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We propose herein a short synthesis of evidence leading to deny organized screening of prostate cancer using PSA plus or minus rectal digital examination. Nevertheless, many scientific societies support opportunistic screening on basis of shared decision. Today, numerous proposals had been made to reduce the overdiagnosis and overtreatreatment.

Background Intrapartum ultrasound has been proposed as a method of assessing labour progress but its acceptability has not been comprehensively assessed. Aims We evaluated the acceptability of intrapartum ultrasound in women having vaginal examination (VE) and ultrasound (US) assessment (transabdominal (TA) and transperineal (TP)) prior to delivery, with and without regional analgesia (RA). Materials and Methods Women at 24–42 weeks gestation were included in a prospective observational cohort study. The acceptability of digital VE and TP US were assessed pre‐ and post‐examination using the modified validated Wijma Delivery Experience Questionnaire. Acceptability scores ranged 6–36 (6 being most and 36 being least positive) in six domains: positive‐trust and relax, negative‐harmful to baby, worrying, painful, intrusive. Results Of 119 women recruited, 104 completed both pre‐ and post‐assessment questionnaires. Eighty‐nine per cent of women were nulliparous with median gestation 40 + 2 weeks (25–42+1). Thirty‐two per cent had RA before assessment, 91% in total. The combined acceptability scores of both negative and positive experiences (6 = most acceptable, 36 = least acceptable) for VE and US pre‐assessment were 15 and 7 respectively (P < 0.0001: Mann‐Whitney U‐test). VE was associated with less positive / more negative domain scoring post‐assessment 12 and 6, respectively (P < 0.0001). Although RA made no difference to the perceived experience pre‐VE (P = 0.9), post‐VE, women with RAs considered VEs more acceptable than those without RA (P = 0.0022). Conclusion(s) This is the first study to comprehensively assess the acceptability of VE and intrapartum US. US assessment prior to delivery is more acceptable than VE. RA ameliorated the negative experience of the VE post‐assessment.

Bruxism is a disease with a multifactorial etiology. Its clinical manifestations are most often an unaesthetic smile with abraded tooth surfaces, temporomandibular disorders and muscle hyperactivity. Here we present a case of bruxism where proper articulation of the occlusal splint was performed using the T-scan Novus system. A patient with bruxism underwent treatment with stabilization splint made by 3D printer technology. Intraoral scanning was performed using Trios Color (3Shape, 2014), and the digital design was achieved using the 3Shape Dental system design - splint studio. Formlabs Form 2 printer with biocompatible resin Dental LT Clear Resin was used for printing. The T-Scan Novus system with software attached to it, version 9.1, was used for digital examination of the occlusion. A 2.7 mm thick occlusal splint was developed, and the software adapted the occlusion with antagonists. After adjustment with T-Scan Novus, a reduction in disocclusion time of the patient was achieved, which is a desired result in the treatment of bruxism. The position of the joint components was proven radiologically. The treatment of bruxism with splint therapy continues to be the main method of treatment. Using digital technology allows for more accurate constructions and precise balancing of occlusal relationships.

Fetuses with malpresentation and malposition during labor represent important clinical challenges. Women with fetuses presenting with malpresentation or malposition are at risk of increased perinatal complications, such as cesarean delivery, failure of operative vaginal delivery, neonatal acidemia, and neonatal intensive care admission. Intrapartum ultrasound has been found to be more reliable than digital examination in assessing malpresentation and malposition. The use of intrapartum ultrasound to assess fetal position and presentation, in addition to fetal attitude, to predict and aid in decision making regarding delivery can help in improving management decision making. Cephalic malpresentation and malposition is a unique subset of fetal orientation and can benefit from intrapartum ultrasound identification and assessment for delivery.

