Perineum and rectum The conventional anorectal examination positions are the lateral and prone folding position. Although the prone position is said to provide adequate exposure, the left P position is a good choice and is more acceptable to the patient, especially in elderly patients or those who are incapacitated. Occasionally, however, the patient must be placed in a squatting position in order to demonstrate rectal prolapse. The anorectal examination begins with an examination of the patient’s underwear and the skin of the perineum for fecal contamination, which is the result of overflow incontinence (spillage or paradoxical incontinence) associated with fecal impaction, especially in older patients. This condition must be differentiated from true incontinence due to loss of sphincter function and from pseudo-incontinence due to anal dampness or from prolapsed hemorrhoids, anal pruritus, perianal fistula, rectal mucosal prolapse, and anorectal venereal disease that should be excluded. Examination of the perineum will exclude anatomic factors causing constipation such as tumors, strictures, fistulas, fissures, or anal atresia. The patient is placed in a left lateral position with the nose pinched and a poor (graduated) steel measuring cylinder instrument placed on the patient’s sciatic tuberosity. Both methods are not physiologically assessed by engaging the patient in a lateral recumbent position to do more than actual exposure of rectal contents. Defecography criteria included comparison with rest (adding dynamic perineal descent), perineal descent of more than 3 cm when pushing with maximum force and perineal descent of more than 4.0 cm at rest (adding fixed perineal descent). Perineal descent syndrome is considered a vicious cycle that includes excessive and repetitive bowel straining, protrusion of the anterior rectal wall into the anal canal, a sense of incomplete defecation, weak pelvic floor musculature, more straining to defecate, and weaker pelvic floor tissue. Excessive perineal descent is a sign of weaker pelvic floor tissues. However, it represents only one aspect of the interaction of different symptoms and findings. Patients with abnormal perineal descent may present with rectal prolapse, partial or complete incontinence, obstructive bowel movements, isolated rectal ulcer syndrome, incomplete bowel movements with unclear symptoms, or rectal pain. Potential surgical problems such as large non-voiding rectal bulges, intestinal hernias, or sigmoid bulges may co-occur. During simulated defecation, the outer edge of the anus should be observed for any open holes or rectal prolapse. In some patients with constipation, signs of anal incontinence can be found on physical examination, which is a further neurological injury due to chronic bowel straining or childbirth with associated neuromuscular damage. Occasional suspicion of fecal incontinence on physical examination or even during physiologic testing may be caused by the patient’s embarrassment and reluctance to seek physician care or by the lack of clinical symptoms. Patients with neuropathy may have absent perianal skin sensation, which can point to the plane and site of nerve damage. A complete bilateral anal reflex is demonstrated by light pinprick or scratch stimulation to demonstrate the presence of innervation of the external sphincter structures. Fecal impaction often occurs in children and in the elderly with severe constipation and fecal soiling (paradoxical fecal incontinence). Constipated patients often have hard stools in the rectal vault. Patients with congenital macrosomia usually have a non-contractile terminal rectum. The next step is gentle palpation with the index finger wearing a lubricated glove. The lower edge of the internal anal sphincter, approximately 1.2 cm from the dentate line, can be palpated during the examination. The entire perineum of the rectum should be mediated by gentle rotational palpation of the examining index finger around the anus to assess the integrity of the anal ring. This is a strong muscular ring representing the upper end of the anal sphincter, more precisely the puborectalis muscle, above the internal anal sphincter surrounding the perianal-rectal junction. Patients with spinal lesions are characterized by a very slow recovery of anal resting tone after fingering. The sulcus between the internal and external anal sphincter (intersphincter sulcus) can be seen or easily palpated. The distinction between internal and external anal sphincter hypertonicity can be assessed by talking to the patient to induce relaxation during extended examination. Most hypertonicity may be caused by overexcitation of the transverse muscle. Finger palpation should include a complete 360o examination of the rectum, including the anterior sacral cavity behind and the lateral wall of the pelvis. During dynamic palpation, the examiner should note the increase in anal canal tone and the mobility of the posterior ring of the puborectalis during compression. To assess the presence of paradoxical puborectalis syndrome, the patient is asked to make a straining bowel movement while the examining finger is placed on the rectum. Patients with paradoxical puborectalis syndrome will squeeze and some will have intermittent contractions. The presence of a rectal herniation can be assessed on examination by assessing the curvature of the examining finger and the anterior rectal wall pressure until it appears in the vagina and elsewhere in the perineum (Figure 1). This anterior herniation of the rectal wall is more common than the posterior herniation and is particularly seen in women with weak rectovaginal septum whose causes include multiple births and vaginal birth injuries. Regardless of whether it is detected on physical examination or on a televised defecography, 70% of women with rectal herniation are asymptomatic, so overtreatment must be avoided. A high degree of suspicion is required when the patient describes a history of needing pressure on the posterior