Diagnosis of Rectal prolapse
Rectal prolapse Diagnosis: Book Excerpts
Diagnostic Tests for Rectal prolapse: Online Medical Books
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RECTAL PAIN:
Ask the Following Questions:
(Algorithmic Diagnosis of Symptoms and Signs)
- Is there bleeding? The presence of bleeding with pain suggests an anal fissure, hemorrhoids, carcinoma, rectal prolapse, and intussusception.
- Is there a mass? The presence of rectal pain along with a mass would suggest internal and external hemorrhoids, rectal carcinoma, and perirectal or ischiorectal abscesses. However, in females, masses in the cul-de-sac, such as an acute salpingitis, ectopic pregnancy, or endometriosis, will cause rectal pain. In males, prostatic abscess, foreign bodies, and seminal vesiculitis may cause rectal pain.
- Is there a purulent discharge? Fistula in ano, perirectal abscess, ischiorectal abscess, and submucous abscess may cause a purulent discharge.
DIAGNOSTIC WORKUP
Routine diagnostic studies include a CBC, sedimentation rate, urinalysis, chemistry panel, VDRL test, anoscopy, sigmoidoscopy, and barium enema. In females, a pregnancy test and vaginal smear and culture should be done. Ultimately, culdocentesis, pelvic ultrasound, and laparoscopy may be necessary, but a gynecologist should be consulted before considering these tests. In males, prostatic massage may yield a urethral discharge for smear and culture. An intravenous pyelogram or cystoscopy with retrograde pyelography may also be helpful.
» READ BOOK EXCERPT ONLINE »
Source: Algorithmic Diagnosis of Symptoms and Signs, 2003
Hemorrhoids:
Differential Diagnosis
(In a Page: Signs and Symptoms)
-
External hemorrhoids
–Located below the pectinate line
–Typically painful
-
Internal hemorrhoids
–Located above the pectinate line
–Typically not painful, unless thrombosis
occurs
-
Pregnancy
–Up to 35% of pregnant females will develop hemorrhoids around the time of delivery, with most cases occurring after a vaginal delivery and/or a prolonged labor
-
Condylomata acuminatum (genital warts)
- Rectal prolapse
–External protrusion of the rectum
–Complete prolapse versus partial full thickness prolapse versus prolapse of mucosa only
–Partial rectal prolapse or mucosa-alone rectal prolapse is typically concentric, thus can be differentiated from internal prolapsing hemorrhoids that tend to have separation between cushions and inflammation
-
Rectal polyp
-
Rectal or anal cancer
-
Hypertrophied anal papilla (polypoid structure at pectinate line)
-
External skin tag
–Redundant fold of tissue along the external anal margin
-
Perirectal abscess
-
Anal fissure or fistula
-
Rectal varices
–Develop secondary to portal hypertension
-
Rectal cavernous hemangioma
Workup and Diagnosis
- History: The most common presenting complaints are bright red bleeding following defecation (in toilet or on paper), itching, and prolapse of a hemorrhoid
–Hemorrhoids are usually not painful unless thrombosed, ulcerated, or gangrenous
–Sudden onset of excrutiating perirectal pain with palpable mass usually suggests acute thrombosis of a hemorrhoid - Physical exam: Evaluate for prolapse by having patient
strain (may place them on a toilet to facilitate)
–First-degree hemorrhoid: No prolapse
–Second-degree: Prolapse during defecation followed by
spontaneous return to anal canal
–Third-degree: Prolapsed but manually reducible
–Fourth-degree: Constant, irreducible prolapse
-
Anoscopy and proctosigmoidoscopy are used to evaluate symptoms and bleeding
-
Full colonoscopy is indicated in all patients over 50 years old or if diagnosis is inconclusive
-
Rectal manometry is indicated if the patient complains of incontinence
-
Biopsy is necessary for any rectal polyp or palpable lesion
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
Rectal Pain:
Differential Diagnosis
(In a Page: Signs and Symptoms)
- Anal fissure
–Acute fissure presents with pain and bleeding (noticed on toilet paper) immediately following defecation
–Chronic fissure presents with long-standing itching and mild pain, with or without bleeding
-
Perianal abscess (with or without associated fistula formation
-
Thrombosed hemorrhoid
-
Levator ani syndrome
-
Proctalgia fugax (rectal muscle spasm)
-
Coccyodynia/coccygodynia
-
Fecal impaction
-
Neoplasm (rectal, pelvic, or cauda equina)
-
Idiopathic
-
Inflammatory bowel disease (ulcerative proctitis, Crohn's disease)
-
Solitary rectal ulcer syndrome
–Misnomer: May be multiple, not restricted to rectum, and lesion may be polypoid
–Neoplasm is a concern
-
Pruritus ani
-
Trauma
-
Anal sex
-
Constipation
-
Diarrhea
-
Less common causes (“zebras”) include familial rectal pain, endometriosis, pelvic inflammatory disease, prostatitis, myopathies, foreign bodies, and compression or inflammation of sacral nerves
Workup and Diagnosis
- A careful history and physical exam are crucial and often diagnostic for many conditions
–Acute anal fissure presents as an anal tear (typically posterior) with a tender perineum; no further workup is necessary if the classic history and exam are found
–Chronic anal fissure presents as an open ulcer with drainage and sentinel pile
–Levator ani symptoms can be elicited by digital rectal
examination
–Proctalgia fugax symptoms cannot be elicited by exam
–Coccyodynia: Palpation of coccyx reproduces symptoms
-
In cases of perianal abscess, must rule out the presence of an anal fistula and inflammatory bowel disease
