Asshole Wink

Asshole Wink
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Anal wink reflex—Contraction of the external anal sphincter follows application of a sharp stimulus.
Suzanne Fredrickson Mullin MD , in Pediatric Clinical Advisor (Second Edition) , 2007
Location and size of the anal opening
Presence or absence of an anal wink
May need to wait 24 hours for intraluminal pressure to build up in order to force meconium through a fistula
If no anal opening is present, careful inspection of the genitourinary (GU) area should be performed to evaluate for a fistula.
In males, a fistula may be found in recto prostatic or rectourethral.
In females, the fistula may open at the posterior vestibule or vaginally.
Focus on search for associated abnormalities (VACTERL).
Vertebral abnormalities occur in 33% of patients with anal atresia.
Cardiovascular malformations (12% to 22%)
Most commonly tetralogy of Fallot or ventricular septal defect
Gastrointestinal malformation (10%)
Renal (other GU tract) malformation: 50% of patients
Inspection—for gaping orifice or puckered anal sphincter
Visual observation of anal squeeze and perineal relaxation and descent with Valsalva maneuver
Evaluate for anocutaneous reflex ( anal wink ); bulbocavernosus reflex
Examination of sensation to light touch and pinprick; sensation to deep anal pressure
Ability to do a voluntary anal contraction and rectal squeeze
Ability to relax sphincter and pelvic floor and push finger with simulated defecation
Evaluate for paradoxic contraction of the sphincter with pelvic floor relaxation during simulated defecation
On examination we look for scars, stomas, and skeletal deformities, and perform a pertinent neurologic examination. This includes mental status, sensory and motor function, and reflex integrity. Evaluation of the S2-4 reflexes using bulbocavernosus reflex and anal wink can help determine whether this pathway is intact, the absence may indicate sacral nerve disease. In females, determination of the pelvic floor strength and bimanual examination is performed to assess the neurologic system.
Routine office investigations include a 72-hour voiding diary ( Fig. 12.1 ). This records the date, time, and volume of each void. In addition, each incontinent episode is recorded by the amount and the precipitating cause. This is very important to gauge the magnitude and frequency of incontinence, the overall voiding pattern, and the daily urine output, and estimates a functional bladder capacity. If incontinence is present, we insist on pad weight measurement; this is the most accurate and objective measure of incontinence before any invasive treatment. In adult male patients, an American Urological Association (AUA) symptom score ( Fig. 12.2 ) is also a useful screening and baseline tool for LUTS/benign prostatic hyperplasia (BPH).
Noninvasive urodynamics (UDs) such as uroflow ( Fig. 12.3 ), and postvoid residual (PVR) are used routinely in our clinic. The uroflow by itself, although it cannot actually determine the etiology of abnormal voiding (some classic patterns are seen however; Figs. 12.4 and 12.5 ), serves as an excellent screening tool to determine whether further, more invasive testing is needed. 19 In most patients without symptoms, a normal uroflow study and the absence of residual urine on ultrasonography are sufficient to rule out significant bladder dysfunction. Abnormal uroflow patterns or incomplete bladder emptying may be situational and should be repeated. 20,21
Routine laboratory investigations (in addition to transplant workup) include urine analysis (UA) and culture. If hematuria or sterile pyuria is detected, this will lead to more invasive investigations with cystoscopy (discussed next).
A thorough inquiry regarding sexual dysfunction should include obtaining information about the medical, sexual, and psychosocial history of the patient. There are multiple validated tools for assessing sexual dysfunction. The ALLOW, PLISSIT, and BETTER models are three different approaches (eSlide 22.7) .
The Brief Sexual Symptoms Checklist is a self-report tool that can be a useful adjunct to the physician’s comprehensive sexual history ( Fig. 22.1 ).
A complete and comprehensive examination should include neurologic examination, paying particular attention to reflexes such as the anal wink and bulbocavernosus reflexes. These reflexes evaluate the integrity of the pudendal nerve and should be performed in both men and women.
Recommended laboratory tests for all men and women with sexual dysfunction include complete blood cell count, chemistry panel, fasting glucose test, and fasting lipid profile. Other laboratory tests that are warranted on the basis of history and physical examination findings include thyroid function studies and serum free testosterone, prolactin, and prostate specific antigen levels. Measurements of other sex hormones, such as estrogen, follicle-stimulating hormone, luteinizing hormone, or total testosterone, have been shown to have a far less utility in a majority of individuals.
The pudendal nerve provides motor innervation to the external anal sphincter and sensory innervation to the perineum. Pudendal nerve injury is caused by traction on the nerve during straining (as seen during childbirth or prolonged efforts at defecation), and it results in denervation and subsequent reinnervation of the external anal sphincter and pelvic floor musculature. This reinnervation can be documented with needle electromyography (EMG), which demonstrates polyphasic motor unit action potentials and an increase in fiber density. 24 However, because the examination is uncomfortable, needle EMG is not widely used. Additional useful tests include the pudendo-anal and anal reflex (or anal “wink”). The levels of the sacral cord involved in sacral reflexes are S2-S4. The pudendo-anal reflex is elicited by stimulating the dorsal nerve of the penis or clitoris. The pudendo-anal reflex is absent or delayed in many patients with fecal incontinence. The absence of an anal wink can also indicate injury, but it is more unreliable. 25
Pudendal nerve integrity is now most commonly assessed by determination of pudendal nerve terminal motor latency (PNTML). PNTML is measured using the finger-mounted St. Mark's electrode (St. Mark's Pudendal Electrode), which stimulates the pudendal nerve at the level of the ischial spine and records the conduction time to the sphincter. 26 Prolonged conduction times are indicative of pudendal neuropathy, which is caused by traction injury to the nerve from vaginal childbirth, prolonged straining, rectal prolapse, or excessive perineal descent. 26 The test is affected by the skill of the examiner and body habitus of the patient; therefore, the significance of an undetectable PNTML is uncertain. Furthermore, because the test evaluates the function of the fastest remaining nerve fiber, incomplete nerve injuries can be missed with this technique. Indeed, fiber density but not pudendal nerve latency correlate with clinical and manometric variables in patients with fecal incontinence. 27 Some investigators have found an abnormal PNTML to be highly predictive of failure after sphincteroplasty, 28,29 but many others have observed no such correlation. 30,31
Fever, anorexia, nausea, vomiting, poor weight gain, and weight loss indicate an organic disorder.
Growth parameters and velocity must be measured (e.g., short stature may indicate hypothyroidism).
A thorough neurologic examination should be conducted because children with neurologic abnormalities (e.g., cerebral palsy, diskitis) or myopathy (e.g., muscular dystrophy) may have abnormal stools.
Tone, strength, and deep tendon reflexes
Abdominal distention and bowel sounds should be assessed.
The perineal examination looks for acute infections (e.g., candidal, group A streptococcal), anal tags, fissures, and anal placement. Ectopic anterior displacement of anus is one of the most common and under diagnosed anatomic causes of constipation.
A ratio of the female anus‐fourchette to the coccyx‐fourchette measurement of less than 0.34 is abnormal.
A ratio of the male anus‐scrotum to the coccyx‐scrotum measurement of less than 0.46 is abnormal.
Rectal examination includes the following:
The anal canal should relax, although it may be initially tight on examination.
A dilated ampulla, especially if filled with stool, indicates retention.
Perirectal ulcers, fistulas, abscess, and strictures are associated with Crohn's disease.
Rectal prolapse should be identified.
The backs of all infants and children new to the practice should be examined for pigmented spots, hairy patches, and sinuses that extend into the spine.
Certain findings may be signs of occult spinal dysraphism (OSD), which predisposes to meningitis.
Neurologic deterioration may occur as a result of diastematomyelia, lipoma, syrinx, or tethering of the spinal cord.
Scoliosis is common in patients with myelomeningocele.
Motor function, sensory level, and anal wink
Upper extremity strength, including grip (i.e., deterioration may indicate syrinx or malfunction of a ventricular shunt)
Head circumference and palpation of the anterior fontanelle
Assessment of the cranial nerves (especially of extraocular movements)
Palpation of the shunt valve and tubing
Assessment of posture (e.g., scoliosis, lordosis, kyphosis)
Perform a dermatologic examination. Seek evidence of lesions (e.g., decubitus ulcers) in insensate areas.
Developmental assessments are especially important before school entry to optimize learning.
Verbal, performance, and educational measures
Fine motor, gross motor, language, and social‐adaptive skills
Executive functions (e.g., planning future activities, organizing, inhibiting competing (inappropriate) responses, self‐regulation, remembering rules, initiating tasks, remembering to remember an activity)
Eric R. Sokol , in General Gynecology , 2007
The physician should perform a complete general examination, including examinations of the cardiovascular system (to look for evidence of volume overload), abdomen (to evaluate for masses and tenderness), extremities (to assess for mobility), and pelvis. In addition, a neurologic examination should include sensory and motor strength testing of the lower extremities. During the pelvic examination, further neurologic evaluation should include testing the bulbocavernosus reflex and the “ anal wink .” This testing should be done at the beginning of the pelvic examination because these reflexes accommodate to touch and are less likely to be elicited later in the examination. The bulbocavernosus reflex confirms proper function of the sacral reflex arcs and can be elicited by gently touching a cotton‐tipped applicator lateral to the clitoris and observing contraction of the external anal sphincter. The anal wink can be elicited by gently touching a cotton‐tipped applicator lateral to the external anal sphincter and observing its contraction. These reflexes are absent in about 15% of healthy patients. In addition, the voluntary contraction of the external anal sphincter suggests intact innervation of the pelvic floor muscles through the pudendal nerve.
The pelvic examination continues with inspection of the external genitalia, noting evidence of genital atrophy or excoriation and irritation, possibly due to contact with wet pads or undergarments. If the vulva is irritated, petroleum‐based barrier products (such as those used for diaper rash) and frequent pad changes should be encouraged. Vaginal examination should include an assessment for pelvic organ prolapse, hypoestrogenic vaginal epithelium, and anatomic abnormalities. The physician should examine the base of the bladder, and the urethra should be evaluated for evidence of a diverticulum and for any discharge from the urethral meatus. Furthermore, pelvic muscle tone can be assessed both at rest and with a voluntary contraction. Support defects of the anterior, apical, and posterior segments of the vagina should be independently staged using the Pelvic Organ Prolapse Quantification system (see Chapter 23 , Pelvic Organ Prolapse and Pelvic Floor Dysfuction). A Q‐tip test can evaluate for mobility of the urethral‐vesical junction. In patients with SUI, upward deflection of the tip of the cotton swab greater than 30 degrees with straining suggests that the patient's symptoms will respond to surgical correction.
A rectovaginal examination should be performed to rule out fecal impaction or rectal masses, as well as to assess for external anal sphincter tone and squeeze pressure. It can also screen for any palpable defects in the rectovaginal septum suggestive of a rectocele. Occult blood testing should be performed if it has not been done recently. A full bimanual examination should be performed to assess for uterine or adnexal abnormalities and pelvic masses. For an adequate bimanual examination to be performed, the patient's bladder must be empty because a full bladder can interfere with the evaluation of the pelvic organs. If the patient's bladder is full before the pelvic examination, the patient should be asked to cough and perform the Valsalva maneuver to see whether transurethral leakage of urine occurs. Observing involuntary urine leakage that occurs with coughing or the Valsalva maneuver confirms the presence of SUI. Leakage of urine from channels other than the urethra is highly suggestive of a fistula.
If the patient reports a sensation of incomplete bladder emptying or has risk factors for urinary retention, the physician should measure a postvoid residual volume using a sterile bladder catheter or bladder ultrasound. Finally, a urine specimen should be sent for urinalysis and culture to rule out infection and hematuria, and urine cytology can be sent to screen for urothelial cancer in patients with risk factors such as a history of hematuria, smoking, or exposure to aniline dyes.