What you need to know Approximately 100 000 people in the UK have an intestinal stoma,1 which are most commonly formed after surgery for cancer or inflammatory bowel disease (IBD). They can be described according to the part of the bowel (small or large) used to create the stoma and can be temporary (with potential for reversal at a later date) or permanent. Many different types of stoma exist (eg, nephrostomy, urostomy), but in this article we focus on common complaints associated with intestinal stomas that may lead patients to present to general practice. Imagine a patient presenting to you in general practice with concerns about discomfort in their stoma. After a thorough history, you might examine them as follows: Ask the patient whether the stoma has changed in appearance. Then, inspect the stoma looking specifically at whether it sits proud of the skin and if it is healthy, pink, and moist. Consider digital examination of the stoma if you have concerns about function. This is an intimate examination, so good communication is essential. Ensure your patient has a replacement stoma bag and ask them to …

Importance Measurement of cervical dilation is one of the major indicators of labor progression. At present, the criterion standard for this evaluation is digital examination, which results are sometimes inaccurate and extremely dependent on the subject (ie, obstetrician or midwife) experience. Objective In this systematic and meta-analysis review, the authors have gathered the vast majority of the instruments used for measuring cervical dilation and their clinical application; main features, potentialities, and the most significant constraints are underlined for each device. Evidence acquisition Three of the most popular databases (ie, Web of Science, PubMed, and ClinicalTrials.gov) were used to identify all available cervimeters, by using single or combinations of the following keywords: "cervical," "dilation or dilatation," "cervimetry," "cervix," "uterine," "measurement," "labour or labor," "birth," and "monitoring." Only articles describing the design or a specific clinical application of an instrument for cervical dilation measurement during labor were selected. Results Twenty-five articles were deeply investigated by classifying them in 4 different homogenous groups on the basis of the method proposed for measuring cervical dilation. Suitable devices have not been realized yet, and this is the reason why nowadays the gynecologist/obstetrician still evaluates labor progression by digital examination. Conclusions and relevance Based on a critical analysis of the selected devices, ultrasound seems to be the most promising technology for future cervimetry realization; ultrasound is accurate in distance measurement, and the behind technology can be miniaturized. However, additional studies are necessary for optimizing the technology and developing an optimal solution.

Introduction: The aim of this study is to evaluate the utility of digital examination in addition to ultrasonic measurement of cervical length for predicting spontaneous preterm delivery in women with threatened preterm labor. Material and methods: This was a prospective cohort study in Strasbourg University Hospital, France, between January 2013 and January 2015 All the women with a singleton pregnancy hospitalized with threatened preterm labor between 23 to 34 weeks of gestation were included. Cases of iatrogenic preterm delivery were excluded. A multivariable logistic regression model to estimate the significant predictive parameters of spontaneous preterm delivery was performed. The primary endpoint of our study was a preterm birth before 34 weeks of gestation. Results: A total of 395 women were included in our study. The rate of preterm delivery before 34 weeks was 13%. In univariate analysis every single cervical parameter assessed by the digital examination and all the ultrasound parameters were significantly associated with preterm delivery. The final model included five variables predicting preterm birth: visualization of the membranes at the speculum examination (OR, 15.8; 95%CI, 2.43-146), ultrasound cervical length (OR, 0.82; 95%CI, 0.75-0.89), signs of inflammation (OR, 6.23; 95%CI, 2.07-22.9), gestational age on admission (OR, 0.84; 95%CI, 0.71-1.0), and presence of vaginal infection (OR, 4.28; 95%CI, 1.52-12.7). None of the cervical parameters assessed by the digital examination provided additional predictive value of preterm delivery. Conclusion: Our study suggests that digital examination does not add to the information given by vaginal ultrasound evaluation in predicting preterm labor. This article is protected by copyright. All rights reserved.

