Today, we're going to be talking about the anal rectal examination of the adolescent adult sexual assault patient. My name is Tara Henry, and I am a forensic nurse in Alaska. I've been a forensic nurse for 25 years and a nurse practitioner for 13 years. So we're going to just jump right in and talk about the anal exam and we'll do an overview. And since this is a recorded webinar, there won't be any time for questions because there's nobody on here watching live. But if you take my email down at the beginning of the slide, you're welcome to send me emails after you watch this webinar, if you have any questions, and I would be happy to answer them further. All right, so let's get started. Okay. So the objectives for today are to review the anal rectal anatomy and physiology. And then we're going to also review a little bit of literature regarding anal rectal injury post-sexual assault, and we're going to discuss using anoscopy as an assessment tool. So to jump right in talking about anatomy. To be clear on terminology, to make sure that all of us are using the correct language when we're referring to anus and anal canal and rectum, perianal area, I wanted to just go over the basics of all of that anatomy and some physiology with you. So the anus is actually the opening at the terminal end of the digestive tract. And the perianal area is the tissue surrounding the opening, the anal opening. So it's a circular area. It includes all of the folds around the anus. So those perianal folds, the skin around in the perianal area is more pigmented in course than what the buttock tissue is. So you can see on this photograph, it's a little bit darker for some many people. There is also hair associated with in that pigmented area around in the perianal area. And this is also sensitive to touch, meaning that the nerve endings there that you can feel, you know, heat, cold, pain, it's sensitive to touch. There is no natural lubrication in the perianal area of this tissue. So right here, that circular demarcation area, this is the buttocks. This begins the perianal area here. And then the anus is the actual opening. So when you're talking about where injuries are, you're really looking when you have injuries in this area. There are perianal injuries around the anal opening. As you go from the anus into the anal canal, you have the anal verge. And that is the rounded kind of curved part of the anal opening when it's going in. That is called the anal verge. That's where a lot of your injuries are going to be seen is on that anal verge versus the perianal area or more inside. So that anal verge goes from the perianal externally into where we call what we call Hilton's white line. And Hilton's white line is that transition point between the perianal tissue and the anal canal. The anal canal then starts at Hilton's white line, and it goes up to the pectinate or dentate line. That is the junction between the anal canal and the rectum. And that pectinate dentate line is a bunch of little columns. And those anal columns contain the terminal branches of the superior rectal artery and vein. And the inferior ends are joined by anal valves. And just superior to those anal valves are little small recesses called anal sinuses. And the anal sinuses are what exude mucus when they're compressed by feces as feces is trying to come out of the anal canal. And that mucus then that's exuded by those anal sinuses help the evacuation of the feces through the anal canal. This tissue on the anal verge where Hilton's right line is, you can see that is where the transition point is from the keratinized squamous epithelial tissue of the perianus that transitions into the non-keratinized squamous epithelium of the anal canal. So this diagram here, you can see, excuse me, as the, you have your perianal tissue, it comes in on the anal verge to Hilton's white line. So it's right here. It's basically this curved section and then you have Hilton's white line. And this is where the anal canal begins. And then the anal canal goes to the pectinate dentate line, which is right here. And these are those columns that I was referring to a minute ago. And then here at the pectinate dentate line is where the rectal mucosal starts. Okay. Perianus, anal verge, Hilton's white line, anal canal, pectinate line, rectum. So this is just a diagram to show you those anal sinuses. So you have, here is, you know, the anal verge, here is Hilton's white line. You have the anal canal, and then where the pectinate dentate line is, and these anal columns are at. So the anal sinuses are just right here. And there's little valves at the end of those sinuses. So as the feces comes down and that pressure begins to compress there, then it exudes that mucus and then it helps the feces then transition through the anal canal. So a couple of photographs where you can see this is Hilton's white line right here. And you can see also right over here, Hilton's white line. These are some photographs of the pectinate line. So you can see, this is some patients you can't see the columns real well, and in other patients you can. This particular patient, you could see the outline of the columns very well on the pectinate line. This is rectal mucosa. These are the columns. In here, you can see the transition point. These right here are actually the columns. And it's transitioning then into the rectal tissue from the anal canal. Again, here, the anus scope, the edge of the anus scope is kind of compressing those columns down. But you can see here is where the pectinate dentate line is transitioning into the rectum. And again, over here, this is the anal canal that is then transitioning at the pectinate dentate line into the rectum. And in this photograph, this is the rectal tissue right here, and this is the pectinate line here. Okay, so the anal canal is also on each end of the anal canal. You have hemorrhoidal plexuses. So the external hemorrhoidal plexus, it's basically both hemorrhoidal plexuses are vascular areas that are formed by the anastomosis of the rectal veins. And they kind of form like they're like anal cushions kind of in here on around the anal opening. So the external hemorrhoidal plexus is also referred to as the external hemorrhoidal ring. The internal hemorrhoidal plexus is also referred to as the internal hemorrhoidal ring. So that terminology is used interchangeably. The external hemorrhoidal ring is basically right where the anal verge is. So it surrounds the anal opening right there. And then the internal hemorrhoidal ring is at the same location as the pectinate-dentate line. So it kind of has the rings on both ends of the start and the end of where the anal canal is. Internal, you can see here, this is the internal hemorrhoidal ring right there where the pectinate-dentate line is. You can see this discoloration. This is an area that's always like much more, it's very vascular because it's a plexus, a venous plexus. And so it's always going to be a darker purple or red. And oftentimes, particularly new examiners who are still learning how to use an anuscope and how to interpret anal rectal findings with an anuscope can often misdiagnose or miscall an injury, thinking that this is bruising and swelling when it's not. This is normal finding of the internal hemorrhoidal ring. So it takes a little bit of time to get used to what that looks like so that you're not calling it an injury when it's not. Again, here's another photograph of that internal hemorrhoidal plexus here. So it's right there at the pectinate-dentate line. This is a photograph of or a diagram of the external hemorrhoidal ring. So you can see it's just a band of vessels that go around the anal opening there, right about the anal verge. In this particular diagram, it's demonstrating a hemorrhoid there at the external hemorrhoidal ring, but this is the location that you're seeing it at. Okay. For the external hemorrhoidal ring, when you're doing exams, you can see venous pooling. This happens when the patient is lying on their back in that lithotomy position. So they're in a dependent position and it can become more prominent with time. So you really want to make sure that when you're doing the exam of the perianal area and the anal canal and the rectum, that you don't confuse the venous pooling with bruising or swelling. I remember when I was a new examiner 25 years ago, I was having all these patients. In our training years ago, we were just brand new up here. We didn't have a lot of resources. We didn't have a lot of training on anal exams and anal findings. It was really pretty focused on the genital findings that we might see in sexual assault and the state of the science as we thought it was in the mid-1990s. And so I often would see this dark colored purplish swollen area on the anus and the patient had not reported any anal penetration. I kept thinking, gosh, why? There's bruising and swelling on their anus. They must have had anal penetration and not remember. And so in the first several months of my practice as a new sane with no other resources really here, I was over-calling injury to the anus because I didn't understand what venous pooling was. I'd never been taught that. And it wasn't until I consulted with a colorectal surgeon to figure out and ask for more guidance and more education on anal rectal anatomy that I learned about venous pooling back then in the 90s. And so then I went back to all those cases that I had done and looked at them again and recognize that, okay, this wasn't bruising or swelling. This was venous pooling and had to write addendums to kind of address that in the record so that I made sure that I wasn't, that I had corrected that. So what happens in venous pooling is when that person is lying in that dependent position, just like if you're sitting on an airplane