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Anus and Rectum
ANUS AND RECTUM J.
KENNETH HARRIS, M.D.
Of special importance to the examiner of children are the anatomic relations of the rectum, anus, sacrum and coccyx. In the adult there is considerable concavity of the sacrum and coccyx which causes a corresponding angularity of the rectum at the anus. In the child this concavity is relatively minimal, and there is nearly a straight-line relation of the rectum and anus. As a result of this anatomic relation the stress of defecation, crying and breath-holding is made directly downward on the anus, accounting for the frequency of prolapse and procidentia in the younger age group. The rectal mucosa is thinner and nonnally much redder than that of the adult. The size of the stool of the child of one year of age or older indicates the use of adult-sized instruments and utilization of the index finger in digital examination. The little finger and pediatric-sized instrument should be used in the child under a year of age. INSPECTION
The infant is most conveniently examined on his back with the knees held in flexion upon the abdomen by the mother or assistant. The older child is asked to kneel upon the examining table and then bend forward, placing the side of the face upon the table. In this position, gentle lateral pressure to the sides of the anus, reassuring comments to the child, and a request to strain as at stool may lead to relaxation of the sphincter and allow brief visualization several centimeters through the anus. The presence of circumanal erythema suggests irritating feces, Oxyuris vermicularis infestation, antibiotic pruritus ani, mycotic infection or faulty hygiene, whether it be too little attention by the child or too vigorous wiping by the parent. More peripheral erythema accompanies ammoniacal diaper rash, detergent burns, and rubbing of a coarse diaper. Cellulitis and abscess formation are apparent. Congenital or acquired fistulous openings may be more difficult to see. Multiple excoriations 1 ~l
152
ANUS AND RECTUM
and superficial fissuring may signify pruritus ani or congenital syphilis. Congenital anal tags are frequently accompanied by fissures. Acquired anal fissure is the most common pathologic lesion of the anus. The location in the infant is usually lateral in contrast to the posterior position for the older child, a fact related to the angulation of the rectum in the latter. The straining of the child may cause the appearance of prolapse or procidentia, or the expulsion of mucus, pus or blood. Hemorrhoids are an uncommon finding in children, although internal hemorrhoids are often mistakenly diagnosed because of the normally reddened mucosa of the child. PREPARATION FOR INTERNAL EXAMINATION
Psychological
The mother needs a brief explanation of the examination contemplated, with reassurance about pain and discomfort. The infant is helpful in that the procedure usually brings about straining. The older child is told of anticipated discomfort, but he should be reassured that should pain occur, the examination will be interrupted. Compare the feeling to a need for defecation. Constant verbal assurances are needed during the examination. The asking of questions by the examiner makes the child feel that he is being a helpful participant. Tense children can be helped by administration of a tranquilizing drug several hours before examination. Physical
Usually no preparation is necessary, especially for examination limited to the rectum and anus. The use of a cleansing saline enema or the prepackaged enema will evacuate fecal material, but may also wash away excretions of significance. The use of suppositories before visual examination is contraindicated because the coating imparted to the mucosa may obscure small lesions. Digital
The patient lies on his back with the hips flexed. It is helpful for the buttocks to be elevated slightly on a low pad. The gloved finger is lubricated with warm water-soluble jelly. For the infant under one year the little finger should be used. Since the long axis of the ovoid anus runs anterior-posterior, the finger should be inserted so that the palmar finger surface is against the lateral anus wall. The insertion should be made slowly and with pauses until the sphincter has reached full relaxation. Once the anal canal is passed, the finger should be directed posteriorly to explore the curve of the sacrum. After palpation for obvious masses a bimanual examination should be made, the opposite hand palpating the lower part of the abdomen. Then the thumb,
J.