Objectives This study compared the accuracy of ultrasound cervical assessment (cervical length and cervical index) and digital examination (Bishop score and cervical score) in the prediction of spontaneous birth before 34 weeks in twin pregnancies. Methods In a prospective multicenter study, digital examination and transvaginal sonography were performed consecutively in twin pregnancies attending for routine sonography at either 22 weeks (175 women) or 27 weeks (153 women). The digital examination took place first, and the Bishop score and cervical score (cervical length minus cervical dilatation) were calculated. Ultrasound measurements were then made of cervical length and funnel length to yield the cervical index (1 + funnel length/cervical length). The association between each variable and delivery before 34 weeks was tested by the Mann–Whitney U-test. The receiver–operating characteristics (ROC) curves of the ultrasound and digital indicators were determined for both gestational age periods, and the areas under the ROC curves compared. The best cut-off values for each indicator were used to determine predictive values for delivery before 34 weeks. Results The median gestational age at delivery among the women included in the 22-week examination period was 36.0 (range, 21–40) weeks; 10.9% (19) gave birth spontaneously before 34 weeks. The median cervical length was 40 (range, 6–65) mm. All four parameters were predictors of delivery before 34 weeks. The areas under the ROC curves for cervical index, cervical length, Bishop score and cervical score did not differ significantly. The median gestational age at delivery among the women in the 27-week examination period was 36.0 (range, 27–40) weeks; 9.2% (14) gave birth spontaneously before 34 weeks. The median cervical length was 35 (range, 1–57) mm. All parameters except the Bishop score were predictors of delivery before 34 weeks. The likelihood ratio of the positive and negative tests for cervical length ≤ 25 mm was 5.4 (range, 3.2–9.0) and 0.3 (range, 0.1–0.7), respectively, compared with 2.3 (range, 1.3–4.2) and 0.6 (range, 0.3–1.1), respectively, for cervical score ≤ 1. The area under the curve for the cervical index was significantly larger than that for the Bishop score (P = 0.008) or cervical score (P = 0.02). Conclusion Transvaginal sonography predicted spontaneous delivery before 34 weeks better than digital examination at the 27-week but not the 22-week examination. Copyright © 2005 ISUOG. Published by John Wiley & Sons, Ltd.

The management of fistula-in-ano has been based on digital examination and operative findings. MR imaging has shown significant limitations to this approach, particularly in the management of recurrent fistula. The most cost-effective approach may be using a combination of endosonography and MR imaging. Preoperative confirmation of fistula complexity facilitates surgery planning of sphincter saving techniques and prevents sepsis being missed, which has been shown to reduce recurrence. Imaging has a significant role to play in this condition to improve patient outcome.

Serious perineal birth damage may contribute to anal incontinence, but exactly what constitutes adequate repair is not agreed on. This study was designed to show whether digital examination immediately after repair of a third- or fourth-degree laceration is able to confirm reapproximation of the external anal sphincter and perineal body. Digital measurements were compared with transperineal ultrasonography in 34 randomly selected women who underwent end-to-end sphincteroplasty and perineal reconstruction for significant lacerating injuries but had no past history of perineal injury or episiotomy. There was no attempt to standardize the repair technique. Digital examination assessed the thickness of the external sphincter, the presence or absence of a gap in the sphincter, and perineal length from the introitus to the anus. The findings of two examining physicians were averaged. Ultrasound studies were done using a 5-MHz convex scanner by imaging in the sagittal and horizontal planes. A midline episiotomy had been created in 9 of 26 patients with third-degree lacerations and 7 of 8 with fourth-degree injuries. Only two third-degree injuries resulted from third-degree episiotomies for dystocia. There were no mediolateral episiotomies, and no vacuum extractions had been done. Digital examination and ultrasonography both identified an external sphincter more than 1 cm thick with no apparent gap in 29 patients. Four women whose sphincter was found on digital examination to be less than 1 cm thick had the same finding on transperineal ultrasonography. One patient had an impalpable anal gap that was noted on ultrasound study. The correlation coefficients comparing digital and ultrasound assessments of the external sphincter and perineum were 0.88 and 0.40, respectively. The internal anal sphincter was visualized in 69% of subjects having third-degree repair but in only 12% of those with fourth-degree repairs. The authors believe that simple digital evaluation of the external sphincter muscle and perineal body, done directly after repair of a laceration, can help to reduce long-term morbidity.

