Evaluation of pelvic disease: Positioning, inspection, Palpation, Investigations

February 20, 2013 | By | Reply More

Evaluation of pelvic disease: Positioning, inspection, Palpation, Investigations

Positioning and inspection
Examination is performed in up to three positions: supine (for transabdominal palpation of the ‘false’ pelvis); supine with hips flexed and abducted (for vaginal and bimanual palpation, which may be performed to help assess rectal disease); and left lateral position with hips flexed (for rectal palpation and rigid endoscopy). Any intimate examination should always have a chaperone present and particularly so for pelvic examinations.
Inspection is of limited value.
  • Anus. Is the anus deformed? Is there evidence of mucosal or rectal prolapse? Does the vaginal introitus look normal? Is there vaginal prolapse or evidence of a cystocele? Are there scars from previous surgery, sinuses, or evidence of sepsis?
Palpation
  • Palpate the lower abdominal quadrants.
  • Rectal examination. Is anal tone normal and the sphincter symmetrical? Is the prostate normal size with a normal central sulcus? Does the rectal mucosa feel normal? Is there any mass or tenderness anterior to the upper rectum (pouch of Douglas)? The latter may be due to sigmoid disease, small bowel in the pelvis, a pelvic appendix, or ovarian disease.
  • Vaginal examination (often omitted unless there is a clear indication that valuable information may be gained from it). Is the cervix present and normal? Is the vagina of normal calibre and feel? Is there tenderness in either vaginal fornix?
Investigations
Rigid proctoscopy and sigmoidoscopy
  • Performed in outpatients without sedation.
  • Only visualizes the rectum, and views may not be good if done without enema preparation.
Flexible sigmoidoscopy
  • Low-risk, outpatient procedure usually performed without sedation.
  • Should visualize up to the descending colon.
  • Allows minor therapeutic procedures.
Transabdominal/transvaginal ultrasound
  • Easy, safe, and avoids radiation dose.
  • Good for identification of ovarian disease (e.g. in RIF pain).
Endoanal/transrectal ultrasound
  • 360° scanning endoanal/endorectal probe without sedation.
  • Endoanal scans—for assessment of anal sphincter integrity.
  • Transrectal scans—for assessment of some rectal tumours, prostatic disease (including biopsy), pre-sacral lesions.
CT scanning
  • Easy, safe, but significant radiation exposure and IV contrast.
  • Investigation of choice for undiagnosed pelvic symptoms and postoperative complications.
MRI scanning
  • Usually via conventional body scanner with external coils (occasionally performed with endorectal coil).
  • Investigation of choice for the assessment of advanced rectal, gynaecological, and urological cancer or complex pelvic sepsis.
  • Investigation of choice for complex pelvic and anal sepsis.
Key revision points”pelvic anatomy
  • The true pelvis lies between pelvic inlet (sacral promontory, illiopectineal lines, symphisis pubis) and outlet (coccyx, ischial tuberosities, pubic arch)
  • Pelvic floor muscles (levator ani) support and are integral to the function of the ano-rectum, vagina, and bladder. They are innervated by anterior primary rami of S2, 3, 4
  • Anterior relations of the rectum (palpable during PR exam) are:
    • women: vagina, cervix, pouch of Douglas (from below up)
    • men: prostate, seminal vesicals, recto-vesical pouch

Category: Surgery

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