or you get a kind of pooling in your lower extremities from sitting there, it's the same thing that can happen to that external hemorrhoidal ring is the blood just starts to pool there. And so it will begin to engorge over time, the longer the patient is lying there. And so you can sometimes actually just watch it engorge in front of you over time. And particularly if you're starting to manipulate the tissue and start looking around, that's going to bring a little bit more of that blood there into that external hemorrhoidal ring. So just be cautious of that. All you have to do if it becomes too difficult to examine somebody is you can just have them get up for a minute and walk around and be able to, it'll go away. So just takes a minute or two for them to move around the room and then they can lay back down and you can finish that exam. So let's look at just a couple of examples here of venous pooling. So this is a patient that over time, you can see she had a little bit of venous pooling at the start. And then as the tissue was manipulated, that venous pooling began to get more. And then by the time towards the end of the examination, you can see that there's a lot of venous pooling now. Now, had I not known what this was and she didn't report any hemorrhoids or anything like that, and maybe there was anal penetration and you just initially look at that, for some examiners, you might think, oh, there's swelling of the perianal and anal verge, or there might be some bruising and that's not what this is. So you can have her walk around and it'll go away. Here's another example of that external hemorrhoidal ring is starting to get some venous pooling just basically from about 10 o'clock to one o'clock. You're starting to see some of that discoloration there. Some more examples. This one is almost circumferential. There's a little gap that isn't pooled yet between two and three o'clock and from like eight to 11 o'clock here, it doesn't have the pooling yet, but from 11 o'clock to two o'clock and then from three o'clock to seven o'clock, you can see that the venous pooling. In this photograph here on the bottom, you can see just a little bit of venous pooling starting from about four o'clock to six o'clock, but then you can really start to see it from six to seven and you can see it again from about 10 to 12 on this particular patient that's starting. So you can see that discoloration happening and that swelling happening. Okay, so you do run into hemorrhoids. The hemorrhoids occur at that external hemorrhoidal plexus or external hemorrhoidal ring or the internal. So this is where those anal cushions are and they can become engorged. So it's just like anywhere else where you might have like a little aneurysm in your vessel where the wall of your vessel begins to be weak and it begins to bulge. You can kind of think of a hemorrhoid like that where over, you know, due to trauma or straining over time or weakness of the vessel wall, it begins to, you end up getting a hemorrhoid, becomes weak, it begins engorging with that blood and pooling there, expanding in that localized area. And so you get either external hemorrhoids from that external area or the internal hemorrhoids you may see. Now, sometimes those hemorrhoids, you know, if they're external hemorrhoids, if they are, when they first happen, they can be very tender to touch. It might hurt for them to walk around. And so if they have a new hemorrhoid from like an assault, then, you know, that area is going to be very sore when you are trying to manipulate it. If it's a hemorrhoid that's been there for a while, you know, they may be able to tell you, yeah, I have hemorrhoids or this happened a long time ago and they still have it. They're used to it. It doesn't hurt anymore. They become accustomed to it and it's desensitized. For the internal hemorrhoids, these ones, you don't, they don't feel them internally unless they prolapse out. So what happens is they may have internal hemorrhoids and it's not until they become large enough where they end up prolapsing out of the anal opening that they become painful because what happens then is when they prolapse out the anus and the internal sphincter and the anus close around that hemorrhoidal, that hemorrhoid, that internal hemorrhoid. And so it basically cuts off the blood supply to it and makes it necrotic and it's really painful. And those ones have to either be pushed back inside. Sometimes they have to have some type of surgical incision to decompress them or remove them. So this is just another example here of your normal rectum and anal canal here. And then as the hemorrhoid, like internal hemorrhoids for staging wise. You can see on this left side, this internal hemorrhoid diagram is showing us just starting to prolapse kind of down into the anal canal a little bit. This one is a little bit further than in stage three. It's prolapsed down to the anal verge. And then stage four is when it's actually prolapsed out of the anal opening. Where you can visibly see it then externally. And that would be a stage four internal hemorrhoid. Okay. So it's just a couple of examples of new onset hemorrhoids after an assault has occurred. So right here, this is a new hemorrhoid, very tender, very sore to manipulate and to touch that tissue. This one here at the six o'clock position, again, it was a very sensitive, very tender area, a new hemorrhoid that happened after the anal penetration. Okay. So you might see anal tags when you are doing your perianal exam and the anal skin tags are herpetrophied redundant skin folds. And basically they're where you have like healed fissures and healed hemorrhoids have taken place because those hemorrhoids, when they eventually heal, they don't always stay really engorged like that. And so you'll end up with like a tag where that hemorrhoid was. You'll see these frequently in patients who have some type of chronic bowel disease like Crohn's or irritable bowel or colitis. And so that you, it's not unusual in someone who has those types of bowel diseases to see several anal tags. Sometimes after a sexual assault, when somebody has a hemorrhoid, then when you do, if your program, like our program where I work, we do follow-up exams. So if you work at a program that does follow-up exams, then you may have, you may be able to see a skin tag that has occurred from the healing of a hemorrhoid that was there that occurred right at the time of the assault. And then you see them and do follow-up exams. And once that hemorrhoid is resolved, you may see that anal tag that's associated with that. So here's some, just some examples of what those anal tags might look like. Like I said, there are those redundant skin folds in here. Okay. So in this particular patient here, you have a skin tag here, an anal tag, but then you also have a hemorrhoid here that they have. For those of you who may not recognize this, this is just basically toilet tissue that needed to be wiped away a little bit better. So it's just little rolled pieces of toilet tissue that was on their anal area. There is a small laceration right here on the perianal tissue here at one o'clock, but that's not what the purpose of this photo is. So more skin tags here. Here's the 12 and 6. You have another skin tag here, anal tag at 12 o'clock on this patient. And another tag here. These are tags. And there's multiple ones here on this patient. They did have a chronic bowel disease. And so you have multiple areas where they'd had some fissures and some tags on hemorrhoids. Okay. Just throwing it out there that when you are looking at the anus, make sure that you are familiar with what warts look like, genital warts, condyloma on the anus, because you don't want to misinterpret a anal wart for a tag or vice versa if they have warts on the anus. They definitely need to be treated versus a tag that doesn't. So these are just some examples of what anal warts might look like on the anus. Okay. So let's move in and talk a little bit about the sphincter muscles for some physiology of the anal canal. This is important for you to understand when you're thinking about anal sex, for injuries that might occur in a sexual assault, and also for when you are doing your examination, if you're doing a digital rectal exam or doing an anus scope exam. So for the anal canal, it has two sphincter muscles. So you have your internal sphincter muscle, which is an involuntary, it's a voluntary muscle, it's a smooth muscle, and it surrounds the upper three quarters of the anal canal. And it surrounds the upper three quarters of the anal canal, essentially close to where the pectinate dentate line is, and your internal hemorrhoidal ring, that is where your internal sphincter muscle also is. So it's between the pectinate and Hilton's line. It has the internal venous plexus that we just talked about, that internal hemorrhoidal ring, that's what separates the muscle, the internal sphincter muscle from the membrane of the anal canal wall. And then on the other side of the internal hemorrhoidal, I'm sorry, internal sphincter muscle is the levator ani longitudinal muscle sheath. And that's what separates the internal sphincter muscle from the external sphincter muscle. So it's basically sandwiched between the internal venous plexus and the levator ani muscle sheath. So it looks like this for an example here, this is the internal anal sphincter muscle. And so right here, it goes down to right about Hilton's line and goes up to the pectinate dentate line. And then this is your levator ani muscle. And then you have your external anal sphincter muscle, which we'll talk about here in just a second. So the, the role of the internal sphincter muscle, you know, that muscle stays constricted all the time and it helps keep stool from coming out when somebody, you know, when their species in your rectum, so that internal sphincter stays closed. And because it's an involuntary muscle, we don't have control. We can't just automatically relax that muscle or, or not. We don't have any control over that. So what causes that sphincter muscle to relax is pressure. So when the feces is coming down out of the rectum and that stool begins to put pressure on that internal sphincter and the internal sphincter is like, Oh, okay, I have some pressure there. And that slow pressure then causes the internal sphincter to relax. And then as the feces starts coming down, then your external sphincter takes control as to whether or not the feces actually comes out at that moment or not. Okay. So the second sphincter muscle, your external sphincter muscle, now there's three parts to your external sphincter muscle. So the, unlike the internal sphincter muscle, which is smooth muscle and involuntary the external sphincter muscle is skeletal muscle. So it is voluntary. We do have the ability to contract it and relax it and control that, that muscle. So the external sphincter muscle surrounds the entire length of the anal canal. And there's three parts. So the first part to it is the subcutaneous part of the muscle. And that is a flat band muscle band that goes around the anus. It basically is in the same location as that external venous plexus, the external hemorrhoidal ring right there at the anal verge. So it's that flat band around the anus and it's, you know, it's circular and it's separated from the perianal skin by the external venous plexus. And then that is what is voluntary. And that is the muscle part, the part of the external sphincter muscle that you have control of. The other two muscles that are the other two parts, the superficial and the deep muscle of the external sphincter are involuntary muscles. So the superficial part of the, sorry, of the external sphincter it's elliptical and shaped. And it basically is like it's skeletal muscle that is going to extend superiorly to the puborectal, puborectalis. And then it's, it goes down posteriorly to your coccyx and anteriorly to the perineal body as its attachment sites. And then you have your deep muscle and it is annular in shape. So it goes around the anal canal as well and surrounds that anal rectal junction and it's inserts into the perineal body. And so, so you have a better visual than my explanation. So you have your anal opening here. This is the subcutaneous band of the external sphincter. So that's the muscle that I told you was that flat band that goes around that you have control of. And then you have that superficial elliptical shaped that comes up here and then down here to your coccyx. So elliptical shaped right here. And then the deep portion of the external sphincter muscle is this annular muscle band that goes around right here. Okay. So basically you have two annular bands, and then you have an elliptical band of muscle tissue in between there. So any of these can be injured in a, in a, with anal penetration. Oftentimes, if you have an injury, the most common one to be injured would be this, this external one here, the superficial one, I mean, the subcutaneous one, but you certainly, depending on the type of injury that the, you know, the depth of the wound, the type of item that caused the injury you certainly can have injury to those deeper muscles. But the most common one is this external, the subcutaneous part of the external muscle. Okay. So a couple of things to, to think about here that you also have going on with the puborectalis muscle. So the puborectalis muscle here is like a U-shaped muscle that's connected to the pubis. And it comes around that anal canal and attaches at the other side here. And this puborectalis muscle, it basically stays tonically contracted all the time at rest. So that's its normal state is to be contracted. And it creates this anal rectal angle, like a 90 degree angle here. And in addition to the internal sphincter muscle being closed with the puborectalis muscle maintaining a contraction and creating this 90 degree anal rectal angle, that's those two things together helped keep the stool up inside of the rectum so that it doesn't until it's ready to be evacuated out. And then during the evacuation process, when you're having the bowel movement and that stool then puts the pressure on that internal sphincter and, and you're going to, to go to the bathroom, then that internal sphincter begins to relax and the puborectalis muscle relaxes as well. And so it takes away or decreases that anal rectal angle. So it allows the stool then to, to come out. Okay. Okay. So once that's, that's like all the information that you really need to know about the anal canal what you have on the structure surrounding the canal and kind of the physiology of what's happening there in the, in the anal canal area. So then you move into the rectum and the rectum is the lower portion of the large intestine. It's about 12 centimeters long. And this tissue is made up of columnar epithelial tissue, like the rest of your kind of digestive tract. And so you do see that that pectinate dentate line is that transition zone from the non keratinized epithelial tissue squamous epithelial tissue of the, the anal canal to the now columnar epithelial tissue of your rectum. Inside of the rectum, you will see that it has the valves of Houston, which are three transverse semilunar folds that are staggered. And the purpose of those is to kind of help support the feces that is coming down so that it's just not like a straight tube where the feces can come out. So it kind of helps, you know, stagger it a little bit to keep it from just coming out and help support that. Now the rectal tissue is is insensitive and remember that the nerve supply superior. So the nerve supply above the pectinate line is a visceral innervation from the parasympathetic fibers. So you, it feels pressure only, but it doesn't, if you touch it, it doesn't really feel touch. It's not really sensitive to pain, unless you have like a pressure surrounding it. Now, other areas are sensitive. You may feel pain, but so when you're doing an exam, you know, if you're not, if you're doing a swab where you're actually swabbing the rectum itself, they don't feel that. They just feel pressure from, you know, the expansion or manipulation of that tissue, but it's not, otherwise it's insensitive. Unlike your perianal area, which is sensitive to touch. Okay. So let's just walk from the beginning here. So you have your perianal area, then you go into the anal verge right here to Hilton's white line. This is the beginning of the anal canal. And then you have your anal canal up to the pectinate dentate line here. And, and then you have your rectum here. These are the interior middle and superior valves of Houston. So you can see instead of the stool coming straight down, it kind of has a, some support there before it comes out. And then again, you have your internal hemorrhoidal plexus, your external hemorrhoidal plexus would be here. This is your internal sphincter and your external sphincter here. So that kind of covers all of those, all of that anatomy that we just went over. Okay. So here are some photographs of what the rectal tissue looks like. It's normally kind of pink to salmon colored. And so, and it's, if you, if you have the anus scope right in the center of the rectum, like you should, then it's going to be kind of wrinkly and folded over on itself. You can see those folds if you're right. You know, if you have it right in the center, so you can, you know, you just see all the folds here. If you have the anus scope where it's pressed up like this against one of the, like the, you know, anterior posterior rectal wall, then it's going to be flat where you're not going to see those folds. So again, nice pink, healthy tissue here on the rectum is what you're looking at in these photographs. Now, when you, you know, when you're doing an anus scope exam, I mean, you might have some feces in there. You can also, you know, some of those anal sinuses, when you're putting that pressure in, you know, it doesn't know the difference, right. If it's stool that's causing pressure or something else. And so a little bit of mucus can be secreted. So you might see some mucus in the rectum around the pectinate dentate line that when you're doing your exam, because that is the anal sinuses having some, expressing some of that mucus. So all just photos of nice healthy pink salmon colored rectal tissue here. Okay. And so really you want to think about that pectinate line as being a clear demarcation area in the anatomy for the destination for your lymphatic drainage, the type of epithelial tissue that is lining the anal rectal canal, your, where your arteries and your veins are, what's innervating it, what hemorrhoids like your hemorrhoidal plexus classifications, whether internal or external, what nerves are innervating it, that area. So really that pectinate dentate line is an important part of the anal rectal anatomy and the physiology of the anal rectal canal. Okay, I think that's plenty on anatomy. So let's talk just a little bit about anal sex. So, anal sex is historically and currently still often considered taboo. There is still very much a social stigma around anal sex and it's propagated by ignorance and homophobia and there's shrouded in a lot of myths around it being something that is dirty, perverted, unnatural, immoral, dangerous, only gay men have anal sex, male receptive partners wish they were female. There's lots of myths and stigma around anal sex. And that prevents us from being able to talk to our patients about their normal sexual practices that they have, because you need to make sure that you are addressing your own biases around and perceptions