Constipation physical examination

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Eiman Ghaffarpasand, M.D. [2]

Overview

Physical examination of patients with constipation is usually remarkable for anal fissure or palpable lumpy mass in abdomen (particularly in left quadrant). The presence of thrombosed external hemorrhoids, skin tags, rectal prolapse, anal fissure, anal warts, excoriation or evidence of pruritus ani due to fecal soiling on physical examination are suggestive of constipation. Patients with chronic constipation usually appear to be discomfort while sitting due to anal pain.

Physical Examination

• Physical examination of patients with constipation is usually remarkable for anal fissure or palpable lumpy mass in abdomen (particularly in left quadrant).
• The presence of thrombosed external hemorrhoids, skin tags, rectal prolapse, anal fissure, anal warts, excoriation or evidence of pruritus ani due to fecal soiling on physical examination are suggestive of constipation.

Appearance of the Patient

• Patients with chronic constipation usually appear to be discomfort while sitting due to anal pain

Skin

• Dry skin may be seen in systemic sclerosis

HEENT

• Extra-ocular movements may be abnormal

Neck

• Thyromegaly/thyroid nodules may be seen in hypothyroidism

Abdomen

• Abdominal distention
• Abdominal tenderness in the left lower abdominal quadrant
• A palpable abdominal mass in the left lower abdominal quadrant

Neuromuscular

• Altered mental status
• Clonus may be present
• Hyperreflexia
• Positive (abnormal) Babinski
• Muscle rigidity
• Abnormal gait (Parkinsonian gait)
• Unilateral/bilateral tremor (pill-rolling)

Digital rectal examination (DRE)

Method and findings of digital rectal examination include:

DRE steps respectively		Method	Findings
Inspection		Patient in left lateral decubitus, hips 90° flexed Looking to the perineal area under reasonable light	Skin excoriation Skin tags Anal fissure Scars Hemorrhoids
External sensation		Using a stick with cotton head Tapping and touching all 4 quadrants centripetally (anocutaneous reflex)	Slight contraction of the skin and the external anal sphincter (normal reflex) No contraction with cotton head but slight contraction with wooden head (decreased reflex) No contraction with either of heads (absent reflex)
Internal examination	Digital palpation	Inserting the index finger into the patient anus Palpating the parts, such as mucosa, muscle, bone, uterus, or prostate	Tenderness Mass Stricture Stool consistency
	Sphincter tonometry	Evaluating the resting tone of the anal sphincter	Normal Decreased Increased
	Squeeze maneuver	Evaluating the voluntary squeezing pressure of the anal sphincter Asking to hold up to 30 seconds	Normal Decreased Increased
	Defecation maneuver	Asking to push as if to defecate Evaluating the push effort with a hand on the abdomen	Push effort (Normal, decreased, excessive) Anal relaxation (normal, impaired, paradoxical contraction) Perineal descent (Normal, excessive, absent)