Intraocular pressure (IOP) assessment is a valuable skill for any physician working in the emergency room. Measuring the IOP digitally (when the examiner uses his fingers to evaluate a patient's IOP) or with a simple inexpensive tonometer can aid in the diagnosis of vision-threatening ocular conditions (figures 1 and 2). The following case illustrates the usefulness of this examination in the workup of a young patient presenting with severe headache. Figure 1 Measuring the intraocular pressure using digital examination. The aim of this technique is to assess the force required to indent the orbital wall. The patient is asked to shut his eyes and look down. Gentle pressure is applied alternately to the superior part of the lid by both index fingers.2 Figure 2 This rebound tonometer contains a lightweight disposable probe that measures the intraocular pressure (IOP) by a brief contact with the …

PURPOSE: We evaluated the usefulness of magnetic resonance imaging for the preoperative diagnosis of deep anorectal abscesses. METHODS: Subjects were 21 patients with deep anorectal abscesses. Deep anorectal abscesses were classified into two types, ischiorectal and pelvirectal, according to their location. Patients were also classified into a single abscess group, which showed either an ischiorectal or pelvirectal abscess, and a double abscess group, which showed both ischiorectal and pelvirectal abscesses. The final diagnosis was made from surgical findings, and the types of deep anorectal abscesses determined by digital examination and magnetic resonance imaging were compared. RESULTS: Sensitivity of ischiorectal abscesses (20 lesions) with digital examination and magnetic resonance imaging was 75 and 95 percent, respectively, and that of pelvirectal abscesses (10 lesions) with digital examination and magnetic resonance imaging was 60 and 70 percent, respectively. Sensitivity of the magnetic resonance imaging was significantly higher than that of digital examination in ischiorectal abscesses. Diagnostic accuracy of digital examination and magnetic resonance imaging were both 83 percent in the single abscess group (12 patients), whereas in the double abscess group (9 patients) it was 22 and 78 percent, respectively. The rate of accurate diagnosis of magnetic resonance imaging compared with digital examination in the double abscess group was significantly higher than that in the single abscess group. CONCLUSION: Magnetic resonance imaging was useful for diagnosing and differentiating ischiorectal and pelvirectal abscesses.

Fecal impactions occur in both sexes at any age but are particularly concentrated in children, in the institutionalized or impaired elderly, and in patients with certain psychiatric disorders or medical conditions that predispose to obstipation. The clinical consequences may be disabling and occasionally life threatening. Clinical manifestations include fecal incontinence, abdominal distention and pain, anorexia, weight loss, intestinal obstruction, and stercoral ulceration with bleeding or colonic perforation. Diagnosis begins with recognition of possible fecal impaction and confirmation by digital examination or abdominal radiography. Management consists of disimpaction, colon evacuation, and a maintenance bowel program to prevent recurrent impactions.

Presentation of Case A 21-year-old woman was admitted to the hospital because of thoracolumbar pain. The patient had been well until 17 weeks earlier, when she began to have pain in the midline thoracolumbar region of the spine, with radiation to the right flank, accompanied by nocturnal fever. The pain was aggravated by coughing, sneezing, straining, and recumbency and was not relieved by acetaminophen. Fourteen weeks before admission she came to this hospital. Her temperature was 38°C. The physical examination was normal except for tenderness in the right costovertebral angle and a narrow introitus that prevented a digital examination. The . . .

