Chapter 1 22 First, the anus and surrounding tissue is carefully inspected for skin excoriation, condyloma, skin tags, scars or external hemorrhoids, gaping anus, prolapsed hemorrhoids, or prolapse of the rectum and anal fissure. Chronic anal fissure could present as a wide and deep ulcer, sometimes with visible sphincter fibers, the presence of a sentinel polyp, keratinous edges, and hypertrophied anal papillae.47 The perineal sensation and anocutaneous reflexes are assessed by stroking the perianal skin in all four quadrants around the anus with a cotton bud. A normal response consists of a brisk contraction of the perianal skin, the anoderm, and the EAS. The anocutaneous reflex examines the integrity between the sensory nerves, S 2, S 3, S 4 neurons and motor innervation of the anal sphincter.46 A careful internal digital rectal examination combined with a vaginal examination is an another essential component of clinical investigation, to inquisite anal sphincter pressure, pelvic floor muscle tone- and function and dyssynergia.48-50 However, it should be mentioned that during medical school there is a lack of emphasis on the use of digital rectal examination and it is inadequately used, nor performed in clinical practice in patients with functional anorectal complaints.50 Besides that, the use of digital rectal examination is often delayed because of the assumption that it is contradicted or should be kept to a minimum because of associated pain. Starting digital rectal examination, the gloved finger should be placed in the center of the anus with the finger parallel to the skin of the perineum in the midline. It is important to wait for several seconds for the IAS to relax. Then slowly advance the lubricated finger into the anus. The resting pressure is predominantly attributed to the IAS. The sphincter pressure can be assessed in rest and scored as low, normal, or high. Any presence of tenderness, mass, stricture, stool, and its consistency should be noticed. The pelvic floor muscle tone is assessed (resistance provided by a muscle when a pressure/ deformation or a stretch is applied to it) on the levator ani muscle on both the right and left sides of the rectum and scored as decreased, normal or increased.48,49,51 Tenderness to palpation with traction on the puborectalis muscle is an important feature of levator ani syndrome.8,42 Tenderness can be scored according to each patients’ reactions: 0, no pain; 1, painful discomfort; 2, intense pain; with a maximum total score of 12.52 To investigate the function of the pelvic floor muscles, the patient is asked to squeeze the pelvic floor muscles as hard as possible (maximum strength), to sustain the squeeze contraction (30 seconds) (endurance), or to repeat squeeze contractions (repetitions). Measurement of squeeze pressure involves the exertion of pressure, compressing the assessor’s finger during digital palpation.52
RkJQdWJsaXNoZXIy MTk4NDMw