Anatomy And Physiology

•The anus:
• the outlet of the gastro-intestinal
tract.
• surrounded by the subcutaneous
muscle of the external sphincter.
•The anal canal:
• held closed by the muscle action of
the voluntary external anal sphincter
and involuntary internal anal
sphincter (extension of the muscular
coat of the rectal wall).
• The direction of the anal canal is on
a line roughly between anus and
umbilicus.
• supplied by somatic sensory nerves
•anorectal junction:
• called the pectinate or dentate line.
• a serrated line demarcates the anal canal
from the rectum superiorly.
• marking the change from skin to mucous
membrane.
• denotes the boundary between somatic
and visceral nerve supplies.
• visible on proctoscopic examination, but is
not palpable.
•The rectum:
• Extending from the level of the third sacral
vertebral body to the anorectal line.
• divided into the sphincteric and ampullary
portions.
• The sphincteric portion corresponds to
the annulus hermorrhoidalis, surrounded
by the levator ani and the fascial collar
from the supra-anal fascia.
• The ampullary portion extends from the
third sacral to the pelvic diaphragm at the
insertion of the levator ani.
• The Columns Of Morgagni
(Rectal Columns)
• mucosal longitudinal folds act as
accommodations for contractions and
dilations of the anal canal and the
sphincteric portions of the rectum.
• consist of a somewhat denser muscularis
mucosa, with richer lymphatics, vascular,
and nerve supply than those of the
adjacent intervening rectal wall.
• sinuses of Morgagni:
• Between the columns directly continuous
with the crypts.
• valves of Houston:

• three inward foldings in the rectal

wall.
• The lowest of these can sometimes
be felt, usually on the patient’s left.
• Indication of digital rectal
examination:
• Change in bowel habits especially chronic
constipation or soiling.
• Blood in the stool.
• Acute abdomen.
• Pain with defecation, rectal bleeding, or
tenderness.
• Anal warts or fissures.
• Weak stream of urine.
• dysuria.
• Technique of examination:
• Relax the child.
• The child lies on his side with legs
drawn up with Flexion of the
patient’s hips and knees.
• Inspect the sacrococcygeal and
perianal areas for lumps, ulcers,
inflammation, rashes, excoriations,
thread worms, skin tags, or
protruding polyps.
• Glove your hands and spread the
buttocks apart.
• Examine for anal fissure (usually at 6
or 12 o’ clock and may be
accompanied with sentinel tag).
• Ask him to strain down. Inspect the
anus, noting any lesions.
• Examine the anus and rectum.
• Lubricate your gloved finger (use the little
finger for neonates and infants, and index
finger for older children).
• As the patient strains, place the pad of
your lubricated and gloved finger over the
anus.
• Approach the rectum from the inferior.
• As the sphincter relaxes, gently insert
your fingertip into the anal canal, in a
direction pointing toward the umbilicus.
• If you feel the sphincter tighten, pause
and reassure the patient. When in a
moment the sphincter relaxes, proceed.
• Occasionally, severe tenderness prevents
you from examining the anus. Do not try
to force it.
• Instead, place your fingers on both sides
of the anus, gently spread the orifice, and
ask the patient to strain down.
• Look for a lesion, such as an anal fissure,
that might explain the tenderness.
• Note the following during
examination:
• The sphincter tone of the anus. Normally,
the muscles of the anal sphincter close
snugly around your finger.
• A tight anus resisting one’ s finger is
suggestive of anal stenosis.
• A loose patulous anus usually indicates a
loower spinal lesion as
meningeomyelocele.
• Tenderness, if any.
• Induration
• Irregularities or nodules
• Insert your finger into the rectum as far as
possible. Rotate your hand clockwise to
palpate as much of the rectal surface as
possible on the patient’s right side, then
counterclockwise to palpate the surface
posteriorly and on the patient’s left side.
• Gently withdraw your finger, and wipe the
patient’s anus or give him tissues to do it
himself. Note the color of any fecal matter
on your glove, and test it for occult blood.
• On examining the rectum look
for:
• Masses (faeces, polyps, teratomas,
appendicular mass).
• Local abdominal tenderns as in
retrocecal appendix.
• Blood or other staining on the
examining glove.
• Foreign body.
• Important notes:

• Inspect the underwear and perianal

region in fecal soiling.
• Rectal examination is important to
differentiate constipation with
overflow incontinence (spurious
diarrhoea) where the rectum is full of
hard faeces, and behavioral soiling
where one find soft feces in the
rectum.
• The anus should be inspected in the
newborn to ensure it is perforate.
• Imperforate anus is usually missed
especially in girls with vaginal fistula.
• Hirschsprung’ s disease is among the
causes of neonatal intestinal obstruction,
the explosive release of flatus is said to be
characteristic.
• The anal wink (anocutaneus reflex) which
is contraction of the anus on stroking the
perianal region, should be done in infants
with spina bifida.