorectal complaint may be an outward manifestation of a serious underlying illness. A thorough history and physical examination must precede any procedure. Because of the nature of these conditions, extreme sensitivity and professionalism must be applied.
Patients may be anxious about anorectal examination or associated procedures, including the simple digital rectal examination (DRE). The results of DRE may lead to performing diagnostic or therapeutic procedures such as anoscopy, excision of thrombosed external hemorrhoids, drainage of anorectal abscesses or pilonidal cysts, reduction of rectal prolapse, or removal of rectal foreign bodies (FBs). For these procedures, analgesia, sedation, or both may be useful adjuncts.
Anatomy
The rectum and anus compose the most distal portion of the gastrointestinal tract. The rectum begins at the level of the third sacral vertebra and extends distally 12 to 15 cm. Blood supply to the anorectum is derived from the superior, middle, and inferior hemorrhoidal arteries. Venous drainage from the rectum and anus returns to both the portal and systemic systems ( Fig. 45.1 ). The dentate (pectinate) line marks the transition from the rectum to the anus and contains submucosal glands in anal crypts. Occlusion with subsequent infection of these glands is the cause of anorectal abscesses. Sensory innervation to the rectum is primarily visceral, whereas the anus is innervated by cutaneous fibers. Therefore patients are often unaware of rectal pathology because the pain associated with it may be vague or absent. By contrast, anal lesions are usually very painful and well localized.
Digital Rectal Exam (DRE)
Indications and Contraindications
The physical examination should be performed in a private location and the patient should be completely draped and relaxed. Generally, a calm atmosphere and caring examiner preclude the need for analgesic or anxiolytic agents, although they may be needed to facilitate a thorough examination. In some extremely painful conditions, such as thrombosed or gangrenous hemorrhoids, DRE may be postponed until the patient is anesthetized. If a sharp-edged FB (e.g., metal blade or broken glass) is suspected, performing a DRE may cause injury to the clinician, as well as the patient. In these cases, radiologic evaluation with subsequent operative management may be indicated.
Procedure
Place the patient in the lateral decubitus position and wear protective gloves. Begin the examination with a preliminary visual inspection of the perianal area for important information regarding patient hygiene, trauma, or sexually transmitted diseases. Next, ask the patient to perform a Valsalva maneuver and look for prolapsing rectal mucosa or hemorrhoids. When the patient relaxes, prolapsed structures may retreat or remain external to the anus. By placing a gloved finger firmly against the anal sphincter, it will relax and allow entry of the examiner's gloved, lubricated finger ( Fig. 45.2 A ) . Once inserted into the anus, make a 360-degree sweep to identify any irregularities in the anorectum and prostate. After withdrawing the finger, examine stool remaining on the glove for the presence of visible or occult blood (see Fig. 45.2 B and C ). Testing for blood in stool is discussed in detail in Chapter 67 .
Complications
Although DRE causes some vasovagal depression, it is safe to perform in patients with acute myocardial infarction. Although it is not a firm contraindication in patients whose absolute neutrophil count is dangerously low, many would defer routine DRE, especially avoiding vigorous prostate manipulation, to minimize the likelihood of bacteremia.
Anoscopy
Indications and Contraindications
When evaluating a patient for anal pathology, some practitioners use anoscopy as an adjunct to DRE. Internal hemorrhoids, tears in the distal rectal mucosa, FBs, and distal anorectal masses may be visualized. An imperforate anus is the only absolute contraindication to anoscopy; however, severe rectal pain, a common complaint in the ED, may preclude awake anoscopic examination in anxious patients or those suffering from thrombosed hemorrhoids or other painful conditions. Internal visual inspection in these patients is better performed with sedation. In many cases a more definitive study such as sigmoidoscopy or colonoscopy is being planned by the treating physician, and thus anoscopy can be deferred in the acute care setting.
Equipment and Setup
The anoscope is a plastic or stainless steel tube with a removable obturator ( Fig. 45.3 ). It may have an integrated light source or require an external light or head lamp. An appropriate examination table, topical anesthetics, lubricant, gauze, and forceps may also be required.
Positioning
Ideally, place the patient in a prone position on a proctoscopic examination table. The lateral decubitus position with the knees and hips flexed may also be adequate and is sometimes tolerated better. In the lateral decubitus position, place the patient on the left side if the examiner is right-handed ( Fig. 45.4 , step 1 ).
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