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The Dreaded Digital Rectal Examination

“It still brings tears to my eyes!!!”


Qualitative Research Data

Patient: “The doctor talked to me


while he was doing the rectal exam
and told me what he was doing, what
he was finding, so that was good. So
he was kind of walking me through it
while he did it.”
Qualitative Research Data

Patient: “The way she used the


bedsheet to cover me up, that was
fine. She covered me up with this, so
basically I was exposed only for the
few seconds of the exam. That was a
nice touch.”
Terminology

• Haemorrhoides (Greek)
Haem = blood, rhoos = flowing
 flowing of blood
Anorectal Anatomy
HEMORRHOIDS
Normal anatomical structures

1. Treitz’ muscle 8. Int. Hemorrhoidal


1 plexus
2. M levator ani
9. Columns
2 of Morgagni
3. Internal
sphincter 10. Anal crypt
8
4. Ext. Sphincter 11. Dentate line
9
(deep band) 3
12. Ext. Sphincter
4 (subcutaneous
5. Parks’ ligament
10
band)
11
5 13 Ext. Hemorrhoidal
plexus
12
13
PLEXUS HEMORRHOIDS
HEMORRHOIDAL DISEASE

Increased
arterial flow
Disfunction of
arteriovenous shunt
Extended
venous back flow
Microvascular stastis

Venous
stasis

 Capillary fragility
 Hyperpermeability

Local inflammatory
process
Haemorrhoidal prolaps
Prolaps with vein dilatation
Assessment of Patients
HISTORY :
- Colour & Character of the Bleeding
- Discomfort to Defecation
- Unequivocal History of Relief from Reduction of the
Prolapse into the Anal Canal

INSPECTION : - Relaxed in the left lateral position


- Good light
- Careful inspection and palpation

PALPATION : - Gentleness
- Slowly with adequate lubrication
Endoscopy
o Proctoscopy : - the presence of internal vascular
cushions ( bleeding ?)
 dd/ of causes of rectal or anal bleeding

Proctoscopic View of Haemorrhoids


Diagnosis & Differential Diagnosis
o Painless Bleeding
dd: - Colorectal malignancy
- Inflammatory Bowel Disease
- Diverticular Disease
- Adenomatous Polyps
o Painful Bleeding associated with a level movement:
– Rectal ulcer
– Anal Fissure
o Mucus Discharge
o Moisture or Maceration, dd: condylomata acuminata
o Straining at stool, dd: obstructed defecation
o Hemorrhoid Prolapse, dd: Rectal Prolapse
o Anal Sweeling, Mass
o Discomfort
(L.W. Way & G.M. Doherty, Current Surgical Diagnosis & Treatment, 2003)
Skin tag fibrous polyp
Essentials of Diagnosis
Internal Hemorrhoids:
o Bright red blood per rectum
o Mucus discharge
o Rectal fullness or discomfort

External Hemorrhoids:
o Sudden, Severe Perianal Pain
o Perianal Mass
Staging of Internal Hemorrhoids
Management for Hemorrhoid
Internal Hemorrhoid:
Grade 1  conservative
 infra red photocoagulation

Grade 2  conservative
 infra red photocoagulation
 rubber band ligation

Grade 3  high fiber diet


 rubber band ligation
 hemorrhoidectomy

Grade 4  hemorrhoidectomy

Internal/external Hemorrhoid with thrombosis


 emergency hemorrhoidectomy
Prolaps Recti

• Prolaps rekti adalah suatu extrusi atau


keluarnya seluruh ketebalan dari dinding
rektum ke atau melalui anal kanal.
Etiologi

• Etiologi prolaps disebabkan oleh intususepsi


• peritoneal cul de sac
• diastasis dari levator, redundan rectosigmoid,
stretching dan denervasi dari anal sphincter
• hilangnya posisi horizontal rektum dengan
attenuation dari sacral dan pelvic attachment,
• kehilangan support ke uterus dan bladder
dan perineal descent.
Faktor Predisposisi

• Straining
• Schistosomiasis dan Amubiasis
• Gangguan Neurologis
• Melahirkan Pervaginam
• Konstipasi
Gejala Klinis

• Prolaps , keluarnya mucous, kadang-


kadang perdarahan, dan diare. Sebaliknya
juga dapat terjadi yaitu konstipasi berat.
• Diare dan urgensi sering pula terjadi pada
pasien yang disertai proktitis dan pada
pasien dengan irritable bowel syndrome.
• idiopathic fecal incontinence saja untuk
jangka waktu yang lama sebelum tampak
adanya prolaps.
Pemeriksaan Penunjang

• Sigmoidoskopy
• Barium Enema
• Videoproctography

Pemeriksaan Fisiologis

• Manometri Anal
• Saline infusion test
• Rectal Sensation and Compliance
• Anal Reflex
• Electromyography and Nerve Conduction
Terapi Konservatif

• Pengelolaan secara konservatif jarang berhasil dalam


menangani prolaps rekti.
• mendidik pasien muda untuk buang air besar tanpa
mengedan sangat menolong karena beberapa
rekurensi dini
• Pada penderita-penderita yang konstipasi baik untuk
mengupayakan kebiasaan untuk buang air besar
dengan anjuran diet dan penggunaan laxative ringan.
• Latihan dasar panggul
• Beberapa anal plug yang memberikan stimulus listrik
faradic dipakai untuk menangani prolapas rekti, tetapi
tidak pernah dapat mengontrol prolaps rekti.
Pengelolaan Bedah

• Tujuan dari pembedahan yang sama


pentingnya selain untuk mengontrol prolaps
adalah memperbaiki gangguan fungsional
usus sehingga pasien dapat kembali
menjalani kehidupan yang normal.
• Ada 2 tujuan yang diharapkan :
• (1) mengontrol prolaps
• (2) memperbaiki kontinensia atau mencegah
konstipasi dan gangguan evakuasi.
Berbagai prosedur
• perianal suture
• Resection
• pelvic floor repair
• ligation exclusion dan rectopexy;
prosedur-prosedur ini dapat dilakukan
melalui abdominal ataupun perineal
Hemmorhoid vs Rectal prolapse
Hemmorhoid vs rectal prolaps
Proctitis
• An inflammation of the rectum causing discomfort, bleeding,
and occasionally, a discharge of mucus or pus, And the anus
may also be involved.
• Causes:
* Sexually-transmitted diseases(gonorrhea, herpes, Syphilis ,chlamydia, and
lymphogranuloma venereum.
* Non-sexually transmitted infections( Beta-hemolytic streptococcus ,
Amoebic dysentry, Bilharzial dysentry)
*Autoimmune diseases (Ulcerative colitis and crohn’s disease)
* Tuberculous proctitis
* AIDS
*Radiation Proctitis
* noxious agents
Proctitis
• Symptoms:
• pain, discomfort
• rectal bleeding
• rectal discharge, pus
• stools, bloody
• constipation
• Tenesmus

*Tests:
• proctoscopy
• sigmoidoscopy
• rectal culture
Proctitis
• Treatment: treatment of the underlying cause usually
cures the problem. Proctitis caused by infection is
treated with antibiotics specific for the causative
organism. Corticosteroid or mesalamine suppositories
may relieve symptoms in Crohn's disease or ulcerative
colitis.
Thank
You