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Rectoscopy
Last reviewed: 03.07.2025

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Rectoscopy (or rectoscopy) is an endoscopic method of diagnostic examination of the epithelium of the rectum, and sometimes also the distal parts of the sigmoid colon.
Rectoscopy involves a visual examination of these sections of the intestine using a device called a rectoscope (or rectoscope). The device is inserted through the patient's anus into the rectum and can examine areas of the rectum and sigmoid colon at a distance of up to thirty to thirty-five centimeters from the anus.
A rectoscope is a curved tube of small diameter up to thirty centimeters long. It is equipped with a cold light illuminator - a light bulb and a device for supplying air. Air is supplied to expand the rectal cavity in order to allow its examination. Then, after the air has inflated the rectal cavity, the device for its supply is disconnected and an eyepiece (or camera) is attached to the rectoscope, designed for visual examination. With the help of the eyepiece, information about the state of the intestine is transmitted to a special monitor, on which the image can be scaled.
Diagnostic capabilities using rectoscopy allow for examination of the rectum to a depth of thirty to thirty-five centimeters from the anus. In modern medical practice, this method of examination is used very often, since it is highly informative and completely painless for the patient.
The duration of the bowel examination depends on the number of procedures used in the diagnosis. In normal cases, a rectoscopy is performed within ten minutes.
During the entire examination, the proctologist evaluates the color, moisture, shine, relief and elasticity of the epithelium, its folding, the pattern of blood vessels, tone and motor function of the intestine. Great importance is attached to the search for pathological changes or formations of the rectum.
Preparation for rectoscopy
Preparation for rectoscopy is of great importance, since the reliability of diagnostic results depends on it.
A few days before the rectoscopy, the patient must use a special diet. It consists of refusing certain foods. Bakery products, vegetables, fruits, legumes (beans, peas, lentils, beans, chickpeas, soybeans, etc.), dairy products, eggs, alcoholic beverages, coffee, carbonated drinks are prohibited. During the day preceding the rectoscopy, a low-slag diet should be used, which does not cause flatulence.
In the evening before the next day of diagnostics, the only food and drink allowed is tea.
Also, a cleansing enema is performed in the evening, which is repeated an hour or two before the procedure in the morning. To perform an enema, you can use special cleansing gels designed for this purpose. Or an enema with one and a half to two liters of water at room temperature is used using an Esmarch mug, which is available at any pharmacy. It is very important to thoroughly cleanse the intestines before the examination, as the validity of the examination results depends on this.
It is recommended to skip breakfast on the day of the procedure. Before the examination, it is recommended to drink only clean, non-carbonated water.
If the rectoscopy procedure is scheduled for the evening, then during the day you need to limit yourself in food as much as possible. Two hours before the rectoscopy, you will need to use two or three microclysters of the drug Microlax. This can be done at work - using Microlax is a convenient and quick procedure.
Method of performing a cleansing enema:
- Take Esmarch's mug, with a capacity of one and a half to two liters, which is a glass, enamel container or a reservoir made of disposable plastic. Most often, Esmarch's mug is rubber. A nipple is attached to the bottom of the container, onto which you need to put a rubber tube. At the end of the tube there is a removable tip, eight to ten centimeters long, which is made of plastic. You need to inspect the tip before use - it should be intact, and its edges - even. Near the tip there is a valve, with the help of which the flow of water opens and closes. If the valve is missing, then various clamps or clothespins can be used instead.
- An enema is performed using drinking water. If the cleansing procedure is performed on children, it is recommended to boil the water and cool it to room temperature. Water at a temperature of twenty-five to twenty-eight degrees is used for an enema. Colder water should not be used, since it increases the motor function of the intestines and also causes discomfort in it. Water for an enema at body temperature or higher is also unsuitable for use, since it has the property of being quickly absorbed into the intestinal walls. 3.
- Water is poured into Esmarch's mug, the volume is one to one and a half liters, the reservoir is raised to a height of one to one and a half meters and fixed there. It is best to do this in the bathroom. The tip is lubricated with baby cream, Vaseline or vegetable oil. After this, the tip is lowered down, and the valve is slightly opened to release a small amount of water from the tube, as well as air. Next, you need to fill the tube with water, after which the valve must be closed.
