Chapter 3 — Clinical Examination — General Approach

Once the history is complete, the next step is a proper clinical examination. A good examination confirms what the history has suggested. It can also reveal problems the patient did not mention, or did not even know about. In anorectal disease, the examination is often quick and simple. But it must be done with care, with the right method, and with real respect for the patient's comfort and dignity. This chapter covers the general approach that applies to every anorectal patient. The chapters that follow will describe each step — inspection, palpation, digital rectal examination, and proctoscopy — in full detail.

3.1 Preparing the Patient

Before touching the patient, take a moment to explain what will happen. Most patients have never had this kind of examination before. Fear of pain, and fear of embarrassment, are both very common.

Explain, in simple words, what you are about to do and why it is needed. Tell the patient that the examination is usually quick, and that you will stop at once if it becomes too painful. Ask for the patient's consent before starting. If the patient is anxious, allow a few extra minutes. A calm patient is easier, and safer, to examine.

A brief, honest explanation builds trust. It also makes the patient's muscles relax, which makes the examination easier and more accurate.

3.2 The Examination Room

The room should be private, well-lit, and warm. A good light source is essential — natural light is rarely enough, so use a proper examination lamp or a head light. Keep the following ready before the patient enters:

An examination table with a step, so the patient can climb up with ease. Clean gloves, in more than one size. A water-based lubricant. A proctoscope and sigmoidoscope, cleaned and ready. A good light. A drape or sheet for the patient. Tissue paper or swabs, to clean the area after the examination.

Gathering these items in advance saves time, and it also avoids the discomfort of leaving a half- examined patient waiting on the table.

3.3 Positioning the Patient

Correct positioning is the foundation of a good anorectal examination. Several positions are used around the world, but the one most commonly used in Indian clinical practice is the left lateral position, also called Sims' position.

In the left lateral position, the patient lies on the left side, with the hips and knees bent well up toward the chest. The buttocks should be brought to the edge of the table. This position gives a clear, comfortable view of the anal region for both the doctor and the patient, and it does not need any special equipment.

Other positions are used in some settings:

Lithotomy position — the patient lies on the back, with the legs raised and supported in stirrups. This is used mainly in operating theatres. Knee-chest position — the patient kneels, with the chest and shoulders resting on the table. This gives an excellent view but is tiring for the patient, so it is used only for short periods, or for special procedures.

For routine outpatient examination, the left lateral position is preferred. It is comfortable, dignified, and practical.

3.4 Draping and Privacy

Even during the examination itself, the patient's dignity must be protected. Expose only the area that needs to be seen, and keep the rest of the body covered with a sheet or gown. Draping is not a small detail — it is a sign of respect, and it helps the patient stay relaxed.

Always have a chaperone present, especially when a male doctor examines a female patient. This protects both the patient and the doctor, and it is now considered standard good practice everywhere.

3.5 The Sequence of Examination

A proper anorectal examination always follows the same order. Skipping a step, or doing them out of order, can cause the doctor to miss an important finding.

Inspection — a careful visual look at the perianal skin and anal opening, both at rest and while the patient strains (see Chapter 4). Palpation — gentle feeling of the area around the anus, to check for tenderness, swelling, or induration (see Chapter 5). Digital rectal examination (DRE) — examination with a gloved, lubricated finger, to feel inside the anal canal and lower rectum (see Chapter 5). Proctoscopy and sigmoidoscopy — examination with an instrument, to see inside the anal canal and rectum directly (see Chapter 6).

Each step builds on the one before it. Inspection often points toward the diagnosis. Palpation and DRE confirm it. Proctoscopy gives the final, direct view. A doctor who follows this order, every time, will rarely miss an important finding.

3.6 General Examination Before Local Examination

The anorectal region does not exist in isolation. Before examining it, take a brief general look at the patient:

General condition — pallor (a sign of anaemia, which may point to chronic bleeding), weight loss, or signs of illness. Abdomen — feel gently for any lump, tenderness, or enlarged organ. Groin — check for enlarged lymph nodes, which can be important in some anal conditions. Vital signs — especially in a patient with pain, fever, or heavy bleeding.

This general check takes only a minute, but it can reveal a serious underlying condition that the local examination alone would miss.

3.7 Common Mistakes to Avoid

Starting the examination without explaining it to the patient first. Rushing the digital rectal examination, or skipping it altogether because the patient is anxious. Poor lighting, which can hide small but important findings, such as a fissure or a small fistula opening. Examining without adequate lubrication, which causes unnecessary pain. Forgetting to examine the abdomen and groin, and focusing only on the anal region.

Most of these mistakes come from haste. A calm, unhurried, and complete examination takes only a few extra minutes, but it gives a far more reliable diagnosis.

3.8 Why This Chapter Matters

This chapter has described the general approach: a well-prepared patient, a well-prepared room, correct positioning, proper draping, and a fixed sequence of steps. Together, these form the base for every examination described in the rest of this manual. Master this general approach first, and the specific techniques in the next three chapters will feel natural and easy to learn.