Which rectal exam findings are characteristic of pediatric constipation?

Answer

The most important part of the physical examination is the rectal examination. Perform a rectal examination in any child with chronic constipation, regardless of age, to exclude underlying anatomic abnormalities that might account for the constipation, such as an imperforate anus with perineal fistula, intestinal obstruction (mass effect), or Hirschsprung disease. In young infants, the anus should be sufficiently large to permit the introduction of a pinkie finger.

Upon digital examination, note the size of the anal canal, the size of the rectum, and whether any intrarectal masses are present. Also, note if the rectum is empty or filled with stool and note the consistency of the stool.

Among children with Hirschsprung disease, the rectum is typically quite small and empty of stool. Following the digital examination, the infant may have a gush of liquid stool, because the functional obstruction has transiently been relieved.

Among children with functional constipation, the rectum is generally enlarged, and stool is present just beyond the anal verge.

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Media Gallery

Plain abdominal radiograph that demonstrates stool throughout the colon.
This table differentiates functional constipation from Hirschsprung disease.
This unprepared single-contrast barium enema demonstrates a transition zone consistent with Hirschsprung disease.
The images illustrate normal anorectal manometry with relaxation of the internal anal sphincter in response to rectal distention.
This image delineates common withholding behaviors in young children.
Contrast enema of a patient with megasigmoid and impacted stool.
Contrast enema in a patient in whom the rectosigmoid was resected.
Position for enema administration in an infant.
Another position for enema administration.
Administration of an enema.
Incorrect enema administration. The enema is administered against stool impaction and cannot be successful.
Enema administration with a tube.
Enema with inflated Foley balloon catheter.
Administration of an enema against impacted stool.
Administration of an enema against fecal impaction.

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