- In the bathroom, you need to take a knee-elbow position, leaning on one elbow, and insert the tip into the anus with the other hand. It needs to be inserted in a circular motion, at a slow pace and with great care. Next, you need to open the tap and introduce water into the intestines. If it happens that the water does not flow into the intestines in full, but there are painful sensations, you need to close the valve and breathe a little. Then you can open the valve again and continue introducing water. When the water flows out of the reservoir, you need to remove the tip from the anus and put a pre-prepared pad in its place.
- The recommended time to hold the water is at least ten minutes. If you feel pain or a feeling of distension, you can relieve these symptoms by lightly stroking your abdomen in a circular motion. You can walk around the house or lie on your stomach for the entire time you hold the enema.
- The second option for performing a cleansing enema is to lie down on the bed. You need to lie down on your left side, bend your legs and pull them towards you. Place a sheet of oilcloth or polyethylene film under the buttocks, with one edge lowered into a bucket next to the bed. This should be done in case you fail to retain all the water in the intestines. The lubricated tip is inserted into the anus. The initial three to four centimeters are inserted towards the navel, and the next five to six centimeters of tip movement are carried out in a direction parallel to the coccyx, slightly lifting the part of the tip that is located outside towards the perineum. If various obstacles are observed, for example, the tip rests against hard fecal matter, then the tube should be moved back and the valve opened. Water supplied under pressure will begin to flow into the intestines and with its help, “blockages” can be eliminated. At the same time, a feeling of distension of the intestines will arise and you will want to empty it. At this point, you need to reduce the water supply by closing the valve. When discomfort occurs, you can stroke your stomach with gentle circular movements. After introducing water, you need to lie on your side or back for ten minutes, breathing deeply.
- If the rectum is so clogged with feces that water cannot pass into the intestines, the tube must be removed from the anus, cleaned outside and inside, and then the procedure repeated.
- When the water is introduced into the intestine, do not pour it all out of Esmarch's mug - it is best to leave a small amount of liquid at the bottom. After that, the valve is closed, and the tip is removed from the anus.
- After performing a cleansing enema, the tip is removed, thoroughly washed with soap under running warm water, and then boiled.
- During one cleansing procedure, no more than one and a half to two liters of liquid can enter the intestines. If two enemas are performed, one after the other, then a time interval of thirty-five to forty-five minutes should be made between them. The second enema should be administered only after there is confidence that the contents of the first enema have completely left the intestines.
Microlax before rectoscopy
The drug Microlax can be used before a rectoscopy instead of a cleansing enema. It is a solution of local action, already prepared for use, which is packaged in tubes of five ml each. The drug package contains four tubes, each intended for one-time use.
To use Microlax, it is enough to carefully read the instructions and follow them. At the same time, the drug is created in such a way that it can be used in almost any conditions where there is a toilet, including at work and so on.
After the introduction of Microlax into the anus, the effect is observed after five to fifteen minutes. With this medication, you can easily clean the distal sections of the sigmoid colon at a distance of twenty to thirty centimeters. Cleansing at such a distance is quite suitable for conducting an examination and rectoscopy procedure.
The drug has a soft and smoky effect, it does not have an aggressive effect on the patient's intestines, and does not have side effects for the entire body. Since Microlax is a safe drug, it is prescribed for use by adults and children, as well as pregnant women and nursing mothers during breastfeeding.
Microlax is used as follows: remove the seal located on the tip of the tube. Then squeeze the tube a little so that a drop of the medicine coats the tip of the enema. Then insert the tip of the micro enema into the anus, squeeze the tube, and squeeze out all of its contents. At the very end of the procedure, remove the tip from the anus, while continuing to squeeze the tube.
To prepare for a rectoscopy, two or three tubes of the drug should be inserted into the intestines with a time interval of five to ten minutes between them. Bowel movement is observed five to twenty minutes after using the medication.
If, for some reason, there is no bowel movement after using the second tube of the drug, this means that there is simply no content in the intestines, and the preparation for the rectoscopy was successful. But if the patient still has doubts about the quality of the preparatory manipulations, a third micro enema can be administered.
Microlax is used for diagnostic examination no later than three hours before the procedure and no earlier than six hours before the examination.
How is a rectoscopy performed?
Before performing the procedure, the specialist must obtain the following information from the patient:
- Does the patient have allergic reactions to any medications?