KENNETH HARRIS
153
apposing the examining finger, is used to palpate the perianal area in systematic clockwise fashion, searching for areas of tenderness. PROCTOSCOPIC EXAMINATION
The anoscope or proctoscope may be successfully used without further preparation if the digital examination reveals an empty rectum. But if the rectum is full, an appointment for the next morning may be made. After the morning defecation a prepackaged disposable enema provides good cleansing for an examination several hours later. The anoscope and proctoscope are the instruments of choice in young patients, since none but the highly experienced examiner should try to pass beyond the angulation of the sigmoid. As previously suggested, these instruments may be of adult diameter in children over one year of age. The instrument is warmed and well lubricated with water-soluble jelly. After digital examination the sphincter becomes more relaxed and insertion of the instrument is facilitated. The instrument is pointed toward the umbilicus during insertion. The obturator is removed, and further advancement is made by visually following the lumen of the bowel ahead. It is well to keep in mind that the mucosa is very thin and that the peritoneal reflection is within Y2 inch of the perineum in the infant. Pause at any sign of discomfort from the patient, and discontinue the examination if forceful restraint becomes necessary. TREATMENTS
Anal stenosis of type I as described by Ladd and Gross is a relatively common finding in the young infant. Treatment consists in daily dilatations with progressively larger dilators until the index finger is admissible. The dilatations should be continued several times weekly for four months. If the stenosis is not so severe that an instrument has to be used for the initial dilatation, the mother may do the entire procedure at home, progressing from the tip of the little finger to the insertion of the index finger past the level of the distal interphalangeal joint. Anal fissure, uncomplicated by cryptitis above or the presence of a sentinel pile below, usually responds to medical treatment. There are two objectives in children: (1) the maintenance of soft stools and (2) the relaxation of muscle spasm. The method of obtaining soft stools is largely a matter for the individual physician to decide, but harsh laxatives should be avoided because of consequent local irritation with its accompanying increased sphincter spasm. The application of moist heat, whether by compression or sitz bath, is universally accepted as the best means of reducing irritation and spasm. Further help can be had by application of a topical anesthetic, preferably in a solution. An ointment may tend to delay healing. Topical antibiotics in a water-miscible base will help to reduce inflammation of the contaminated fissure.
154
ANUS AND RECTUM
Prolapse and procidentia are treated acutely by wrapping the finger in tissue, inserting it into the lumen and gently guiding the mass back through the anus. The tissue is left in place as the finger is withdrawn. A ball of cotton is placed over the anus, and the buttocks are taped together. Sclerosing solutions to produce scarring and fixation should be injected only by the expert. Symptomatic cryptitis, papillitis or deep abscesses should receive the care of a proctologist, since operation is ordinarily indicated. A superficial abscess may be opened, provided incision is wide and a drain is left in place for 24 hours. Acute pruritus ani responds slowly to wet dressings and an oral antipruritic agent. Ointments are contraindicated. Tight underpants, pinworms and improper hygiene are common causes in childhood and should be corrected. Fecal impactions are fragmented by pressing the mass against the sacrum with the examining finger. Enemas of mineral oil or saline solution are then normally sufficient to effect passage. The use of hydrogen peroxide as an enema for this purpose has been abandoned as a dangerous procedure. ENEMAS
Since ancient Egyptian times the enema has been a fascinating tool of the medical healer. Through the ages the enema has been utilized for the removal of evil spirits, toxic gases and other supposed noxious substances. The present-day approach seems to be a more rational one utilizing the enema for these basic functions: ( 1) to cleanse and empty the lower bowel; (2) to reduce body temperature; (3) to administer fluids, electrolytes or medication. The Cleansing Enema
The infant is placed on his back with the thighs flexed on the abdomen. The older child lies on the left side with the thighs flexed. The bedding is protected by plastic or rubber sheeting, or the bathinette may be utilized for the infant and the bathtub (warm, please) for the older child. It is convenient to elevate the buttocks on a pad so that a shallow basin can be placed under the anus to catch spillage. The warmed and lubricated tube is inserted, with pauses, to a maximum of 3 inches. The flow should be nonforceful, and even small amounts should take at least one minute to instill. If possible, the open-funnel type of container should be used in combination with an appropriate-sized catheter (i.e. no. 14 to 24 French). Held at a level 18 inches above the anus, gravity provides a safe force to the instillation. If expulsion starts before the enema is completed, continue the flow until the return is clear. If distention takes place, cease the flow and encourage evacuation. Appropriate volumes of fluids for the various ages are 3 ounces at birth, 16 ounces at 4 years, and 32 ounces for the teenager.
J.