around anal sex so that you can talk with your patients about it. If patients are not able to openly discuss their sexual practices, then it becomes a safety issue, right? Because they may have injuries, they may have infections, there may be things that they need to have guidance on or need to be comfortable being able to talk to their healthcare provider about and if they think you're going to judge them or that you won't understand, or that you think that you believe in one of these myths, then it's not going to allow that patient to be able to disclose to you to talk about it. And so they also may have their own stigma and beliefs around anal sex. So if they have been anally assaulted, it may prevent them from wanting to disclose that. And so being able to understand it yourself and to normalize it and to talk with someone and make them feel comfortable to disclose it is really important. So what we know from the limited research is that anal sex is not just men who have sex with men. A survey that was done in the US several years ago for 14 to 94-year-olds. And I believe it was around almost 6,000, it was like 5,800 men and women that were surveyed and how many of them had had anal sex at some point in their lifetime. And what they found in that survey was for women, 40% of women ages 20 to 49 had reported that they'd engaged in anal sex at some point during their life. And 30% of women ages 50 to 69 had reported that they had engaged in anal sex at some point in their life. So that's a pretty significant number of women who are engaging in anal sex that we didn't really have much data on before. And then lifetime receptive anal sex for men, you can see the numbers here for 20 to 24-year-olds, about 10% of them, 40 to 49-year-olds, about 8.5%. And then 50 to 59 was about 9.5%. And then they also surveyed like in the past year, how many of them had engaged in anal sex. And over 20% of the men in the 25 to 39-year-old range and women in the same age range basically had reported that they had engaged in anal sex in the past year. So this is really important information for us to look at because I think sometimes we forget or we don't think about, it's we think more often think about men having sex with men and anal receptive sex in those situations. And we haven't always historically thought about women engaging in anal sex. And so we need to make sure that we are asking and normalizing that practice for our patients that we are talking to about whether it's safe sex, sexual assault, when we're talking about their lifestyle, their partners, when we're trying to do education on sexual transmitted infections and those kinds of things. We wanna make sure that we are treating our male and female patients the same in asking them about their anal sex practices. In 2018, there was another survey that was done. It was from 2011 to 2015. It was the National Survey of Family Growth. And they looked at and asked about anal sex in heterosexual relationships. And they found that women ages 15 to 44 reported, about 33% of them reported they had engaged in anal sex at some point. For the men, it was about 37%. And the adolescent age range from 15 to 19, they were reporting about 11% had engaged in anal sex at that point. And that's a pretty big, it's a pretty big study or a survey. It's, I believe around 20,000 respondents were surveyed in that particular study. Okay, so that just kind of sets the tone. And just to remember that anal sex happens. It happens in same-sex partners. It happens in heterosexual sex partners. And so we need to make sure both men and women engage in it. And we need to make sure that we are addressing that with our patients. Now, the other thing you need to think about with anal sex is anal dysperiornia. So that is pain during anal receptive intercourse because it is very common for anal receptive intercourse to have pain associated with it. So this is helpful for us to have just a brief discussion out here so that you're thinking about that when you're trying to do education with your patients. And understand that a large amount of women reporting that they do have anal dysperiornia or pain when they have receptive anal sex. A little bit higher number in the women than what the men have reported, but they're certainly, they have pain in both men and women. What the limited studies that have looked at anal dysperiornia and like the causes or what may be contributing factors for the pain, what they have found is that lack of relaxation on the receptive partner, being able to relax that external sphincter and having insufficient or a lack of lubrication. Remember that perianal area and the anal verge does not have any natural lubrication. And so that makes it difficult to insert anything in. And so it can cause pain when they're trying to insert a penis or a finger or an object into the anal canal and the rectum. And then lack of foreplay, anal foreplay. So whether it's a digital anal massage to help relax, because that massage will also, and that stimulation, that stimulation with the finger will help to relax that individual. So that's having the receptive anal sex. So they can relax that external sphincter and also get, if they're having digital anal massage, that digital penetration can also stimulate the internal sphincter to begin to relax. If you're doing analingus or having, because that external, the perianal tissue is sensitive to stimuli. So any type of anal foreplay that can be done, whether it's with the mouth or whether it's fingers will help to be able to decrease that pain. So people who weren't able to relax or they didn't have enough foreplay, anal foreplay, or didn't have enough lubrication contributed to the pain. There was a study in 2007 that people who had receptive anal sex had indicated that the size of the penetrating penis for them also contributed to whether or not they were having pain. And then some of the older, an older study talked about those patients who were having receptive anal sex, that if they didn't use a popper, that they would have pain most or all of the time with that penetration. And then there's also some medical conditions that can contribute to having pain. So hemorrhoids can be painful, anal fissures, if you have a chronic bowel problem where you've had a really, you've been constipated and you end up getting a fissure, certainly infections, sexual transplant infections can cause you to the tissue to be even more friable and painful. And there's some recent studies in the last couple of years that have been coming out on analgesic peri unit and they post prostate cancer treatment. And so that cancer treatment now is contributing to having painful anal receptive sex. So things that you can talk to patients about who are engaging in consensual anal sex, and for you to understand how to decrease that, really relaxation is the key to successful penetration. So being able to relax that external sphincter first is going to be really important. And then knowing that relaxing that external sphincter is a learned behavior, it's something that they have to learn how to do, they have to practice to be able to do that. And then the internal sphincter will relax with patients and some gentle stimulation or pressure. So when you think about that external sphincter being closed and the feces coming down, there's a gentle pressure on that sphincter from the feces that's in there. That's then going to gently cause that internal sphincter to open up for the feces to come out. So when you have something going from outside to in, it's the same thing. If you're going to do a digital exam and you put your finger in, if you just stick your finger all the way in like fast, it's going to cause the patient pain. And the pain comes from, even if they're not nervous and their external sphincter isn't really tight, even if they're able to relax that external sphincter and you put your finger in too fast, that pain is causing because you're forcing your finger through that internal sphincter when it's not open yet. So if you just put your finger in a little bit until you reach that internal sphincter and then give it a few seconds for it, and just, you can stimulate that and allow that to relax. And then you can put your finger or the anoscope the rest of the way in. So it's the same way if you're trying to have receptive anal sex. If your partner is putting their finger in or their penis or an object, if you can relax your external sphincter and then they can put whatever it is that they're using to penetrate into your anal canal, it just goes in a couple of centimeters, so just a little bit. And then that's where the internal sphincter is. And then if they just pause to allow that internal sphincter a little bit of time for it to relax, then they can push through that internal sphincter. And so they have that full penetration. Now, anxiety and fear can result in both of those sphincters contracted due to the sympathetic nervous system activity. So if someone's trying to engage in consensual anal sex and they're really nervous or they're scared, it's their first time or it's a new partner or whatever the reason, then it can be extra difficult for them to relax those muscles. And even with gentle pressure for that internal sphincter to relax due to the sympathetic nervous system activity of just that fear and stress. So then when you think about that, when you have somebody who's being sexually assaulted and if they're scared and they're anxious and there's stress, then those sphincters may be closed even more. And so they may have an increased amount of pain with that penetration and the tighter that that is and the more constricted it is, the increased chance that you can get of creating injury to that muscle tissue or to the skin because it isn't able