From the Guidelines
To assess rectal sphincter function in a child, a digital rectal examination is recommended, as outlined in the american gastroenterological association medical position statement on constipation 1. This examination should be performed with the child in the left lateral position, with the buttocks separated, to observe the descent of the perineum during simulated evacuation and the elevation during a squeeze aimed at retention. The key components of the rectal examination include:
- Observing the perianal skin for evidence of fecal soiling and testing the anal reflex by a light pinprick or scratch
- Evaluating the resting tone of the sphincter segment and its augmentation by a squeezing effort
- Assessing the external sphincter tone (voluntary control) and internal sphincter tone (involuntary control) Additionally, anal manometry and imaging with ultrasound or MRI may be considered to identify anorectal dysfunctions and anal sphincter defects, as discussed in the study on surgical interventions and the use of device-aided therapy for the treatment of fecal incontinence and defecatory disorders 1. However, the most recent and highest quality study, 1, provides the most relevant guidance for assessing rectal sphincter function in a child. The assessment should be performed gently and quickly to minimize discomfort, and findings should be documented carefully, including baseline tone, voluntary contraction strength, and presence of reflexes. If abnormalities are detected, further neurological examination or specialized testing may be warranted. It is essential to note that the child's age and ability to cooperate with the examination should be taken into account, and the examination should be adapted accordingly. The use of a gloved, lubricated finger (pinky finger for infants and small children) is recommended to minimize discomfort and ensure a thorough assessment. The examination should be performed in a calm and gentle manner, with clear explanations to both the child and parents to reduce anxiety and ensure cooperation.
From the Research
Assessing Rectal Sphincter in a Child
To assess the rectal sphincter in a child, several methods can be employed, including:
- Digital Rectal Examination (DRE) 2, 3, 4, 5, 6
- Transabdominal ultrasound 3
- High-resolution anorectal manometry (HRAM) 4, 6
- Balloon expulsion test 6
- Surface electromyography (s-EMG) 6
- Transperineal ultrasound 6
Indications for Assessment
The assessment of the rectal sphincter in a child may be indicated in cases of:
- Diarrhea 2
- Constipation 2, 3
- Fecal incontinence 2, 4, 6
- Abdominal pain 2
- Gastrointestinal bleeding 2
- Anemia 2
- Abdominal mass 2
- Urinary symptoms 2
- Neurologic symptoms 2
- Urogenital or gynecologic symptoms 2
Diagnostic Value
The diagnostic value of DRE compared to other methods has been studied, with results showing:
- High sensitivity and positive predictive value of DRE in detecting dyssynergia compared to HRAM 4
- Moderate agreement between DRE and HRAM in diagnosing dyssynergia 4
- Poor agreement between DRE and HRAM in assessing anal resting tone in patients with fecal incontinence 4
- Correlation between DRE and 3D-HRAM or s-EMG was better for squeeze pressures than resting pressures 6
Clinical Utility
The clinical utility of assessing the rectal sphincter in a child includes: