The medical history, surgical history, family history, and review of systems should focus on uncovering potential systemic and obstructive disorders shown in Table 28.1. A complete obstetric history should include the number of vaginal deliveries, operative vaginal deliveries, or presence of a third-or fourth-degree laceration, which is critical for patients with fecal incontinence. Length of the second stage of labor, birth weight, and the use of episiotomy should be ascertained because they may pose risk factors for sphincter damage and denervation. The sexual history should include questions about rape, anal intercourse, and dyspareunia. Use of over-the-counter, prescription, and illegal drugs should be recorded as well as food allergies.
Physical Examination The evaluation of anorectal dysfunction requires a basic general examination as well as a focused abdominal and pelvic examination. The general physical survey should include a global assessment of mobility and cognitive function. Routine examination of the abdomen involves inspection, palpation, and auscultation to rule out the presence of masses, organomegaly, and areas of peritoneal irritation. This examination should be followed by a detailed evaluation of the vagina, perineum, and anorectum. The goals of the pelvic examination are to define objectively the degree of prolapse and determine the integrity of the connective tissue, neurologic function, and muscular support of the pelvic organs.
Neurologic Examination Important elements of the neurologic examination are assessment of cranial nerve function, sensation and strength of the lower extremities, and reﬂexes for the lower extremities, bulbocavernosus, and anal wink. These examinations evaluate the function of the lower lumbar and sacral nerve roots, recognizing the importance of the second through fourth sacral nerve roots in pelvic ﬂoor dysfunction. The perineal reﬂexes can be elicited by stroking the labia majora and perianal skin or tapping the clitoris with a cotton-tipped swab. The anal wink, bulbocavernosus, and cough reﬂexes all test the integrity of motor innervation to the external anal sphincter (S2–4). Sensation over the inner thigh, vulva, and perirectal areas should be tested for symmetry to light touch and pinprick.
Muscle Strength The integrity of the pelvic ﬂoor muscles should be assessed at rest and with voluntary contraction to determine strength, duration, and anterior lift. The ability to relax these muscles and tenderness on palpation should also be evaluated. Several standardized systems have been described to objectively measure muscle strength, but none has been accepted as a standard. The puborectalis muscle should be readily palpable posteriorly as it creates a 90-degree angle between the anal and rectal canals. Voluntary contraction of this muscle “lifts” the examining finger anteriorly toward the pubic rami. An intact external anal sphincter muscle that has decreased tone and contractility often indicates pudendal neuropathy. Similarly, neuropathy affecting the puborectalis can be recognized by an obtuse anorectal angle and weak voluntary contraction. Similar to the urethral axis, the anorectal angle can also be tested using a cotton-tipped swab, although this test is rarely performed. Deﬂection is measured in the supine position at rest, with strain, and with squeeze.