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Anoscopy

  • Author: Fazia Mir, MD; Chief Editor: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS  more...
 
Updated: Feb 01, 2016
 

Background

Patients may present in the outpatient or emergency department setting with various anorectal conditions.[1] Professionalism is especially warranted in these cases because of the nature of the examination. As part of the initial evaluation, obtain a complete history of the present illness, perform a physical examination of the abdomen, and perform a visual inspection of the anus and perineum. The next step, if necessary, is a digital rectal examination (DRE). If the data obtained from the external visualization and DRE are insufficient to make a definitive diagnosis, anoscopy may be performed to visualize the anus, anal canal, and internal sphincter.[2, 3]

The anal canal is the most terminal part of the lower gastrointestinal (GI) tract (large intestine), which lies between the anal verge (anal orifice, anus) in the perineum below and the rectum above. The pigmented, keratinized perianal skin of the buttocks (around the anal verge) has skin appendages (eg, hair, sweat glands, and sebaceous glands); compare this with the anal canal skin above the anal verge, which is also pigmented and keratinized but does not have skin appendages. For more information about the relevant anatomy, see Anal Canal Anatomy.

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Indications

Indications for anoscopy include the following:

  • To visually investigate anorectal conditions for which a DRE does not provide sufficient diagnostic information
  • To obtain information on conditions such as internal hemorrhoids or disruption and other pathology of the rectal mucosa, or to examine for an anorectal mass or foreign body in the anal canal
  • To obtain samples for cytology as a screening method for anal squamous lesions,[4, 5, 6, 7] particularly in high-risk patients with HIV infection[8, 9]
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Contraindications

Anoscopy should not be performed on an imperforate anus. Caution should be exercised on patients who have recently undergone anal or rectal surgery.

High-resolution anoscopy is a preferred screening method in the diagnosis of anal intraepithelial neoplasia (AIN)[10] ; however, despite its sensitivity in identifying patients with AIN, its routine use is not justified, and conventional anoscopy is carried out for the diagnosis of other conditions.

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Contributor Information and Disclosures
Author

Fazia Mir, MD Fellow, Department of Gastroenterology, University of Missouri-Columbia School of Medicine

Fazia Mir, MD is a member of the following medical societies: American College of Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Additional Contributors

Andrew K Chang, MD Associate Professor, Department of Emergency Medicine, Albert Einstein College of Medicine, Montefiore Medical Center

Andrew K Chang, MD is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Neurology, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

References
  1. Coates WC. Anorectum. Marx JA, Hockberger RS, Walls RM, eds. Rosen's Emergency Medicine: Concepts and Clinical Practice. 5th ed. St Louis, Mo: Mosby; 2002. Chap 91.

  2. Jay N. Elements of an anal dysplasia screening program. J Assoc Nurses AIDS Care. 2011 Nov. 22(6):465-77. [Medline].

  3. Strear CM, Coates WC. Anorectal Procedures. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 4th ed. Philadelphia, Pa: WB Saunders; 2004. Chap 46.

  4. Arain S, Walts AE, Thomas P, Bose S. The Anal Pap Smear: Cytomorphology of squamous intraepithelial lesions. Cytojournal. 2005 Feb 16. 2(1):4. [Medline].

  5. Friedlander MA, Stier E, Lin O. Anorectal cytology as a screening tool for anal squamous lesions: cytologic, anoscopic, and histologic correlation. Cancer. 2004 Feb 25. 102(1):19-26. [Medline].

  6. Pineda CE, Welton ML. Controversies in the management of anal high-grade squamous intraepithelial lesions. Minerva Chir. 2008 Oct. 63(5):389-99. [Medline].

  7. Silvera R, Gaisa MM, Goldstone SE. Random biopsy during high-resolution anoscopy increases diagnosis of anal high-grade squamous intraepithelial lesions. J Acquir Immune Defic Syndr. 2014 Jan 1. 65(1):65-71. [Medline].

  8. Weis SE, Vecino I, Pogoda JM, Susa JS, Nevoit J, Radaford D, et al. Prevalence of anal intraepithelial neoplasia defined by anal cytology screening and high-resolution anoscopy in a primary care population of HIV-infected men and women. Dis Colon Rectum. 2011 Apr. 54(4):433-41. [Medline].

  9. Dalla Pria A, Alfa-Wali M, Fox P, Holmes P, Weir J, Francis N, et al. High-resolution anoscopy screening of HIV-positive MSM: longitudinal results from a pilot study. AIDS. 2014 Mar 27. 28(6):861-7. [Medline].

  10. Crawshaw BP, Russ AJ, Stein SL, Reynolds HL, Marderstein EL, Delaney CP, et al. High-resolution anoscopy or expectant management for anal intraepithelial neoplasia for the prevention of anal cancer: is there really a difference?. Dis Colon Rectum. 2015 Jan. 58 (1):53-9. [Medline].

  11. Elorza G, Saralegui Y, Enríquez-Navascués JM, Placer C, Velaz L. Anal intraepitelial neoplasia: A narrative review. Rev Esp Enferm Dig. 2016 Jan. 108 (1):31-9. [Medline].

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Disposable anoscope with integrated light source. Image courtesy of Welch Allyn.
Plastic disposable anoscope with obturator in place.
Plastic disposable anoscope with obturator removed.
Standard lubricating jelly.
Stainless steel anoscope. Image courtesy of Welch Allyn.
 
 
 
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