physical checked - Page 2

ANUS AND RECTUM — Examination of the anus and rectum is relatively standard for all age groups. Inspection of the perianal area under normal circumstances should reveal an intact, symmetrically wrinkled area of pigmented skin. Aside from the rare finding of an imperforate anus or an anteriorly placed anus, anatomical abnormalities in the pediatric age group are unusual.

Infantile perianal pyramidal protrusion (IPPP) is a perianal lesion, previously described as a skin tag or skin fold, that is reported almost exclusively in girls [12,13]. Some authors propose that the lesion be called "infantile protrusion" since it is not always pyramidal and may be perineal rather than perianal [14]. The lesion is typically located in the midline, just anterior to the anus, although posterior lesions have been reported [15]. It is described as a pedunculated pyramidal protrusion with a tongue-like lip that is covered with smooth red or rose-colored skin [12,13,16]. The clinical course is one of recurrent swelling and resolution. Constipation and/or lichen sclerosis may be associated findings [14,15,17]. The history of swelling and resolution and characteristic appearance distinguish this lesion from condyloma acuminata, trauma, skin tags, rectal prolapse, and granulomatous lesions of inflammatory bowel disease [16]. (See appropriate topic reviews).

External hemorrhoids and prolapsed internal hemorrhoids are found primarily in older patients. Perianal fissures caused by straining during defecation and passage of hard stools or by dry irritated skin are seen in all age groups, particularly infants. Careful attention to bruises, tears, and lacerations in patients suspected of having been sexually abused should be noted. (See "Evaluation of sexual abuse in children and adolescents").

Digital rectal examinations are not performed routinely as part of the regular physical examination of children. When digital examination becomes necessary, the examiner should remain sensitive to the potential embarrassment and discomfort for the patient. The patient and/or guardian should be given an easily understandable explanation of why the examination is being done and what discomfort might be involved. The examination is performed best with the patient Iying on his or her left side and legs flexed at the hips and knees. Gloves and an appropriate lubricant should be used.

In the child with a lower abdominal mass and/or history of constipation or infrequent passage of stools, a rectal examination may help make the diagnosis. A smooth-walled rectal vault with soft stool in the rectal ampulla is the normal finding. A palpable abnormal mass or blood tinged stool on a gloved finger requires more extensive investigation.