to dilate or open up as well. So it can be even more painful for patients who are being sexually assaulted. Now, poppers, alkyl nitrites, these are something that's commonly used. I say sometimes, but if you talk to people who are engaging in receptive anal sex, particularly men who have sex with men, this is something that is very common used to help relax that anal musculature. So a popper is basically, when you inhale a popper, it lasts for just a few minutes. It makes you feel like you might be like instantly kind of drunk there for a minute. But what happens is when you inhale that popper, that alkyl nitrite, it releases a nitric oxide, which then binds to the heme group of the enzyme guanylate cyclase. And so what happens is that then causes the smooth muscles to relax and to dilate open. And so when you're trying, you're having a difficult time where that internal sphincter is not wanting to dilate, remember that's a smooth muscle. And so if you are able to inhale this alkyl nitrite, then just for a couple of minutes, it's going to bind to that enzyme, and then it's going to be able to relax that internal sphincter. And then the person who is penetrating is able to get through that internal sphincter and the pain is less. So that's something that you might hear people use regularly that engage in receptive anal sex. Other things to think about is making sure for pain-free anal sex that some type of artificial lubrication is used. And this will help reduce the friction, pain and injury as well. And then having a slow gradual penetration, kind of a start-stop where you start to penetrate and the person, the receptive partner is able to then help to relax their external sphincter and then penetrate a little bit further and just pause while that internal sphincter is relaxing and then be able to penetrate the rest of the way in. And then, you can penetrate in and out after that, but that initial penetration, going slow, gradual start-stop type of penetration to be able to get all the way in is really beneficial to decrease the pain. Certainly having the person who's receiving the penetration to be aroused, having stimulation, all of those things are going to help contribute to having pain-free anal sex. Now, engaging in anal sex, it does have an effect on your anal rectal function. And so, if you engage in anal sex regularly, you can end up having just an increase in minor incontinence or some urgency where those sphincter muscles have a hard time staying closed and so, as soon as they begin to feel pressure, then they, particularly that external sphincter, where you're used to it naturally being closed and you having to actually consciously relax it in order for the stool to come out, if you have been engaging, it's like muscle memory, as you've been engaging in penetration, some of the muscle gets a little bit weakened, if you will, and then you can end up having some urgency or incontinence because that external sphincter has a hard time staying closed when it begins to feel any type of pressure. And so, you might have some skid marks or you might need to be on near like a bathroom when you have to have a bowel movement. There's also a reduction in the anal resting pressure, particularly when you have a brachial proctus intercourse and you have a reduction in that mucosal sensitivity and then you certainly have, if you are engaging in brachial proctic intercourse, then you have a lot more tolerable rectal volumes. And so, brachial proctic intercourse, what I'm referring to is like fisting or hand arm insertion into the rectum. And so people who engage in that type of sexual activity then are at risk for like megacolons, like significant rectal pooling or pooling of stool or feces into their rectum. And so those have to be monitored carefully so they don't have impactions or trouble with their stooling. So consensual anal sex injury, there's not a lot of information out there for us to look at. If you look at the like HIV literature, it does indicate that there's a higher risk of transmission with anal sex and it's likely from mucosal tearing or inflammation is what it refers to. But there are no studies out there that, at least I'm currently aware of, that are focused on specifically on documenting the type, the frequency, and the location of anal and rectal injuries in consensual anal sex. So over the last, you know, 20 years, 25 years, we have done a better job at trying to look at consensual sex and consensual sex injuries in the female genitalia and what the types of injuries, the location, is there frequency, what's the pattern of injury we might see in trying to figure out what is, you know, when we're thinking about in forensics, you know, the sexual assault versus consensual sex and is there a different pattern of injury that we might see in there. But that hasn't been done for consensual anal sex. And so we really don't know much about the type, the frequency, and the location of anal or anal canal or rectal injuries in consensual anal sex situations. When we look at the studies around anal dyspareunia, it doesn't indicate, none of them indicate that injury was, you know, really a cause of what the pain was, you know, from the anal sex. You know, it talks about the relaxation and the lack of foreplay and the lack of lubrication, you know, medical, you know, things that, you know, diseases and infections and hemorrhoids and such, but it doesn't list injury as being a cause. So we don't know if that was just not asked or if they didn't interpret that as injury, they didn't know they had injury, it hasn't been looked at, we just don't really know. So the literature around consensual anal sex injury is really very sparse to non-existent at least as it pertains to the type, the frequency, location, pattern that you might see. We do know there are, have been a couple of studies, you know, mostly case studies, but there have been a couple out looking at sex stimulation device injuries. And so you do have some, you know, lots of numerous case reports with patients that have used, you know, some type of, you know, vibrator dildo, you know, foreign object of some sort and it getting stuck in their vagina or their rectum resulting in, you know, that they had constipation or pain or bleeding afterwards, or there was some type of a perforation or a peritonitis. So there's lots of case reports around there, but not a lot of, you know, studies where there's, you know, numerous patients included. There was a population study that was done from 1995 to 2000, a population study that was done from 1995 to 2006, where they surveyed almost 7,000 patients that were treated in emergency department for, you know, sex stimulation device injuries, about 5,000 men and 1,700 females were surveyed and looked at. And what they found was that the body region that was injured, about 78% of it was the anal rectal area. 18% was either vagina or penile. And then about a little, almost 4% was not really specified or was other. And vibrator was the number one cause of sex stimulation device that was used at that time, followed by a dildo or ring. And then about 11% were listed as other or unspecified. When they looked at the males, they did find that the anal rectal area was the most common site that was injured for males. And for females, it was the vagina that was the most common site for both males and female vibrating device was the most often cause. But in this population study, there wasn't a description of what those injuries were. So we don't know if it was, you know, a superficial abrasion or if it was, you know, a perforated bowel, or we just don't know what those are because there really wasn't a description of the injuries. But what we do know is that, you know, they occur. So moving on to sexual assault, here, there is an abundance of literature on injury in general for sexual assault, particularly around genital injuries, right. And so we've done lots and lots and lots and lots of studies studies out there that you can you can find on types of injuries, frequencies of injuries, patterns of injuries, as it comes to sexual assault for the the genitalia, but there is a very limited focus on the anal and rectal injury. Now, most of the studies that are out there, even if they're they, it's kind of just a very subtle comment someplace within the study, it's not really focused specifically on the anal and rectum. Many of these studies combine the anus and the rectum instead of identifying them as a separate site that they'll say anal rectal. So we don't really know is that the anus is at the anal canal, or is it the rectum, or they may just talk about anal injuries. But they aren't specifying whether it's like, really just the perianal area, or are they using the term anus to account for everything? Or they might just talk about rectal injuries. But they don't say anything about the anus. So, so they are combining that anal rectal instead of having it a separate sites like we do with the external genitalia on the female, you know, the labia minora, the clitoral hood, the posterior foreshad, flaccid avicular, so we have all the, all the different anatomical sites. But for a lot of the, for the sexual assault studies that have anything talked about for the anal rectal, those anatomical sites aren't specifically listed very often in studies. So oftentimes, what you'll also find is that they just briefly mentioned the anal injury and the percentage. So really, the majority of the literature is focused on what the genital findings were, and the genital patterns of injuries and sites and types of injury. And then it might just say something like, you know, anal injury was, you know, 20%, or, you know, 2%, or whatever it is. So it's just like a sentence, or maybe not even a sentence is even mentioned in the