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Surgery - Assessment of pelvic pathology
Positioning and examination
The examination is conducted in a maximum of three positions: supine (for transabdominal palpation of the 'false' pelvis); supine with hips flexed and abducted (for vaginal and bimanual palpation, which may assist in evaluating rectal pathology); and left lateral position with hips flexed (for rectal palpation and rigid endoscopy). Any personal examination should always be conducted with a chaperone present, especially during pelvic examinations.
• Examination of the perineum. Is the anus malformed? Is there evidence of mucosal or rectal prolapse present? Is the vaginal introitus appearing normal? Is there vaginal prolapse or indications of a cystocele? Are there any scars from prior surgeries, indications of sinus issues, or signs of sepsis? Examine for supplementary or atypical tissue. Are there skin tags, external hemorrhoids, warts, or atypical skin regions, such as anal intraepithelial neoplasia (AIN)? Is an exterior punctum, as observed in a fistula, or the outer boundary of a fissure discernible? Palpation Palpate the inferior abdominal quadrants.
Digital rectal examination
Is the anal tone normal and is the sphincter symmetrical? Is the prostate of normal size with an intact central sulcus? Is the rectal mucosa exhibiting normal characteristics? Is there any lump or pain anterior to the upper rectum (Douglas pouch)? The aforementioned conditions may result from sigmoid disease, small bowel located in the pelvis, a pelvic appendix, or ovarian disease.
• Vaginal examination is frequently excluded unless there is a definitive indication that it may yield significant information. Is the cervix intact and functioning normally? Is the vagina of standard caliber and texture? Is there tenderness in either vaginal fornix? Inquiries Rigid proctoscopy (also known as anoscopy) is conducted in outpatient settings without the need of sedation. Visualizes the inferior rectum and anal canal, facilitating the evaluation of hemorrhoids. It may be supplemented with therapeutic interventions such as banding, injection, or cryotherapy. Rigid sigmoidoscopy, more accurately referred to as 'proctoscopy'
• Conducted procedures on outpatients without the need of anesthesia.
• Seeks to see the rectum up to the recto-sigmoid junction. The sigmoid colon is not sufficiently visualized with this. Results may be suboptimal if conducted without enema preparation.
Transabdominal/transvaginal ultrasonography
• Simple and secure; eliminates radiation exposure.
• Effective for the diagnosis of ovarian pathology (e.g., in right iliac fossa pain). Endoanal/transrectal ultrasound: A 360° scanning endoanal/endorectal probe performed without anesthesia. Endoanal examinations for evaluating anal sphincter integrity. Transrectal imaging for the evaluation of certain rectal tumors, prostate conditions (including biopsy), and presacral abnormalities.
CT imaging
• Preferred diagnostic approach for unexplained pelvic complaints and postoperative complications.
Magnetic Resonance Imaging
Typically conducted with a normal body scanner with external coils, although it may occasionally be executed with an endorectal coil.
• Preferred diagnostic modality for evaluating advanced rectal, gynecological, and urological malignancies, as well as intricate pelvic and anal infections.
The true pelvis is situated between the pelvic inlet, defined by the sacral promontory, iliopectineal lines, and symphysis pubis, and the outlet, delineated by the coccyx, ischial tuberosities, and pubic arch. The 'false pelvis' is situated superior to the pelvic inlet and can be palpated during abdominal examination. The pelvic floor muscles, including the levator ani, are essential for the support and functionality of the anorectum, vagina, and bladder. They receive innervation from the anterior primary rami of S2, S3, and S4. • The anterior relations of the rectum (palpable during a PR examination) are (from inferior to superior): • Women: vagina, cervix, pouch of Douglas. • Men: prostate, seminal vesicles, recto-vesical pouch.
Positioning and examination
The examination is conducted in a maximum of three positions: supine (for transabdominal palpation of the 'false' pelvis); supine with hips flexed and abducted (for vaginal and bimanual palpation, which may assist in evaluating rectal pathology); and left lateral position with hips flexed (for rectal palpation and rigid endoscopy). Any personal examination should always be conducted with a chaperone present, especially during pelvic examinations.
• Examination of the perineum. Is the anus malformed? Is there evidence of mucosal or rectal prolapse present? Is the vaginal introitus appearing normal? Is there vaginal prolapse or indications of a cystocele? Are there any scars from prior surgeries, indications of sinus issues, or signs of sepsis? Examine for supplementary or atypical tissue. Are there skin tags, external hemorrhoids, warts, or atypical skin regions, such as anal intraepithelial neoplasia (AIN)? Is an exterior punctum, as observed in a fistula, or the outer boundary of a fissure discernible? Palpation Palpate the inferior abdominal quadrants.
Digital rectal examination
Is the anal tone normal and is the sphincter symmetrical? Is the prostate of normal size with an intact central sulcus? Is the rectal mucosa exhibiting normal characteristics? Is there any lump or pain anterior to the upper rectum (Douglas pouch)? The aforementioned conditions may result from sigmoid disease, small bowel located in the pelvis, a pelvic appendix, or ovarian disease.
• Vaginal examination is frequently excluded unless there is a definitive indication that it may yield significant information. Is the cervix intact and functioning normally? Is the vagina of standard caliber and texture? Is there tenderness in either vaginal fornix? Inquiries Rigid proctoscopy (also known as anoscopy) is conducted in outpatient settings without the need of sedation. Visualizes the inferior rectum and anal canal, facilitating the evaluation of hemorrhoids. It may be supplemented with therapeutic interventions such as banding, injection, or cryotherapy. Rigid sigmoidoscopy, more accurately referred to as 'proctoscopy'
• Conducted procedures on outpatients without the need of anesthesia.
• Seeks to see the rectum up to the recto-sigmoid junction. The sigmoid colon is not sufficiently visualized with this. Results may be suboptimal if conducted without enema preparation.
Transabdominal/transvaginal ultrasonography
• Simple and secure; eliminates radiation exposure.
• Effective for the diagnosis of ovarian pathology (e.g., in right iliac fossa pain). Endoanal/transrectal ultrasound: A 360° scanning endoanal/endorectal probe performed without anesthesia. Endoanal examinations for evaluating anal sphincter integrity. Transrectal imaging for the evaluation of certain rectal tumors, prostate conditions (including biopsy), and presacral abnormalities.
CT imaging
• Preferred diagnostic approach for unexplained pelvic complaints and postoperative complications.
Magnetic Resonance Imaging
Typically conducted with a normal body scanner with external coils, although it may occasionally be executed with an endorectal coil.
• Preferred diagnostic modality for evaluating advanced rectal, gynecological, and urological malignancies, as well as intricate pelvic and anal infections.
The true pelvis is situated between the pelvic inlet, defined by the sacral promontory, iliopectineal lines, and symphysis pubis, and the outlet, delineated by the coccyx, ischial tuberosities, and pubic arch. The 'false pelvis' is situated superior to the pelvic inlet and can be palpated during abdominal examination. The pelvic floor muscles, including the levator ani, are essential for the support and functionality of the anorectum, vagina, and bladder. They receive innervation from the anterior primary rami of S2, S3, and S4. • The anterior relations of the rectum (palpable during a PR examination) are (from inferior to superior): • Women: vagina, cervix, pouch of Douglas. • Men: prostate, seminal vesicles, recto-vesical pouch.
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