Andrew I. Sokol , Mark D. Walters , in General Gynecology , 2007
When evaluating women with POP, attention should be paid to all aspects of pelvic support, including a focused neurologic examination and test of pelvic muscle strength. The physician must determine the specific sites of damage for each patient, with the ultimate goal of restoring both anatomy and function. A more complete description of the physical examination can be found in Chapter 6 , Preventive Health Care for Women.
The physical examination begins with a thorough inspection of the external genitalia, noting any masses protruding through the introitus, evidence of vulvovaginal atrophy, or ulcerations. After the external genitalia are inspected, a focused neurologic examination should be conducted to test the integrity of perineal sensation, pudendal reflex arcs (clitoral and anal wink responses), and pelvic floor muscle strength.
After the external examination, the labia are gently spread to expose the vestibule and hymen. The integrity of the perineal body is evaluated, and the approximate size of all prolapsed parts is assessed (see further discussion). A retractor, half of a speculum, or a Sims' speculum can be used to depress the anterior and posterior vaginal walls sequentially to aid in visualization of the opposite vaginal wall. After the resting examination, the patient is instructed to strain down forcefully or to cough vigorously. During this maneuver, the order of descent of the pelvic organs is noted, as is the relationship of the pelvic organs at the peak of straining. Anterior vaginal wall descent usually represents bladder descent with or without concomitant urethral hypermobility. Rarely, an anterior enterocele can mimic a cystocele on physical examination. Posterior vaginal wall descent usually represents rectocele but may also include enterocele. Cervical or apical descent may occur with or without concomitant enterocele. After the supine straining examination is completed, the patient can be reexamined in the standing position while resting and straining to ensure that maximal prolapse has been observed.
Simon Podnar , Clare J. Fowler , in Female Urology (Third Edition) , 2008
Sacral reflexes refer to electrophysiologically recordable responses of perineal or pelvic floor muscles to electrical stimulation in the urinary-genital-anal region. Two reflexes, the anal and the bulbocavernosus reflex, are commonly clinically elicited in the lower sacral segments. Both have the afferent and efferent limb of their reflex arc in the pudendal nerve, and both are centrally integrated at the S2 to S4 cord levels. 49, 53 In women, the bulbocavernosus reflex is clinically elicited by squeezing or taping of the clitoris and observing movement of the perineum or anal sphincter. It is, however, much less reliable than in men, 53, 54 and in our opinion, is not useful. The anal reflex is elicited by a pinprick of the perianal skin, producing an anal wink .
Electrophysiologic correlates of these reflexes have been described using electrical, mechanical, and magnetic stimulation. Whereas the latter two modalities have been applied only to the clitoris, electrical stimulation can be applied to other sites, such as the dorsal clitoral nerve and perianal area. Responses are usually detected by needle electrode inserted into the EAS or bulbocavernosus muscle. The bulbocavernosus detection site is preferred because traces do not contain continuously firing, low-threshold MUPs.
The bladder neck or proximal urethra can be stimulated using a catheter-mounted ring electrode, and reflex responses can be obtained from perineal muscles. With visceral denervation, such as after radical hysterectomy, these reflexes may be lost while the sacral reflex mediated by pudendal nerve is preserved. Loss of vesicourethral reflex with preservation of vesicoanal reflex has been described for patients with urethral afferent injury after recurrent urethral operations.
Reports of sacral reflexes obtained after electrical stimulation of the clitoral nerve give consistent mean latencies of between 31 and 39 ms (see Fig. 10-3 ). Sacral reflex responses obtained on perianal, bladder neck, or proximal urethra stimulation have latencies between 50 and 65 ms. 49 This more prolonged response is thought to be caused by the afferent limb of the reflex being conveyed by thinner myelinated pelvic nerves with slower conduction velocities than the thicker myelinated pudendal afferents. The longer-latency anal reflex, the contraction of the EAS on stimulation of the perianal region, may also have thinner myelinated fibers in its afferent limb because it is produced by a nociceptive stimulus. 49
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