The objective of this study was to determine if transvaginal ultrasound (TVUS) examination of cervical length correlates to digital pelvic examination and if it can predict time to and mode of delivery in term pregnancies.We conducted a prospective cohort study of 726 consecutive non-laboring, term pregnant women presenting to University-based antenatal testing unit between 1 July 2001 and 31 March 2002. Subjects underwent a TVUS for cervical length followed by a digital cervical examination by a physician blinded to the results of the ultrasound. Linear regression analysis was used to correlate the findings of cervical length by ultrasound with cervical dilatation and effacement by digital examination.In 726 women, the relationship between TVUS cervical length and cervical dilatation and effacement measured digitally were found to be significantly related (p0.001), but weak, with a 15 and 23% goodness of fit, respectively, based on the linear model. Using multivariate logistic and linear regression, respectively, TVUS cervical length predicted mode of delivery but did not predict time to spontaneous labor. Digital measurement of cervical dilatation was predictive of time to spontaneous labor.There is a statistically significant correlation between TVUS measurement of cervical length and digital cervical exam though the correlation is weak. TVUS measurement of cervical length was predictive of mode of delivery while controlling for digital cervical examination, parity and time to spontaneous labor. Digital cervical dilatation was predictive of time to spontaneous delivery.

A 35-month-old child presented to the Emergency Department with a suspected coin ingestion. A physical examination and radiographic examination revealed no evidence of the coin, and the child was prepared for discharge. When the child continued to refuse to drink, digital examination of the hard palate revealed the coin lodged behind the upper incisors. It was only possible to visualize when the patient's neck was fully extended. This case represents an unusual presentation of coin ingestion. It points out the importance of a meticulous physical examination and the need for reevaluation when findings are contradictory.

We report herein, a rare case of a 32 year old man who presented with a massive sacrococcygeal tumor found by digital examination. A transrectal biopsy was performed, however, as massive anal bleeding occurred 1 day later, an abdominal perineal resection was carried out. Histologic examination subsequently revealed the giant tumor to be pure seminoma. Residual masses of seminoma were detected by CT examination 1 month postoperatively and, despite irradiation, the patient died 26 months after the operation. Although there have been reports of extragonadal seminoma being located in the retroperitoneum, mediastinum and pineal body, this is the first reported case of it being found in the sacrococcygeal region.

Abdominal abscess resulting from a perforated diverticulitis has never been reported as a cause of acute urinary retention. Our patient is the first case to be reported. Because of the atypical presentation, he was initially misdiagnosed and treated as having acute prostatitis. Emergency physicians should have a high index of suspicion. Detailed history, abdominal sonography, and digital examination are helpful in diagnosing this disease.

Pelvic floor muscle dysfunction may cause severe problems in women such as fecal and urinary incontinence and anorgasm which decrease quality of life. Vaginal palpation is commonly used to evaluate pelvic floor strength and to teach patients correct pelvic floor muscle contraction. Vaginal palpation provides subjective data in evaluating pelvic floor muscle strength; however instruments such as a perineometer may yield objective data. In this study results from palpation test were compared with measurements of vaginal squeezing pressure using a perineometer and the role of digital examination in the assessment of pelvic floor muscle strength and correlation of simple techniques were investigated. (excerpt)

BACKGROUND: This randomized controlled trial compared the diagnostic accuracy of the sonographic assessment of cervical length and clinical digital examination of the cervix in the second trimester regarding the prediction of preterm delivery in a low-risk population. ----- METHODS: In total, 282 unselected, asymptomatic women with singleton pregnancy randomly underwent sonographic cervical length measurement (study group, n=138) or clinical digital examination (control group, n=144) in the second trimester. In the study group cervical length or=95th percentile (>or=4) for our population was defined as high. The primary outcome measure was the diagnostic accuracy of both tests regarding the prediction of preterm delivery (