discussion or finding section. And but you if you look in the graph that's associated with it, that you might be able to find it in the graph. So there's really has been very minimal discussion of the anal or rectal injury types in the sexual assault literature. And rarely does it indicate in there if an anoscope is even used as part of the examination or not. So there, you know, there are some that that differentiate, but not a lot of them. So just a few, you know, articles out there on that mentioned anal injury. Now, none of this is not a one specific to anal, anal assault. But this one did, this is a case out of Australia. And they did just naked eye, you know, macroscopic visualization, they didn't use a culpiscope or anything like that. And Zilken's, this is in 2017. And they found that about 14% of women had anal injury is what they called it. And then they had, it was lacerations, abrasions and bruises. And then the site sites were listed as perianal anus and rectum. So what we don't know is, what is the difference between perianal and anus? You know, are they referring to the anal verge as the anus? Or, you know, what, what are they looking at? And then how did they visualize the rectum, you know, with their naked eye? Was it just by, like, you know, did they use an anus scope? Or did they do separation and traction of the anal openings until it dilated and they were able to see and we don't really, there isn't really specified, you don't really know how that was evaluated. Also from Australia, same authors in 2018, they published one findings on anal injury in men, and there were about 9%. And they did say that they're, you know, what type of injuries, not really the site again, and this particular one listed perianal, anal canal and rectum. So this was great that they did actually specify which anatomical site, and that was, that's great. So that's the best that I've seen recently in identifying the actual anatomical locations. There was another study in 2021 that came out, and now this study was not specific to anal assault as well. But in the study, about 7.3 of the women, percent of the women had anal injury. And the article states that the most common type of anal injury were lacerations followed by bruising. And then the list of the site as being the most common site was the perianal region. So that's about as specific as they got in their article about any types of description of types, sites, location, patterns, anything like that. And they said that a colposcope and nuclear staining and digital imaging was used to do that evaluation. There are a few publications that do specify an anuscope being used. There was a literature review that was done back in 2013. And at that time, the literature review that was looking for that found that the use of an anuscope to detect injuries to the rectum rarely occurred, that people were, so we don't know, was it because they weren't, they just weren't using that, they weren't documented in the literature, in their article, their publications. But as, at least in 2013, it was rarely being documented. But there were a couple studies in, you know, from Jones and colleagues in 2003 and 2004 that did mention that anuscopy was performed at the examiner's discretion. What the, how that discretion came about or what their parameters were, I don't, you know, it doesn't discuss that in there. And they do mention anal injury as a percentage in the graph, and it's mentioned in a sentence. And there's no results for the rectal findings or what those results are. So even though it does have a brief mention of it, there's really not a whole lot of specifics for us to glean from that. In 2008, there was a study that came out, Dropton, Sachs, Chu, and Wheeler, and they did also mention that when indicated, an anuscope was used to delineate injury. Again, I don't know what it means when they say when indicated. So what those parameters were, how often it was used, whether it's something that's routine or not, isn't clear. And again, in that study as well, anal injury is just mentioned as a, like, a sentence. And there's not any comment on any rectal findings that were found with the anuscope. In Rose and Henry and Ernst and colleagues, they did, both of those articles did specifically say specifically say that an anuscope is routinely used to evaluate after injury, after anal penetration. So unlike some of the other few articles that mentioned the use of anoscopy, and that it's just kind of at their discretion, or, you know, when indicated, this is something and these authors had mentioned that they routinely use it every time. Rose and Henry documented the anal injury frequency and type, and the rectal injury frequency and type in their publications. And then Ernst documented that, the anal injury type and frequency, but it just says that anoscopy revealed additional findings, but doesn't really say, like, whether that was in the anal canal or the rectum, or it's not really specified then what those additional findings, you know, the site of them were. So really, we have a lot of unanswered questions when it comes to sexual assault, anal penetrations and sexual assault. You know, so, you know, how are rectal exams being done by our, by sexual assault nurse examiners or forensic nurse examiner programs? You know, are you doing rectal exams at all? Are you using an anoscope to do those exams? And then what are the injuries that we're seeing? So we really need to think about as a profession that we need to start doing some research using anoscopes and being able to do finding documentation, like we've spent so many years doing on the genital findings of a sexual assault, where we're looking at the sites and types and patterns of injury that you might see, we need to do the same thing for sexual assault, because we really don't know. There really isn't much literature that it talks about other than, you know, occasionally something, a brief sentence in another article about the frequency. So, you know, what is the frequency of injuries to the perianal tissue, to the anal canal, to the anal verge, to the rectum? What type of injuries are we seeing? Are they bruises, lacerations, abrasions? And what are those anatomical sites? And what's the pattern? You know, are they commonly at six o'clock? Are they at three o'clock? Are they, like, we just don't really know what those, that information is when it comes to sexual assault, you know, from a standpoint of, you know, out there in the literature. You know, for me, I, we've been using an anuscope since 1997 in our program. So many, many years, we routinely use anuscopes. And so I can talk, if I'm going to testify in court, I can talk about, you know, what I see in my practice and in, you know, in my experience, but there's not a lot of information out there in the literature to, to look at. So limited information, what information is out there? There seems to be a range. It seems to be a anal injury is around 10% to 63%. And then, but the actual unknown anatomical site, we don't really know because of the vagueness or the inconsistency of the site description. So, you know, does that anal injury include the anal verge, just the perianal area? Does it include the anal canal? Like we don't really know. Is it anal and rectal? Because of the combination of the terms, there's even more limited information on rectal injury itself, which says that it's about 2%. And this, I would really question whether this is accurate or not, because I don't know that everybody's assessing the rectum. And if they are assessing it, it's not being defined in the literature that's being published in the research. So we just don't really know that that's an accurate representation. Maybe it is, but we just don't know that if you just look at the, the literature out there. So lots of, lots of missing data for us to, to rely on, at least when it comes to literature. So, so the last part here, what I'd like to just talk to you about is, you know, think about your practice as a forensic nurse in whatever program it is that you are working in and how are you examining the anal canal and the rectum? How are you doing your anal, your perianal exams? Are you making sure that you're doing separation and traction so that you're visualizing the anal verge? Are you, you know, what are you doing and how are you documenting that? So let's just talk a little bit about this. So when you are examining the perianal area, you definitely want to make sure that you're inspecting those anal folds very systematically. And so one of the ways that you can do that is, you know, you do an overall evaluation of that perianal tissue, and then you need to get in there and separate, and you can do it, you know, like from 12 to three o'clock and then from three to six o'clock and from, you know and then, you know, like from four to, you know, seven o'clock where you can spread that tissue and, and around. So you really want to get that anal tissue, those perianal folds separated out so that you can see in between them because injuries are going to hide in there. Okay. And, and then when you are separating that tissue out to look at those perianal folds, you also want to pull some traction so that you're pulling that anal verge out a little bit, because a lot of those injuries on the perianal tissue and the anus, anal area are going to be at that anal verge and not, not always out on the perianal tissue that you initially see. So when you are inspecting that anal tissue, really get it separated out. Now, sometimes it's uncomfortable if you're trying to separate it all out with two fingers or, you know, both, both sides, it can be uncomfortable for the patient. So I, my personal preference is just to do it in sections, you know, to be able to move that versus all at once