KENNETH HARRIS
155
There is a wide choice of ingredients for the cleansing enema. Tap water in sufficient quantity is the favorite. Instead of a soapsuds enema, if soap jelly (softened soap) is used to lubricate the tube for insertion, the anal canal is appropriately irritated to produce the defecation urge. Thus the irritating effect of a soap solution on the colonic mucosa is avoided by the use of clear tap water. As the enema is expelled, the soap is washed from the anus. If prolonged enema irrigation is needed, saline solution should be used to avoid water intoxication or electrolyte depletion. Mineral oil aids in softening fecal matter and in lubricating its evacuation. The use of a wetting agent in the enema fluid has been of doubtful value in my experience. The prepackaged enema containing hypertonic phosphate salts is convenient to use and dramatically effective, but may give rise to considerable mucosal irritation. Do not use hydrogen peroxide as an enema fluid. The Retention Enema
The technique is the same as for the cleansing enema except that a relatively small quantity of fluid is used (2 or 3 ounces for the infant, 4 to 6 ounces for the older child), and efforts are made to encourage retention. Retention is accomplished by rolling the child onto his abdomen as soon as the fluid has been instilled and holding the buttocks together for a few minutes. The enema to reduce body temperature consists of normal saline solution at 50 to 60° F. This is the average temperature of city tap wate.r in the winter. Normal saline solution is made by adding JA. teaspoonful of table salt to 4 ounces of water. Repeated retention enemas of saline at a three-hour interval are an effective means of administering fluids and electrolytes. Enterodysis for the vomiting child or the sick child refusing oral fluids is often so successful that hospitalization for dehydration is avoided. The use of an enema to administer a number of systemic medications is a well known procedure. Skimmed milk or starch solution used as a vehicle reduces the rectal irritation of many medicaments and increases the chance of retention and absorption. Starch solution is used as an emollient for an inflamed mucosa. Use one teaspoonful of starch for each ounce of water. SUMMARY
Successful examination of the anus and the rectum of the infant or older child depends lljJon the development of proficiency in certain techniques. An understanding of the anatomic relations of the rectum, the anus and the sigmoid colon is important. Preparation for the internal examination is the key to success, culminating in endoscopic examination. The techniques and local treatment of common anorectal disorders, as they are encountered in office practice, are discussed. The enema
156
ANUS AND RECTUM
stilI has a place in pediatric practice. Its use and technique of administration have been reviewed. REFERENCES
1. Mentzer, C. G.: Anorectal Disease. PEDIAT. CUN. NORTH AMERICA, 3:113, 1956. 2. Turell, R.: Diseases of the Colon and Anorectum. Philadelphia, W. B. Saunders Company, 1959. 4122 Shelbyville Rd. Louisville, Ky.
KENNETH HARRIS, M.D.
Of special importance to the examiner of children are the anatomic relations of the rectum, anus, sacrum and coccyx. In the adult there is considerable concavity of the sacrum and coccyx which causes a corresponding angularity of the rectum at the anus. In the child this concavity is relatively minimal, and there is nearly a straight-line relation of the rectum and anus. As a result of this anatomic relation the stress of defecation, crying and breath-holding is made directly downward on the anus, accounting for the frequency of prolapse and procidentia in the younger age group. The rectal mucosa is thinner and nonnally much redder than that of the adult. The size of the stool of the child of one year of age or older indicates the use of adult-sized instruments and utilization of the index finger in digital examination. The little finger and pediatric-sized instrument should be used in the child under a year of age. INSPECTION
The infant is most conveniently examined on his back with the knees held in flexion upon the abdomen by the mother or assistant. The older child is asked to kneel upon the examining table and then bend forward, placing the side of the face upon the table. In this position, gentle lateral pressure to the sides of the anus, reassuring comments to the child, and a request to strain as at stool may lead to relaxation of the sphincter and allow brief visualization several centimeters through the anus. The presence of circumanal erythema suggests irritating feces, Oxyuris vermicularis infestation, antibiotic pruritus ani, mycotic infection or faulty hygiene, whether it be too little attention by the child or too vigorous wiping by the parent. More peripheral erythema accompanies ammoniacal diaper rash, detergent burns, and rubbing of a coarse diaper. Cellulitis and abscess formation are apparent. Congenital or acquired fistulous openings may be more difficult to see. Multiple excoriations 1 ~l
152
ANUS AND RECTUM