Vaginal foreign bodies are very rarely seen in the practice of obstetrics and gynecology. They are inserted for sexual stimulation by the woman or her partners in most of cases when they are drunk. Different objects cause various degrees of damage. We present three unusual cases of retained vaginal foreign bodies and review the literature. A 26-year-old white woman, gravida 6, para 5, presented to the labor ward at 31 weeks and 6 days of gestation. The patient and her partner had been engaging in sexual activity when he placed a small brush into her vagina and could not remove it. She self-referred to the labor ward with great embarrassment. There was no significant medical or psychiatric history. On admission, fetal wellbeing was established and there were no signs of labor. On speculum examination, no foreign body could be seen owing to vaginal-wall laxity. On digital examination, the foreign body was felt high up in the vagina near the cervix. It was removed remarkably easily, and much to our surprise, was an 18-cm-long paint brush. The woman was given a course of steroids and antibiotics and sent home. She was readmitted with a history of spontaneous

Fifty three women with PROM between 26 and 34 weeks of gestation were examined. Twenty five women (group A) underwent one digital examination for cervical assessment while in 28 women (group B) the cervix was evaluated by speculum. No pelvic examinations were performed throughout the latent period. The latent period increased from 3.1 days in group A to 9.5 days in group B (P less than 0.005). Chorioamnionitis developed in 24% in group A and in 18% in group B (N.S.).

Objective: To compare the diagnostic performance of cervical length measurement determined with transperineal ultrasonography and digital assessment of the cervix for the prediction of preterm delivery in patients with preterm labor. Method: 90 patients admitted to the hospital with the diagnosis of preterm labor and intact membrane underwent cervical length measurement by transperineal ultrasonography along with digital examination for cervical dilatation and effacement. The main outcome measure was delivery before 37 weeks' gestation. Results: 32 patients (35.5%) delivered preterm. Receiver operative characteristic curve analysis revealed that cervical canal length ≤28 mm measured by transperineal sonography had the highest diagnostic performance with a sensitivity of 78.1% and specificity of 82.7%. The sensitivity and specificity of digital examination were found to be 65.5%, 72.4% and 62.5%, 68.9% for the cervical dilatation>2 cm and effacement≥40%, respectively. Conclusion: Transperineal ultrasonographic examination for cervical length is more accurate than digital examination for prediction of preterm delivery in patients presenting with preterm labor. Transperineal ultrasonographic examination of cervix is invaluable in the prediction of preterm delivery where transvaginal transducers are lacking or skilled staff are unavailable.

Transvaginal sonography was performed in 70 patients diagnosed to have placenta praevia by transabdominal sonography. The diagnosis was confirmed either by digital examination in theatre at term or operative finding at delivery. Forty-nine cases (70%) were correctly diagnosed to have placenta praevia by both modes of sonography. Transvaginal sonography ruled out placenta praevia in 12 cases (17%) thought to be placenta praevia by transabdominal ultrasound. Both transabdominal and transvaginal sonography demonstrated 'placental migration' in 4 cases (6%) which were no longer praevia at delivery. Five patients (7%) were erroneously believed to have placenta praevia by both sonographic techniques. Overall, the diagnostic accuracy of transvaginal sonography was 92.8% compared with 75.7% for transabdominal sonography. None of the subjects experienced any exacerbation of bleeding or other complications. The results suggest that transvaginal sonographic localization of the placenta is safe and superior to the transabdominal route.

When urologists palpate left and right lobes of the prostate on digital rectal examination, they are assessing the gland for the presence of abnormal conditions. Benign prostatic hyperplasia, an abnormal condition may appear lobar by digital examination; however, the normal, nonhyperplastic prostate lacks lobar configuration. Clin. Anat. 13:214–215, 2000. © 2000 Wiley-Liss, Inc.

In 10 patients with emptying disturbances, the anal sphincter reaction was investigated clinically and by electromyography with needle and wire electrodes to elucidate whether pain during the investigation could provoke the paradoxical sphincter reaction. In eight of the patients, the paradoxical reaction was easily felt at digital examination. Two patients complained of pain during the needle electrode recording; none complained during the wire electrode investigation. Nevertheless, all 10 patients had paradoxical sphincter reaction independent of the electrode used at electromyography. With careful clinical investigation, most cases of paradoxical sphincter reaction can be diagnosed. When this is inconclusive, the diagnosis should be confirmed by electromyography, preferably by the wire technique.