- Does the patient have an increased tendency to bleed from minor cuts or during tooth extraction?
- Does the patient use blood clotting medications such as anoprine, warfarin, plavix, ticlid?
- The female patient is not pregnant.
- Is the patient having menstrual bleeding at the time of examination?
Then, before conducting diagnostics, the proctologist examines the anal area, and also conducts a rectal examination of the rectum. This examination allows additional detection of pathological changes in the rectum: it is possible to detect manifestations of hemorrhoids, paraproctitis, anal eczema, dermatitis, genital warts, various tumors, and so on.
For patients who are unfamiliar with this procedure but have a doctor's order to undergo an examination using a rectoscopy, it is important to first learn how a rectoscopy is performed.
The rectoscopy procedure is performed with the patient in a knee-elbow or knee-shoulder position, lying on a couch, or in a supine position on the left side. If the procedure is performed with the patient lying on his side, he needs to bend his knees and press them to his stomach. The examination can also be performed on a gynecological chair, with the patient lying on his back.
Before rectoscopy, the patient removes clothing below the waist and assumes the specified position. Then the specialist performs a digital examination of the anus. Then the tube of the device is lubricated with lidocaine gel and Vaseline (or other indifferent oil). The patient needs to take a deep breath and hold it, then slowly exhale and at the same time relax the shoulder opposite the side on which the patient is lying. It is also necessary to relax the neck muscles at the moment of exhalation.
Now the specialist can slowly and carefully insert the rectoscope into the anus to a depth of five centimeters using rotational movements. After this, since the tube is already located behind the sphincter, the obturator (the plug located inside the tube) is removed, and the examination is carried out using vision only.
When the tube of the device has already advanced twelve to fourteen centimeters into the rectosigmoid flexure zone, the patient is asked to repeat the deep breath and then exhale slowly, as last time. During the inhalation and exhalation, air is pumped into the intestine using a special bulb. The actions of the patient and the doctor help the rectoscope to easily penetrate the sigmoid colon. If, suddenly, the advancement of the device becomes difficult, the examination of the patient is immediately stopped, and the rectoscope is removed.
It is also necessary to take into account that during the entire time when the tube is advanced through the rectum, a small amount of air is constantly supplied to it. This is necessary to ensure ease and painlessness of penetration of the rectoscope into the intestine.
The rectoscopy procedure is performed using circular movements with the distal end of the rectoscope and allows examination of the intestinal walls from the anal canal to the distal third of the sigmoid colon.
Anoscopy and rectoscopy
In order to thoroughly examine the anal canal, an anoscopy procedure is usually used before a rectoscopy. Anoscopy is an examination of the anal canal area of a certain part of the rectum using visual observation. This diagnostic procedure is performed using an anoscope. The anoscope is a special instrument in the form of a cone-shaped tube, similar to a small gynecological speculum and is about six to eight centimeters long. Inside the tube is an obturator (plug), and with the help of a fiber-optic adapter (adapter), a lighting device is connected to the tube, which is built into the handle of the anoscope. Modern anoscopes are equipped with light-guide adapters that can combine the device and any light cables.
There are two types of anoscope - diagnostic and therapeutic. The therapeutic type of anoscope differs from the diagnostic one in the form of a special recess for connecting endosurgical instruments.
An anoscope can be used to examine the anus and rectum to a depth of eight to twelve to fourteen centimeters. The anorectal area with hemorrhoids located inside is also included in the diagnostic area. It happens that hemorrhoids are located too high in the anal canal, which is why they cannot be seen using the anoscopy procedure.
During the diagnostic process, a visual examination of the color and structure of the rectal epithelium is performed. If necessary, a biopsy is performed, i.e. a sample of pathologically altered tissue is taken for histological examination. The anoscopy procedure is reliable for detecting hemorrhoids, rectal neoplasms - polyps and condylomas, and detecting inflammatory processes in the anus.
Anoscopy is performed in the same position of the patient as rectoscopy. Before its implementation, a digital rectal examination of the patient is always used, since this procedure helps to exclude various contraindications to the use of anoscopy. If diseases are detected that cannot be diagnosed, the examination is postponed until the acute conditions are relieved.
