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 foreign body (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

The examiner should place the patient in the lateral decubitus position and wear protective gloves. The examination begins 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 note any prolapsing rectal mucosa or hemorrhoids. When the patient relaxes, prolapsed structures may retreat or remain external to the anus. By placing a finger firmly against the anal sphincter, it will relax and allow entry of the examiner’s gloved, lubricated finger (Fig. 45-2A). Once inserted into the anus, make a 360-degree sweep to identify any irregularities in the anorectum and prostate. On withdrawal of the examining finger, examine stool remaining on the glove for the presence of visible or occult blood (see Fig. 45-2B and C).² 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.³ Although not a firm contraindication in patients whose absolute neutrophil count is dangerously low, some would defer routine DRE, especially avoiding vigorous prostate manipulation, to minimize the likelihood of bacteremia.

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 prone or 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).

Procedure

Although most patients do not require intravenous sedation and analgesia, administer these agents as needed to keep the patient relaxed and comfortable. Before anoscopy, perform a routine DRE to identify sources of bleeding or pain and to locate any palpable masses. After DRE and with the obturator inserted completely into the anoscope, carefully introduce the scope into the anus. Use gentle, constant pressure to overcome resistance from involuntary contraction of the external anal sphincter. Gently advance the anoscope while asking the patient to bear down slightly. Pass the anoscope gently into the anorectum (see Fig. 45-4, step 2). If the obturator falls back during insertion, remove the anoscope completely and replace the obturator to avoid pinching the anal mucosa. Advance the anoscope until the outer flange impinges on the anal verge. Unless the anoscope has an internal light, use an external light source such as a penlight, otoscope, or pelvic examination light.

When the anoscope is fully inserted, remove the obturator (see Fig. 45-4, step 3). While gradually withdrawing the anoscope, visualize the anal canal (see Fig. 45-4, step 4). Swab away blood or debris to aid in visualization, and culture any abnormal discharge that is found. Note whether there is rectal bleeding or an FB beyond the reach of the anoscope. Withdraw the anoscope slowly as the entire circumference of mucosa is inspected for hemorrhoids, anal fissures, ulcerations, abscesses, or tears. Near the last stage of withdrawal, be aware of reflex spasm of the anal sphincter, which may cause the anoscope to be expelled quickly. Use firm counterpressure to prevent such rapid expulsion.

Complications

Although complications are rare, patients often complain of increased pain after the examination. Local mucosal irritation with subsequent bleeding is the most common complication. To prevent transmission of infectious diseases, dispose of or sterilize instruments after each use.

Conservative Treatment

ED management of minor internal hemorrhoids is conservative. Prolapsing internal hemorrhoids will not benefit long-term from conservative intervention and should receive surgical consultation. A useful mnemonic for managing hemorrhoids is WASH: water (increase fluid intake, warm water contacting the hemorrhoid via bath or directed shower), analgesics, stool softeners, and a high-fiber diet.² Psyllium (e.g., Metamucil) is often prescribed as a dietary supplement to increase fiber. Hemorrhoids that fail to respond to medical management may be treated on an outpatient basis with rubber band ligation, sclerosis, and thermotherapy consisting of an infrared beam, electric current, CO₂ laser, or ultrasonic energy. Patients who must push hemorrhoids back in after a bowel movement have symptomatic third-degree internal hemorrhoids and would benefit from elective surgical referral. This condition can easily be demonstrated by having the patient strain before DRE. Nonreducible prolapsed internal hemorrhoids should receive prompt surgical consultation and, frequently, admission to the hospital.⁶

Without treatment, thrombosed external hemorrhoids and those that have spontaneously ruptured will generally resolve over a period of 1 to 3 weeks. Residual skin tags may persist. During the interim, however, they are quite painful and may bleed. Small ruptured or nonruptured hemorrhoids that are seen acutely with minimal discomfort may be managed conservatively with warm water baths or a directed stream of water, topical corticosteroids (Anusol HC), or Preparation H. These topical agents may promote skin breakdown from the corticosteroid or local anesthetic if used for more than a couple of days. Since the pain is most severe within the first 48 hours, patients evaluated within this time window benefit from excision (not incision and drainage) of the contents of the thrombosed external hemorrhoid and its overlying skin. Patients seen after this time are usually best managed with conservative treatment because the thrombosis begins the reabsorption process and may be liquefied (see Fig. 45-5D).^2,4,8,9