Three hundred thirteen patients with signs of depression or spontaneous or evoked pain of coccygeal area were studied over six months. One hundred eighty (58 percent) had no spontaneous pain, 87 (28 percent) had moderate pain, and 46 (15 percent) a severe coccygodynia leading to consultation. In four of the latter group, no other sign of depression was found. Seventy-nine percent of the patients with spontaneous pain and 66 percent without spontaneous pain had coccygeal pain evoked by rectal digital examination (RDE). Seventy-one percent of the patients with spontaneous pain and 56 percent without spontaneous pain had paracoccygeal pain evoked by RDE. Among severely depressed patients (Group III), 76 percent had an evoked pain and 80 percent a coccygeal pain--either spontaneous or evoked. In 178 (57 percent), all signs disappeared when treated with various antidepressants in seven visits and within six months. Seven (2 percent) were failures; 44 (14 percent) were lost during follow-up; 84 (27 percent) did not return after the first consultation. After treatment in five patients was stopped, all signs recurred together and disappeared when adapted treatment was administered again. In 120 consecutive patients who had colonic roentgenologic examination and no depressive sign, two had coccygeal and muscular pain at rectal touch. A highly significant correlation was found between the following parameters: evoked pain and depressive status in noncoccygodynic patients, coccygodynia and evoked pain, coccygeal and paracoccygeal muscular pain. Severity of coccygodynia was not correlated with the number of depressive signs. Sex, age, and treatment efficiency were not correlated. The mechanism of depressive pain is discussed. RDE-evoked pain is proposed as an "objective" diagnostic sign for masked depression and as a means of evolution control. The frequency of the disease and efficiency of treatment are stressed.

A case of villous adenoma complicated by severe fluid and electrolyte depletion has been reported. Some unique features of the villous adenoma and the treatment of the electrolyte depletion syndrome have been discussed. Several points should be stressed in relation to this syndrome: (1) Villous adenomas are easily missed on digital examination because of their soft consistency. (2) The electrolyte depletion syndrome, though uncommon, can be severe, and several deaths are reported in medical literature. They resulted from failure of early or adequate treatment. (3) Malignant change occurs frequently and necessitates wide removal.

We believe that the levator spasm syndrome, coccygodynia, and chronic prostatitis are disorders which frequently may cause rectal pain. In these conditions, the diagnosis may be overlooked easily, due to the vague and unusual terms in which patients describe their complaints, or because of coexistent, unrelated, anorectal disorders. In the presence of vague rectal pain, digital examination should include all pelvic structures within reach of the finger.

An outline has been provided for exploring the pelvis by digital examination of the rectum. Bony landmarks are described for orientation.

1. 1. Carcinoma of the lower bowel costs 35,000 deaths a year in the United States of America. 2. 2. The main cause is late or faulty diagnosis. This is unforgivable, since 50 per cent of these tumors are within reach of the examining finger; therefore, a digital examination must be done as a routine. 3. 3. The next greatest cause is improper treatment. 4. 4. The abdomino-perineal operation, popularized by Miles, is unnecessary. 5. 5. Metastatic spread is along the course of the superior haemorrhoidal artery and lateral or retrograde spread occurs only with the establishment of a collateral lymphatic circulation. 6. 6. The perineal stoma is much to be preferred psychologically and functionally. 7. 7. Reference is made to a simplification of the operation of perineal excision of the rectum for carcinoma. 8. 8. The advantages of the use of 10 per cent tannic acid in alcohol in large granulating wounds is explained.

1. The digital examination of the rectum and the test of a fecal specimen for occult blood should be a routine part of each physical examination.