Before inserting the anoscope, its flaps are lubricated with glycerin, and then the anal canal is widened to insert the instrument. The anoscope is inserted into the anus using slow circular movements. In this case, the presence of hemorrhoids, crypts, hypertrophied papillae and anal tumors can be observed. After removing the obturator (eyepiece for visual observation), the anoscope is slowly and carefully removed from the anus.
Indications for anoscopy:
- The presence of pain in the anal area.
- The appearance of bleeding from the anus.
- The appearance of mucous or purulent discharge from the anus.
- The occurrence of bowel movement disorders – the appearance of constipation or diarrhea.
- Suspected rectal diseases.
Contraindications to anoscopy:
There are no complete contraindications to the use of the procedure.
Relative contraindications are:
- the presence of a narrowed lumen of the anal valve,
- the presence of a narrowed lumen of the rectum,
- existing acute inflammation in the anal area - the occurrence of acute paraproctitis, thrombosis of hemorrhoidal vessels,
- tumor processes in the anal canal of a stenotic nature,
- acute stage of chemical and thermal burns.
Preparation for anoscopy is carried out by using a cleansing enema after emptying the bowels. For this, water at room temperature is taken in the amount of one and a half to two liters and an enema is administered, the technology of which is described in the section "preparation for rectoscopy".
In some cases, along with the examination, it is necessary to carry out therapeutic measures such as the introduction of drugs into the rectum, the use of electrocoagulation or infrared coagulation, or the procedure of ligation or sclerotherapy of hemorrhoidal nodes.
The anoscopy procedure has no complications, so it is absolutely safe and painless.
Colonoscopy and rectoscopy
Colonoscopy is a method of examining the large intestine in modern medicine, which is used for diagnostics and therapy. With the help of colonoscopy, the mucous membrane of the walls of the large intestine is examined using an endoscope.
An endoscope is a flexible tube, up to one centimeter in diameter and about one and a half meters long. At the end of the endoscope, which is inserted into the anus, there is a small lighting device, as well as an eyepiece, with which visual observation is carried out. Colonoscopy and rectoscopy differ in that the first procedure allows you to examine all sections of the large intestine, starting from the rectum and ending with the cecum.
Colonoscopy can be used to establish or confirm the diagnosis of the following diseases: symptoms of non-specific ulcerative colitis, benign tumors, malignant neoplasms, Crohn's disease, etc. are revealed. During the entire examination, the observation process can be recorded using video, photographs of the required areas can be taken, and tissue samples can be taken using a biopsy procedure for further histological examination. During colonoscopy, pathological formations that were discovered as a result of this examination can be removed.
A colonoscopy can be performed by a proctologist or endoscopist. To perform a colonoscopy, the patient takes off all of his or her clothes and puts on a special gown. The diagnostics are performed with the patient lying down: the patient lies on his or her left side, bends his or her knees and presses them to his or her chest.
The general technique for performing a colonoscopy is as follows: a slightly bent device is used to exclude pathological areas with interfold spaces and sharp bends. The endoscope is inserted into the anus with slow and careful circular movements clockwise and counterclockwise. The device is advanced under visual control, for which air is supplied to the large intestine, which helps to form a lumen for the movement of the instrument and observation. At this time, the distal end of the device is bent in the form of large and small screws in the direction up and down, as well as to the right and left. If a large amount of air has formed in the intestine, which interferes with the examination, it is removed through the anus, as well as the liquid filling of the intestine, which has managed to accumulate in it. A special pump is used for these purposes.
Indications for colonoscopy:
Symptoms of any diseases of the large intestine are indications for the use of this method of examination. Colonoscopy is used for:
- Gastrointestinal bleeding.
- Disruption of bowel movements - the appearance of constipation or diarrhea.
- For signs of intestinal obstruction.
- Discharge of clots of mucus or pus from the anus.
- For symptoms of ulcerative colitis, Crohn's disease.
- If there is a suspicion of the presence of benign or malignant neoplasms in the intestine.
There are also therapeutic indications that require treatment procedures:
- Removal of benign tumors.
- Conducting a coagulation procedure for detected sources of intestinal bleeding.
- Elimination of intestinal volvulus or intussusception.
Contraindications to colonoscopy:
- Absolute contraindications that prohibit this examination are the following:
- the presence of a state of shock,
- the occurrence of acute myocardial infarction,
- presence of intestinal perforation,
- the appearance of a fulminant form of ischemic colitis.
