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[edit | edit source]

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[edit | edit source]

* 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.[1]

### Appearance of the Patient[edit | edit source]

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

### Skin[edit | edit source]

* Dry skin may be seen in systemic sclerosis

### HEENT[edit | edit source]

* Extra-ocular movements may be abnormal

### Neck[edit | edit source]

* Thyromegaly/thyroid nodules may be seen in hypothyroidism

### Abdomen[edit | edit source]

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

### Neuromuscular[edit | edit source]

* 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)[edit | edit source]

Method and findings of digital rectal examination include:[2]

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)

## References[edit | edit source]

1. ↑ Rao SS, Meduri K (2011). "What is necessary to diagnose constipation?". Best Pract Res Clin Gastroenterol. 25 (1): 127–40. doi:10.1016/j.bpg.2010.11.001. PMC 3063397. PMID 21382584.
2. ↑ Tantiphlachiva K, Rao P, Attaluri A, Rao SS (2010). "Digital rectal examination is a useful tool for identifying patients with dyssynergia". Clin. Gastroenterol. Hepatol. 8 (11): 955–60. doi:10.1016/j.cgh.2010.06.031. PMID 20656061.

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