A boy, aged 3 years, was referred by Dr. W. E. Beck of De Kalb, Texas. There was nothing of importance in the family or previous history. During the forenoon of the day on which the child was seen he was playing with a pipe stem and, his parents thought, swallowed it. He coughed and gagged somewhat at the time, but there was no marked dyspnea. A physician who was consulted at once thought that he could feel the foreign body by digital examination of the throat. Not being certain, however, he referred the case for further study. The patient came a distance of about thirty-five miles in an automobile over rather rough Fig. 1.—Roentgenologic appearance of pipe stem in bronchus. roads. At one time during the journey, there was a severe attack of dyspnea and cyanosis. This subsided after a few moments, and the boy suffered no further discomfort.

The per-rectal ultrasound scans and digital assessments of 193 patients with prostatic nodules were analysed retrospectively. There were 88 histologically proven cancers and per-rectal ultrasound demonstrated extracapsular spread of tumour in 36 of these patients. In the diagnosis of prostatic cancer, ultrasound had a sensitivity of 97.6% and a specificity of 93.8% whereas digital examination had a sensitivity of 96.5% and a specificity of 53.3%.

In a retrospective review, 62 patients treated for rectal cancer by contact (endocavitary) irradiation at The Cleveland Clinic Foundation were analyzed. This treatment modality delivers high dose, low penetration irradiation to a rectal cancer by direct contact of a 50 KV x-ray source through a special proctoscope. Cancers selected for this treatment include small (3 cm or less), mobile tumors without presacral lymphadenopathy that are within reach of digital examination and are well- or moderately well-differentiated adenocarcinomas. Between 1973 and 1984, 62 patients (37 males, 25 females) were treated--46 by contact irradiation alone and 16 by contact irradiation after excisional biopsy. The median tumor dose was 12,000 rads administered in four fractions at monthly intervals. Mean follow-up was 31 months. Fifty-six patients (90 percent) were disease-free at the time of review or death (ten died from unrelated causes). Eleven patients (18 percent) developed local recurrence but eight of these without distant metastases were rendered disease-free by other treatment--six by surgical resection and two by further radiotherapy. Mean time since secondary treatment is 20 months. Three patients are alive with incurable disease and three have died from cancer--in three of these six patients there was no evidence of local disease. Ulcerated tumors developed local recurrence in five of 17 cases (29 percent) while polypoid tumors recurred locally in six cases (14 percent). Morbidity from the treatment was minor in nature. It is suggested that contact (endocavitary) irradiation is effective treatment for carefully selected cases of rectal cancer.

Fifty-two patients with carcinoma of the rectum under-went computed tomography (CT) in the immediate preoperative period. CT was used in order to assess extrarectal tumour spread. The resected specimen was staged by the pathologist who subdivided spread in continuity beyond the bowel wall into slight, moderate or extensive. In 21 out of 23 patients with no or slight extrarectal local spread CT showed normal perirectal fat. Extrarectal spread was demonstrated by CT in eight of the nine patients found to have extensive local spread. This was seen to be circumferential in the only two patients with inoperable tumors. CT identified discrete nodal enlargement in seven of the 18 patients with histologically involved lymph nodes. CT may help the less experienced surgeon, especially when he is not confident of his findings at digital examination. CT allows assessment of high rectal tumours which cannot be examined digitally. It may play a role where a tumour with extensive local spread is clinically suspected and confirmation is needed before preoperative radiotherapy is given.

The skin and subcutaneous tissues of the perineum are intolerant of irradiation and should therefore be excluded if possible from the treatment volume for tumours of pelvic organs. Accurate localization of the skin surface is therefore essential. Further, the lower border of a tumour detected by digital examination may be localized on the planning film by relating it to the skin surface.

A mucus-secreting presarcal cyst was found in a 49-year-old woman who complained of dysuria. A routine rectal digital examination revealed a retrorectal mass. Diagnostic imaging demonstrated a large presacral cystic tumor. The cyst was removed through a transsacral approach. Histologically, the cyst membrane consisted of squamous and columnar mucus-secreting epithelium, and was diagnosed as a mucus-secreting presacral cyst.