Checklist

WIPER

• Chaperone and good light source

• Gloves and lubricating gel

• Patient on couch, left lateral position, knees up towards the chest

Physiological parameters

General

• Perineal excoriation or dermatitis

• Abnormal discharge at the anal verge: pus, blood, faeces

External

• Inspection of gluteal cleft: pilonidal disease (sinus or abscess)

• Inspection of perineum:

• erythema, abnormal moisture or purulent discharge

• haemorrhoids, abscesses, fissures, fistulas, skin tags

• scars or wounds from previous abscess drainage

• setons

• anorectal prolapse (ask patient to cough)

• Palpation:

• anal sphincter contour

• perianal sensation

•perianal fluctuance

Internal (digital rectal examination)

• Pain

• Anal sphincter tone

• Pelvic peritoneal irritation

• Pelvic abscess

• Masses in anus

• Prostate/uterine cervix (anteriorly)

• Areas of induration or fluctuance: fissures, haemorrhoids, fistulas

• Blood on examining finger

Special tests

• Faecal occult blood testing

• Proctoscopy

• Rigid sigmoidoscopy (10 – 20 cm)

To complete the examination…

• Examine groins for inguinal lymphadenopathy

Examination notes

Tips

Always have a chaperone in the room, irrespective of patient's or examiner's gender.

Have adequate lighting.

Stretch the anal skin with the fingers of the non-examining hand to reveal subtle lesions, such as anal fissures or sentinel tags.

Absence of blood on the examining finger does not exclude lower gastrointestinal bleeding. Microscopic bleeding can be identified with bedside occult bleeding testing kits.

Mnemonic for findings on external inspection of the anus: HAFFSSSHaemorrhoids, Abscesses, Fissures, Fistulas, Skin tags, Scars, Setons