-
Anoscopy may be indicated to rule out inflammatory bowel disease
-
If an underlying disease process is suspected, consider stool cultures, viral titers, serologies, and/or biopsy
» READ BOOK EXCERPT ONLINE »
Source: In a Page: Signs and Symptoms, 2004
RECTAL PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The cause of rectal pain is usually obvious on examination with an anoscope or proctoscope. Careful palpation may be necessary to discover a perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may be missed unless all quadrants of the anus are examined with the slitanoscope.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
Rectal pain:
History and physical examination
(Handbook of Signs & Symptoms (Third Edition))
If the patient reports rectal pain, inspect the area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
After the examination, proceed with your evaluation by taking the patient’s history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Make sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Signs & Symptoms (Third Edition), 2006
Hemorrhoids:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Physical examination confirms external hemorrhoids. Proctoscopy confirms internal hemorrhoids and rules out rectal polyps.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Rectal prolapse:
Diagnosis
(Professional Guide to Diseases (Eighth Edition))
Typical clinical features and visual examination confirm the diagnosis. In complete prolapse, examination reveals the full thickness of the bowel wall and, possibly, the sphincter muscle protruding and mucosa falling into bulky, concentric folds. In partial prolapse, examination reveals only partially protruding mucosa and a smaller mass of radial mucosal folds. Straining during examination may disclose the full extent of prolapse.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Diseases (Eighth Edition), 2005
Rectal pain:
History and physical examination
(Professional Guide to Signs & Symptoms (Fifth Edition))
If your patient reports rectal pain, inspect the area for bleeding; abnormal drainage such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Check for inflammation and other lesions. A rectal examination may be necessary.
After examination, proceed with your evaluation by taking the patient’s history. Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
» READ BOOK EXCERPT ONLINE »
Source: Professional Guide to Signs & Symptoms (Fifth Edition), 2006
Rectal Pain:
Differential Overview
(Field Guide to Bedside Diagnosis)
❑ Hemorrhoid
❑ Rectal fissure
❑ Prostatitis
❑ Anal fistula
❑ Pruritus ani
❑ Fecal impaction
❑ Coccydynia
❑ Perirectal abscess
❑ Infected pilonidal cyst
❑ Ulcerative proctitis
❑ Infective proctitis
❑ Proctalgia fugax
❑ Anal carcinoma
Diagnostic Approach
Tenesmus is a painful urge to defecate with little result.
» READ BOOK EXCERPT ONLINE »
Source: Field Guide to Bedside Diagnosis, 2007
Hemorrhoids:
Diagnosis
(Handbook of Diseases)
Physical examination confirms external hemorrhoids. Anoscopy or proctoscopy provides for visual examination of internal hemorrhoids.
» READ BOOK EXCERPT ONLINE »
Source: Handbook of Diseases, 2003
Rectal pain:
History
(Signs & Symptoms: A 2-in-1 Reference for Nurses)
Ask the patient to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of any associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stool, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he’s experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary history.
» READ BOOK EXCERPT ONLINE »
Source: Signs & Symptoms: A 2-in-1 Reference for Nurses, 2007
Rectal pain:
History and physical examination
(Nursing: Interpreting Signs and Symptoms)
Begin by taking the patient's history. Ask him to describe the pain. Is it sharp or dull, burning or knifelike? How often does it occur? Ask if the pain is worse during or immediately after defecation. Does the patient avoid having bowel movements because of anticipated pain? Find out what alleviates the pain.
Be sure to ask appropriate questions about the development of associated signs and symptoms. For example, does the patient experience bleeding along with rectal pain? If so, find out how frequently this occurs and whether the blood appears on the toilet tissue, on the surface of the stools, or in the toilet bowl. Is the blood bright or dark red? Also, ask whether the patient has noticed other drainage, such as mucus or pus, and whether he's experiencing constipation or diarrhea. Ask when he last had a bowel movement. Obtain a dietary and drug history.
Then inspect the rectal area for bleeding; abnormal drainage, such as pus; or protrusions, such as skin tags or thrombosed hemorrhoids. Also, check for inflammation and other lesions. A rectal examination may be necessary.
» READ BOOK EXCERPT ONLINE »
Source: Nursing: Interpreting Signs and Symptoms, 2007
RECTAL PAIN:
Approach to the Diagnosis
(Differential Diagnosis in Primary Care)
The cause of rectal pain is usually obvious on examination with an
anoscope or proctoscope. Careful palpation may be necessary to discover a
perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may
be missed unless all quadrants of the anus are examined with the slit
anoscope.
» READ BOOK EXCERPT ONLINE »
Source: Differential Diagnosis in Primary Care, 2007
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