and superficial fissuring may signify pruritus ani or congenital syphilis. Congenital anal tags are frequently accompanied by fissures. Acquired anal fissure is the most common pathologic lesion of the anus. The location in the infant is usually lateral in contrast to the posterior position for the older child, a fact related to the angulation of the rectum in the latter. The straining of the child may cause the appearance of prolapse or procidentia, or the expulsion of mucus, pus or blood. Hemorrhoids are an uncommon finding in children, although internal hemorrhoids are often mistakenly diagnosed because of the normally reddened mucosa of the child. PREPARATION FOR INTERNAL EXAMINATION
Psychological
The mother needs a brief explanation of the examination contemplated, with reassurance about pain and discomfort. The infant is helpful in that the procedure usually brings about straining. The older child is told of anticipated discomfort, but he should be reassured that should pain occur, the examination will be interrupted. Compare the feeling to a need for defecation. Constant verbal assurances are needed during the examination. The asking of questions by the examiner makes the child feel that he is being a helpful participant. Tense children can be helped by administration of a tranquilizing drug several hours before examination. Physical
Usually no preparation is necessary, especially for examination limited to the rectum and anus. The use of a cleansing saline enema or the prepackaged enema will evacuate fecal material, but may also wash away excretions of significance. The use of suppositories before visual examination is contraindicated because the coating imparted to the mucosa may obscure small lesions. Digital
The patient lies on his back with the hips flexed. It is helpful for the buttocks to be elevated slightly on a low pad. The gloved finger is lubricated with warm water-soluble jelly. For the infant under one year the little finger should be used. Since the long axis of the ovoid anus runs anterior-posterior, the finger should be inserted so that the palmar finger surface is against the lateral anus wall. The insertion should be made slowly and with pauses until the sphincter has reached full relaxation. Once the anal canal is passed, the finger should be directed posteriorly to explore the curve of the sacrum. After palpation for obvious masses a bimanual examination should be made, the opposite hand palpating the lower part of the abdomen. Then the thumb,
J.
KENNETH HARRIS
153
apposing the examining finger, is used to palpate the perianal area in systematic clockwise fashion, searching for areas of tenderness. PROCTOSCOPIC EXAMINATION
The anoscope or proctoscope may be successfully used without further preparation if the digital examination reveals an empty rectum. But if the rectum is full, an appointment for the next morning may be made. After the morning defecation a prepackaged disposable enema provides good cleansing for an examination several hours later. The anoscope and proctoscope are the instruments of choice in young patients, since none but the highly experienced examiner should try to pass beyond the angulation of the sigmoid. As previously suggested, these instruments may be of adult diameter in children over one year of age. The instrument is warmed and well lubricated with water-soluble jelly. After digital examination the sphincter becomes more relaxed and insertion of the instrument is facilitated. The instrument is pointed toward the umbilicus during insertion. The obturator is removed, and further advancement is made by visually following the lumen of the bowel ahead. It is well to keep in mind that the mucosa is very thin and that the peritoneal reflection is within Y2 inch of the perineum in the infant. Pause at any sign of discomfort from the patient, and discontinue the examination if forceful restraint becomes necessary. TREATMENTS
Anal stenosis of type I as described by Ladd and Gross is a relatively common finding in the young infant. Treatment consists in daily dilatations with progressively larger dilators until the index finger is admissible. The dilatations should be continued several times weekly for four months. If the stenosis is not so severe that an instrument has to be used for the initial dilatation, the mother may do the entire procedure at home, progressing from the tip of the little finger to the insertion of the index finger past the level of the distal interphalangeal joint. Anal fissure, uncomplicated by cryptitis above or the presence of a sentinel pile below, usually responds to medical treatment. There are two objectives in children: (1) the maintenance of soft stools and (2) the relaxation of muscle spasm. The method of obtaining soft stools is largely a matter for the individual physician to decide, but harsh laxatives should be avoided because of consequent local irritation with its accompanying increased sphincter spasm. The application of moist heat, whether by compression or sitz bath, is universally accepted as the best means of reducing irritation and spasm. Further help can be had by application of a topical anesthetic, preferably in a solution. An ointment may tend to delay healing. Topical antibiotics in a water-miscible base will help to reduce inflammation of the contaminated fissure.
