Anoscopy

Related Summaries

● Fistula in ano and anorectal abscess

● Hemorrhoids

Description

● Anoscopy is the direct visualization of the anus, anorectal canal, and anal sphincters

● It is typically used to evaluate anorectal disorders, but can also have therapeutic value (for example,
foreign body removal)

Anatomy

● The anal canal is the distal end of the gastrointestinal tract

● The canal begins just distal to the rectum, and ends at the anus (also called anal ori ce or anal verge)

● The internal and external sphincters are located at the distal end of the canal

● The anus is located at the perineum

⚬ Area includes skin appendages such as hair, sweat glands, and sebaceous glands
⚬ Common site for ssures, abscesses, internal and external hemorrhoids

Indications

● Anorectal disorder such as 1

⚬ Pain or itching
⚬ Bleeding or discharge
⚬ Mass palpable on digital rectal exam
⚬ Hemorrhoids
⚬ Foreign body

Contraindications

● Imperforate anus

● Relative contraindications may include

⚬ Recent anal surgery

⚬ Acute illness, such as

– Peritonitis
– Acute are of in ammatory bowel disease
– Toxic megacolon

⚬ Known anal ssure

⚬ Thrombocytopenia or neutropenia (consider prophylactic platelet transfusion or antibiotics) 2
Preparation

Counseling, including consent

● Advise patient and/or caregiver of reason for and risks of procedure, and obtain informed consent

Equipment

● Gloves

● Water soluble lubricant

● Topical analgesia such as 2% lidocaine jelly

● Cotton balls and swabs

● High intensity light with directed beam if the anoscope is without a light source

● Appropriately sized anoscope (disposable plastic anoscope preferred), typically

⚬ Infant: 1 cm in diameter, 8-10 cm in length

⚬ Child: 1.5 cm in diameter, 12-15 cm in length
⚬ Adolescent: adult-size anoscope

● Ring forceps (if foreign body suspected)

● For specimen collection

⚬ Test for occult blood (such as hemoccult card)

⚬ Glass slides (2) for fecal leukocytes
⚬ Other collection materials as indicated

Preprocedural management

● In patients with signi cant proctalgia, consider instilling 2-5 mL of 2% lidocaine gel into the anal canal

5-10 minutes before inserting the anoscope 3

● Consider procedural sedation in children or patients with signi cant pain

Technique

● Position the patient

⚬ Place infant in supine position, with hips exed and abducted (held in place by an assistant)
⚬ Positioning options in children, adolescents, and adults include

– prone with knees to chest

– left lateral decubitus position with left leg straight and right hip and knee exed, or both legs
exed against the chest

● Position light beam behind clinician

● Inspect anus and perineum

● Perform digital rectal exam to assess for obstruction or masses and evaluate sphincter tone
● Apply a generous amount of lubricant to an appropriately sized anoscope

● Using gentle, steady pressure, slowly insert the anoscope through the anus

⚬ Use thumb to keep obturator in position during insertion

⚬ If patient is able to cooperate, ask him/her to bear down gently on the anoscope to help relax the

anal sphincter 3
⚬ Do not attempt to advance the anoscope beyond its length
⚬ Once anoscope is inserted to desired depth (or as far as tolerated), remove obturator

● Examine the anal canal and sphincter mechanism

⚬ If necessary, remove feces with a swab so that all tissues can be clearly visualized 3

⚬ While gently withdrawing the anoscope, visualize all sides of canal

– assess for both normal and abnormal features (including mucosa, vasculature, blood, mucus,
pus)
– obtain specimens if indicated

● Assess any stool on the anoscope for frank or occult blood

Complications

● Pain

● Mucosa or sphincter tear

● Bleeding

● Anal or rectal perforation

● Bacteremia

Postprocedural Management

● Ensure appropriate follow-up as indicated based on ndings (for example, surgery or

gastroenterology referral)

Tips

● If standard anoscope is not available, consider a limited procedure using a test tube (instead of
anoscope) and otoscope light

● Consider instilling topical anesthetic in patients with signi cant proctalgia before procedure 3

● Relax the anal sphincter by having the patient bear down gently on the anoscope 3

● Use a generous amount of lubricant and insert anoscope very slowly

References

● Topic supported by DynaMed Systematic Literature Surveillance

General references used

1. Foxx-Orenstein AE, Umar SB, Crowell MD. Common anorectal disorders. Gastroenterol Hepatol (N Y).
2014 May;10(5):294-301

2. Tong MC, Tadros M, Vaziri H. Endoscopy in neutropenic and/or thrombocytopenic patients. World J
Gastroenterol. 2015 Dec 14;21(46):13166-76 full-text

3. Ponka D, Baddar F. Anoscopy. Can Fam Physician. 2013 May;59(5):510 full-text

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