like this, it's a little bit easier. Plus I usually just use one hand for the exams and control the culpiscope with the, with the other one, but separating out this, those perianal folds and doing a little bit of retraction so that you can see this anal verge here is really, really important. Okay. So up here, you know, stretching out this tissue so that you can see it stretching here in this bottom photo, you can see from, you know, 12 to three, how you're really stretching that, that tissue out that perianals, perianal folds out so that you can get a nice clear visual on whether or not you have any injury in that area. Okay. So separating them out, these are just different examples of being able to separating that perianal tissue. So that's really important to get in there and separate that do your initial visualization. And then you're going to want to clean your anus as well, because they can be dirty and have, you know, hairs and fibers and toilet paper and feces. They just can be dirty. So when you're getting ready to do your perianal visualization, look at those, inspect those folds. You want to get your anal swabs so that you're doing your external anal swabs so that you don't lose any forensic samples that you might be getting. And then after you get your external anal swabs, then you can clean up the external, the perianal tissue and that external anus so that you can then better visualize the tissue and make sure there's not any injuries hidden underneath any fluid that might be there or debris or anything like that. Okay. So if you're having, if you have an anus that looks like this, then yes, you're going to look at that. You want to get your swabs for your forensic samples, you know, so swabbing from the anal opening out along those perianal folds to capture all of the forensic sample. And then you can clean all of this up nice and neat with, you know, a damp two by two gauze or four by four, or you can use, you know, Fox swabs or Q-tips or whatever it is that you want to use to clean up that area. Now positions to use for doing an exam. You can, the most common or not common, but the best position that you can use is the supine knee chest, whether it's male or female that you're doing an exam on. The lateral position is very hard because then you have that, that top butt cheek that you're having to deal with to try to get out of the way. And then you have the bottom butt cheek that's being pushed up by the bed. And so it's really hard to get in there to be able to see, you know, if they're lying on their side. And then the prone knee chest position for a lot of adults is a very embarrassing, just kind of humiliating position to be on their hands and knees with their butt way up in the air. It can also be difficult on an exam bed to have an adult in that position and their, their buttocks are way high for like equipment that you're using, or for a colposcope to get high enough that can be difficult. Um, and patients get tired being in that position, their arms get tired, their legs get tired. And so really that supine knee chest is the absolute best position to be able to, um, to look at the anus in and putting them in that supine knee chest position does a couple of things. One, it, it increases your ability to do visualization and also makes it difficult for the patient to like tighten their butt cheeks up and to like keep that external sphincter tight. Um, so that, um, that it, you know, can be hard to do an exam or hard to do a digital rectal exam or that anus scope exam. So putting them in the supine knee chest is going to help facilitate and relax those muscles so that you can, um, to do the rest of that internal exam. You should do a rectal exam if there's any report of anal penetration, but you should also do a rectal exam if, um, if you have any anal injury that's, um, that's visible with or without a report of anal penetration, because maybe the patient doesn't know if, um, if they were penetrated or not, or maybe they just don't want to talk about being penetrated anally. And so if you see, if you see injury there, you should do a rectal exam. So this is a, an example where you can see on this, uh, on this patient that if you just stopped here and just did a perianal exam without separating that perianal tissue and, and, uh, using traction to pull out. So you can see the anal verge that you would have missed, uh, these anal, um, lacerations or that were at the anal verge, same thing here. If, um, if you didn't, uh, separate the anal, the perianal folds and do some traction to be able to see into that anal verge, you would miss this really large laceration that is here going into the anal canal. Um, here you can't see that, but then you do the separation, you do the traction so that you can see the anal verge. And now you can see the abrasions, the laceration, laceration, another laceration up here. Um, on this, this is a new hemorrhoid on this patient, uh, very tender, but without that separation and traction, pulling the anal verge out. So you can visualize it would have missed this, um, abrasion and bruising on the, um, on that. Yeah. And so a lot of these injuries are on that anal verge. And so you really, when you separate that tissue out, you also want to do a little bit of traction so that you're getting that anal verge open to be able to see. Okay. Things are all, this is also example. She has a new hemorrhoid here, a very tender, and then, um, you know, the laceration as well. Okay. So multiple lacerations here. So if, if you would not have, um, again, separated this tissue here to be able to see into the anal verge would have missed this big, um, big laceration here. This laceration looks like it might be just a small little laceration here until you separate that tissue, um, and do some traction on it. And then you can see that it is actually pretty significant and has some hemorrhaging in it. Okay. So this bruising here on the, um, on the anus, um, you can't really tell how far it goes in until you put the anus scope in, and then you can see that it is localized to that, um, to that external perianal tissue. Okay. And you also want to do a rectal exam. If you have any bleeding around the anus and you don't know where that bleeding is coming from, you can't, if you don't see anything there, you can't just send that patient home. You really do need to make sure that an anus scope exam is done to look for any injuries on the inside. When you're doing that rectal exam, the first thing you want to do is you want to do a digital rectal exam first, um, use lubrication because you want to be able to assess the sphincter tone of that external sphincter, the internal sphincter you want to see, can you palpate any defects in the anal canal? Uh, so you're palpating for injury. You're palpating to see if there's any hemorrhoids. Is there prostate enlarged? If it's a male, is there any stool or feces right there in the canal? Are they tender? Because that's going to impact your ability to put that anus scope in. So you don't want to be putting an anus scope in blindly, uh, because you don't know what's going on inside of there. So you want to do your digital rectal exam, um, first. And when you do that digital rectal exam, remember lubrication, very slow, insert your finger about, you know, two centimeters or right up to like your first knuckle, um, and then stop until you feel that internal sphincter relax. And then you can insert your finger past there, um, until you get to that anal rectal angle. And once you can push your finger, you know, down where you can feel that anal rectal angle, then you know that you are in the rectum and you can see if there's any stool there or anything like that. And then you're just feeling to see, um, what you have, um, make sure there's not anything in the way for you to put that anus scope in. Uh, I particularly like this anus scope. Uh, there are lots of different kinds out there. Um, this one, um, I've tried them all and I continue to go back to this one. This is, uh, seems to be the most effective of, uh, and best, um, anus scope, um, that, that I like. Um, and you do need a light source. You do need to put some lubrication. So you lubricate the outside of the, um, anus scope. You can use, um, just KY jelly. You can also use like a thin layer. If they have like anal perianal injuries, you can use a thin layer of asylocane gel, um, as well. You want to make sure that the obturator, which is this, um, is in place when you put that anus scope in, and you want to make sure that it stays in place because if that obturator comes out and you try to replace it, once it's in the, um, in the body, you can pinch the tissue, the rectal tissue, um, in there and you can cause an injury. So if you're pushing that anus scope in and the obturator comes out, you have to take the whole thing out and start over. So put the, make sure the obturator is in place. You apply the lubrication on the anus scope. You position the patient in that supine knee chest position. You insert the anus scope in about two centimeters, just like you did with your finger. You wait for that internal sphincter to relax, and then you advance the anus scope fully until the tabs, um, are up against the skin. Now you want the tabs of the anus scope here. You want these tabs of the anus scope to be at 12 and six o'clock position, because if you put them in at nine and three, it's going to catch on the buttocks and you're going to lose a good centimeter, maybe two centimeters of depth inside. So you want to make sure that the, um, the tabs are at 12 and six. So it goes right up against the perineum and your buttock crease. And so that you can get the full benefit of the whole length of the anus scope to be able to see into the rectal canal. And then, um, you want to hold the anus