154
ANUS AND RECTUM
Prolapse and procidentia are treated acutely by wrapping the finger in tissue, inserting it into the lumen and gently guiding the mass back through the anus. The tissue is left in place as the finger is withdrawn. A ball of cotton is placed over the anus, and the buttocks are taped together. Sclerosing solutions to produce scarring and fixation should be injected only by the expert. Symptomatic cryptitis, papillitis or deep abscesses should receive the care of a proctologist, since operation is ordinarily indicated. A superficial abscess may be opened, provided incision is wide and a drain is left in place for 24 hours. Acute pruritus ani responds slowly to wet dressings and an oral antipruritic agent. Ointments are contraindicated. Tight underpants, pinworms and improper hygiene are common causes in childhood and should be corrected. Fecal impactions are fragmented by pressing the mass against the sacrum with the examining finger. Enemas of mineral oil or saline solution are then normally sufficient to effect passage. The use of hydrogen peroxide as an enema for this purpose has been abandoned as a dangerous procedure. ENEMAS
Since ancient Egyptian times the enema has been a fascinating tool of the medical healer. Through the ages the enema has been utilized for the removal of evil spirits, toxic gases and other supposed noxious substances. The present-day approach seems to be a more rational one utilizing the enema for these basic functions: ( 1) to cleanse and empty the lower bowel; (2) to reduce body temperature; (3) to administer fluids, electrolytes or medication. The Cleansing Enema
The infant is placed on his back with the thighs flexed on the abdomen. The older child lies on the left side with the thighs flexed. The bedding is protected by plastic or rubber sheeting, or the bathinette may be utilized for the infant and the bathtub (warm, please) for the older child. It is convenient to elevate the buttocks on a pad so that a shallow basin can be placed under the anus to catch spillage. The warmed and lubricated tube is inserted, with pauses, to a maximum of 3 inches. The flow should be nonforceful, and even small amounts should take at least one minute to instill. If possible, the open-funnel type of container should be used in combination with an appropriate-sized catheter (i.e. no. 14 to 24 French). Held at a level 18 inches above the anus, gravity provides a safe force to the instillation. If expulsion starts before the enema is completed, continue the flow until the return is clear. If distention takes place, cease the flow and encourage evacuation. Appropriate volumes of fluids for the various ages are 3 ounces at birth, 16 ounces at 4 years, and 32 ounces for the teenager.
J.
KENNETH HARRIS
155
There is a wide choice of ingredients for the cleansing enema. Tap water in sufficient quantity is the favorite. Instead of a soapsuds enema, if soap jelly (softened soap) is used to lubricate the tube for insertion, the anal canal is appropriately irritated to produce the defecation urge. Thus the irritating effect of a soap solution on the colonic mucosa is avoided by the use of clear tap water. As the enema is expelled, the soap is washed from the anus. If prolonged enema irrigation is needed, saline solution should be used to avoid water intoxication or electrolyte depletion. Mineral oil aids in softening fecal matter and in lubricating its evacuation. The use of a wetting agent in the enema fluid has been of doubtful value in my experience. The prepackaged enema containing hypertonic phosphate salts is convenient to use and dramatically effective, but may give rise to considerable mucosal irritation. Do not use hydrogen peroxide as an enema fluid. The Retention Enema
The technique is the same as for the cleansing enema except that a relatively small quantity of fluid is used (2 or 3 ounces for the infant, 4 to 6 ounces for the older child), and efforts are made to encourage retention. Retention is accomplished by rolling the child onto his abdomen as soon as the fluid has been instilled and holding the buttocks together for a few minutes. The enema to reduce body temperature consists of normal saline solution at 50 to 60° F. This is the average temperature of city tap wate.r in the winter. Normal saline solution is made by adding JA. teaspoonful of table salt to 4 ounces of water. Repeated retention enemas of saline at a three-hour interval are an effective means of administering fluids and electrolytes. Enterodysis for the vomiting child or the sick child refusing oral fluids is often so successful that hospitalization for dehydration is avoided. The use of an enema to administer a number of systemic medications is a well known procedure. Skimmed milk or starch solution used as a vehicle reduces the rectal irritation of many medicaments and increases the chance of retention and absorption. Starch solution is used as an emollient for an inflamed mucosa. Use one teaspoonful of starch for each ounce of water. SUMMARY
Successful examination of the anus and the rectum of the infant or older child depends lljJon the development of proficiency in certain techniques. An understanding of the anatomic relations of the rectum, the anus and the sigmoid colon is important. Preparation for the internal examination is the key to success, culminating in endoscopic examination. The techniques and local treatment of common anorectal disorders, as they are encountered in office practice, are discussed. The enema
156
ANUS AND RECTUM
stilI has a place in pediatric practice. Its use and technique of administration have been reviewed. REFERENCES
1. Mentzer, C. G.: Anorectal Disease. PEDIAT. CUN. NORTH AMERICA, 3:113, 1956. 2. Turell, R.: Diseases of the Colon and Anorectum. Philadelphia, W. B. Saunders Company, 1959. 4122 Shelbyville Rd. Louisville, Ky.