vaginal wall or finger-assisted bowel movements. Forty-five percent of patients with voiding disorders due to non-relaxing puborectalis syndrome are found to have rectal distention. This form of rectal distention usually indicates a compensatory mechanism for functional closure of the anal canal during the desire to defecate and during increased intrarectal pressure. This finding is important because in these cases, surgical treatment will fail and replacement with biofeedback therapy should be more appropriate. Rectal distension is the result of internal prolapse that presents in the same way as rectal prolapse. Internal prolapse can be mediated by a palpable descending mass on finger palpation during forceful bowel movements. Rectal prolapse initially presents as an internal rectal and rectoanal sleeve: during pushing the rectal wall zou fold forms, prolapses into the rectum, then the sleeve descends to obstruct the anal canal, and finally appears to present as an external prolapse. These findings must be combined with the patient’s clinical history. Further prolapse can cause rectal pain or isolated rectal ulcers that result in the discharge of blood or mucus from the rectum. However, the differential diagnosis can be made with defecography alone, which can also be used to determine the size of the rectal bulge. In addition, if information on rectal evacuation is available, a defecography will be used to identify rectal distension caused by secondary factors. Significant rectal prolapse or prolapse can be diagnosed by examining the patient during straining at the toilet. It may be helpful to combine this with vaginal fingering; with the patient in a straining position, the examiner’s index finger is inserted into the rectum and the thumb into the vagina. The patient should be asked to make a straining motion during this test. A peritoneal pouch including the omentum or intestinal laminae may be palpated between the thumb and index finger, suggesting the presence of a peritoneal or intestinal bulge (Figure 2). This test may be a useful way to differentiate between intestinal hernia, vaginal vault prolapse, rectal distension, or a combination of these conditions. A repeat defecography is an important method to confirm these findings and to assess their role in defecation dynamics. The utero-rectal fossa or recto-uterine sulcus may extend between the rectum and the vagina to varying degrees and may even reach the perineum, which may become the location of a utero-rectal fossa or vaginal hernia. The contents of the hernia may include the omentum, the small intestine and sometimes the elongated sigmoid colon climbing . Hernias are named according to their location rather than their contents. Therefore, strictly speaking, a hernia of the utero-rectal fossa is more appropriate than an intestinal or sigmoid hernia. However, this nomenclature seems to be more recognizable and widely accepted among colorectalists and gynecologists. The presence of both urogynecologic and colorectal dysfunction is common in clinical practice. Therefore, colorectal physicians have an obligation to develop extensive collaborative relationships with other clinicians. When a hernia of the utero-rectal fossa is caused by multiple births, old age, inflexibility, obesity, constipation or increased abdominal pressure, it is classified as primary. And when the intestinal hernia is caused by a previous gynecological operation it is secondary, especially transvaginal hysterectomy. Although elimination of the rectal fossa with a uterosacral ligament suture significantly reduces the incidence of intestinal hernias, the incidence of intestinal hernias one year or more after transvaginal hysterectomy is 6-25%. Sigmoid bulges and intestinal hernias are generally a result of laxity of the entire pelvic structure due to weakness of the vaginal support tissue and pelvic diaphragm. Some defects can coexist including anterior rectal bulge, rectoanal overturning or significant rectal prolapse, bladder protrusion and vaginal or uterine prolapse. Therefore, the clinical relevance of sigmoid bulge or intestinal hernia in this complex syndrome is considered an important issue when planning to treat these conditions. Of course, symptoms of pelvic discomfort, incomplete bowel movements, and prolonged straining to defecate may be more severe in patients with sigmoid hernias. Although most people believe that a prolapse of the posterior wall of the upper vagina, detected on examination when the patient exhales with the nose closed, can be diagnosed as a hernia of the rectal fossa. However, for a more precise identification, especially in sigmoid hernias, only a further defecography is possible. Both anoscopy and proctosigmoidoscopy are often used to rule out anorectal diseases such as tumors, rectoanal condyloma, isolated rectal ulcer syndrome, and inflammatory bowel disease. A rigid rectosigmoidoscopy is a more accurate test, measuring an average of approximately 20 centimeters from the external anal verge. A flexable sigmoidoscopy has 3 to 6 times higher curvature and is more comfortable for the patient. Isolated rectal ulcers are characterized by a triad of bloody and mucusy rectal discharge, benign ulcers in the lower anterior rectum, and defecation dysfunction. The ulcers are probably caused by trauma due to bowel straining. In fact, defecography often reveals intussusception or paradoxical puborectalis syndrome in these patients. Rectal biopsy is required for suspicion of congenital megacolon and to diagnose other uncommon systemic disorders such as amyloidosis. A whole rectal biopsy will confirm the presence or absence of ganglion cells in the Meissner’s submucosa and Auerbach’s enteromysium plexus. Recent histologic studies of cadaver sections have found that the normal distance from the dentate line for a ganglion cell-free intestinal wall is 50 px or less. Therefore, it is important to take biopsies from 2.5 to 3.0 cm from the dentate line to avoid the ganglion cell-free area.