scope in place. You want to hold onto those tabs when you remove that obturator. Um, and you have to remember that you always have to keep that counterpressure there because your anus, your anal sphincter muscles are constantly trying to close up and shoot that anus scope out of you. So you can't ever let it go once you put it in. So you have the anus scope in there, you're holding onto the tabs. You take the, uh, take the operator out and then you can obtain your rectal swabs. And then you slowly start to remove the anus scope just, you know, millimeters at a time, very slowly so that all that rectal tissue starts folding in around the end of the anus scope, the anal canal tissue folds in so that you can visualize all of that tissue, but you do have to put counter pressure, um, the whole time that you are removing that anus scope so that you don't have a rapid expulsion, um, from that sphincter contraction. So, um, let's look real quick at some, um, some findings here. You can see, um, in, um, there's a little bit of bruising here. You can see this laceration with the anus scope in here. Uh, you can see bruising. This is, uh, bruising in here. You have bruising right here. Um, you have all this bruising here. You have a laceration, um, right here in the rectum. You have a laceration right here on the rectal wall that's bleeding. You have multiple lacerations here in the anal canal, um, multiple areas of bruising here in the rectum, um, bruising, bruising on the rectum. Uh, here's a laceration on the rectum, uh, bruising and a laceration, multiple lacerations on the rectum, uh, bruising. This is pretty common that you can see, uh, especially with digital penetration, um, where the fingernails can cause, uh, little, um, lacerations in there. Um, this is a little bit of a distance, but you can see there's bruising here, bruising here, um, got a laceration here, bruising, lots of bruising, lacerations here on the rectum. Um, um, you know, this particular patient had a lot of, uh, warts. Um, so initially just looking, all you see are some warts and a closer up, but you see some warts, but as you separate that tissue out the perianal tissue, you can see this large laceration here. And then when you do the rectal exam, they actually had, uh, warts that went clear up in through their anal canal, into the rectum. And so you have all these warts, um, in here and here as well. So this person needed to be sent to a colorectal surgeon for that to be, uh, those warts, um, to re be removed at a later date. Um, when you are trying to implement anoscopy in your program, um, if you haven't, you want to make sure that you have training that teaches you how to do it. Um, I know that, um, you know, we have a training program where we're at, that we do anoscopes. They have to, the nurses have to do a five on a five before they can do it independently. But, um, if you are going to some of the like preceptor or the clinical skills courses that are around, um, some of the clinical skill sites, um, do anoscopy as a clinical skill checkoff in addition to the speculum. So, um, that's an opportunity to do them at, at those places. If you have a clinical skill sites that's doing it otherwise, what kind of training do you have in your program to be able to, um, practice and learn how to do the anoscope, um, practice until competency is obtained, make sure that you do have some type of a physician or advanced practice, a provider, or somebody who's more, the most experienced, uh, person, um, available forensic nurse or somebody that you have for consultations, um, or referrals. If you need to make sure you have policy and procedures in place on doing the anoscope exam, you want to do quality assurance. Um, I would recommend you did a hundred percent quality assurance peer review to make sure that you're calling injuries and findings, uh, correctly, um, when you're doing these exams. And then I would also recommend that you do follow-up exams to reevaluate, um, anal rectal findings. Um, it's nice to be able to see, you know, you have a patient that comes in with a perianal laceration and then they come back, um, a month later for their follow-up and you can see where that just a little bit of a scar where that is now healed, um, from that exam. So it's nice to be able to show that, um, that healing. Um, it's also nice to be able to, to document that a finding is normal for that patient and it's not an injury so that you're not just assuming that you are trying to attribute everything to, um, an injury from a sexual assault. You can get fissures, you know, stool does not cause injury in the rectum when it's passing through. Um, it also doesn't cause injury to the perianal area, but it can cause injury to the anal canal, like the, in the like anal verge. Um, you can see a little bit of like hard stool can cause injury there. So you might have like a, some, a fissure, which is like a little small crack-like lesion. Most of the time it's at six o'clock, um, but the rest of them might be at 12 o'clock. You don't really have fissures generally that are occurring laterally, um, in or extending out into the perianal, um, area. They're usually really just pretty focused on that anal verge, um, area. So if you do see something laterally or, or extending far out perianally, you want to, you know, be suspecting that it could be something else. Um, and it's normally, um, pretty superficial and oftentimes, you know, these are chronic, so they have like mounted kind of edges to them. They're not necessarily really sore. They have a history of constipation, a history of maybe some bleeding when they wipe afterwards. So you could see on this patient, she had a history of having, um, you know, chronic constipation. She had a history of having fissures and you can see that this, uh, um, defect here ends up being, um, it was a fissure that she had and, um, you know, it was in her, at her anal verge and you see the mounting of tissue very, um, uh, and she, you know, reports that sometimes, you know, she'll have a hard stool and that opens up and she'll start bleeding and, and then it, you know, heals back up again. So it's just a chronic finding there. Um, and the last thing, uh, real quick, uh, on this is sometimes you might see patients that have a rectal prolapse and the question is, um, has it been there or is this something new since the assault? Um, and so being able to ask them about, uh, the prolapse, you can push these back in. Um, you can still do a digital rectal exam. You can still do your anus scope exam if they have a prolapse out, but you really do want to find out if, um, if they have, if that's been there for them, um, or if this is like a new finding. Um, and sometimes if you have a patient that's had a lot of anal trauma or, um, anal rectal trauma, you know, from an assault, they, you know, you do your follow-up exams and now they have like a prolapse or, um, less sphincter tone, or they have some incontinence from that, um, that assault, um, that is one, you know, a longterm, um, effect. So that's another benefit of doing a follow-up exam. Um, and lastly, real quick, I know, um, I think I went over, um, a little bit on, um, on our time. So I do apologize for that. Um, real quickly, and if you're going to testify about anal rectal findings, you really need to understand the anal and rectal anatomy and the physiology. Um, you really want to educate yourself about anal sex practices, um, and learn the research, which isn't too hard right now, right? Because we don't have any research really on consensual anal sex patterns of injury for comparison. Um, and there's very minimal research focusing specifically on anal sexual assault, um, injury and rectal injury, um, specifically from, uh, sexual assaults. So, um, be very careful about the type of opinions that you are giving, um, in, um, in your testimony. Uh, this type of an opinion, this opinion that, uh, is given is there's no evidence-based to it. So, you know, you, you really don't want to set a bad precedence of, um, of poor testimony that's not evidence-based practice and that you can't back up, um, by, um, by anything. So you want to make sure that your testimony as a forensic nurse is always evidence-based opinions and always evidence-based testimony, um, that you can, um, that you can rely on and justify in your practice, um, not only for yourself, um, but for the integrity of our profession as a whole. Okay. Um, so that's enough on butts. Um, this is one of my neighbors in the summer here and, um, and I snatched a photo from him. I just wanted to squeeze his little furry butt, but he didn't let me. So, um, thank you for your time. I hope that that was a good overview for you on anatomy and a little bit about the research, um, that's out there and some photos. Uh, I do really, really encourage you to try to do anoscopes in your program and, um, and get training on being able to do that. So you can fully and adequately assess, um, the anus and the anal canal and, um, and the rectum in your patients. Um, because as you could see, just in a few of those photographs that, um, I went through, um, you oftentimes will have injury in the rectum that you can see, particularly, um, small lacerations or, or bruises that you're missing if you are just looking at the perianal tissue. So, um, I welcome any questions that you want to follow up with me on, uh, you're welcome to send me an email and, um, and reach out to me. I'm happy to, uh, to try to talk with you on it and, um, and help you in any way I can. So thank you for your time. I appreciate it.

forensic nurse

anal rectal examination

sexual assault patients

anatomy

sphincter muscles

anal sex

anal dyspareunia

communication

relaxation

lubrication

anal and rectal injuries

poppers

examination techniques

Tara Henry