- Relative contraindications for the procedure are as follows:
- intestinal bleeding from the anus,
- poor preparation for the procedure,
- previously performed large quantities of surgical interventions in the pelvic area,
- the presence of large hernias,
- presence of pulmonary insufficiency,
- existing heart failure,
- the presence of artificial valves in the patient.
It is necessary to prepare for a colonoscopy: the measures taken will ensure the possibility of conducting the examination, and will also make the diagnosis more reliable and informative. The main condition for conducting a colonoscopy is the absence of feces in the large intestine. If the patient's intestines are not clean enough, the examination is not carried out. Sometimes, a specialist can still make a diagnosis, but in this case, there is a high probability of errors, since some changes in the intestines may be missed.
Preparation for a colonoscopy involves the following steps:
- It is necessary to use a special dietary nutrition, which the patient resorts to two days before the appointed time of diagnostics. In case of constant constipation, it is necessary to go on a diet three to four days before the examination. All food products that contribute to the occurrence of voluminous stool and flatulence are excluded. For a while, it is necessary to refuse to use fruits (peaches, apples, grapes, dates, apricots, tangerines, oranges, bananas), raw vegetables (beets, cabbage, carrots, radishes, turnips, horseradish, garlic, onions), raspberries and gooseberries, as well as greens. Pearl barley, oatmeal and millet porridge, as well as bakery products, especially black bread, are removed from the diet. Banned – for the time being – are nuts, seeds, mushrooms, carbonated drinks and alcohol, legumes (beans, peas, lentils, soybeans, chickpeas, beans), kvass and milk.
- While on the diet, you are allowed to eat lean boiled fish and poultry, clear broths, fermented milk products, dry non-sweet biscuits, jelly, non-carbonated drinks, and weak tea.
- On the day of the colonoscopy, you can only eat liquids: broths, boiled water, tea.
- During the preparatory diet, you cannot use iron supplements or activated charcoal.
- Twenty-four hours before the examination, you need to cleanse your intestines with an enema and laxatives.
Carrying out rectoscopy in children
Rectoscopy, due to its pain and safety, can be recommended for children. The following indications for the procedure are available:
- The presence of bleeding from the lower intestines, which has varying intensity and frequency.
- The appearance of a feeling of incomplete bowel movement.
- Prolapse of tumor-like formations from the anus, as well as hemorrhoids and the wall of the rectum.
The rectoscopy procedure performed on children allows us to identify various diseases of the digestive tract: it is possible to detect ulcerative colitis, acute and chronic proctosigmoiditis, developmental anomalies of the distal colon, various tumor processes and other pathologies.
Contraindications for performing rectoscopy in childhood are the presence of inflammatory processes in the area of the anus and perianal part of the intestine, as well as a large degree of narrowing of the anal canal.
In order to prepare the child for the examination in the morning, a cleansing enema is given in the evening, which is repeated in the morning one or two hours before the rectoscopy. If there is a possibility of endoscopic intervention, the child's intestines are prepared in the same way as for a colonoscopy.
The method of performing rectoscopy for older children is no different from the procedure for rectoscopy in adult patients. For younger children, the examination is performed under general anesthesia and in a supine position.
Rectoscopy for children is performed using children's rectoscopes, to which replaceable tubes of various diameters are attached. Different sets of instruments for children are also used, with the help of which endoscopic intervention can be performed.
As with adults, when making a diagnosis, the specialist pays attention to the condition of the intestinal mucosa: the color of the epithelium, characteristic features of the surface, shine, vascular pattern, presence or absence of overlays, and severity of haustration are taken into account.
Rectoscopy of the intestine
Rectoscopy examination is performed both for the purpose of preventive examination, in order to, if possible, prevent the development of various diseases, and in the presence of certain alarming symptoms. For the purpose of prevention, intestinal rectoscopy is prescribed to patients over forty years of age and is performed once a year.
Indications for the use of rectoscopy:
- The presence of pain in the anal area.
- The appearance of bowel disturbances – constipation or diarrhea.
- The occurrence of intestinal bleeding.
- The appearance of mucous or purulent discharge from the anus.
- The appearance of a feeling of incomplete bowel movement.
It can be said that any pathological changes in the rectum and lower sigmoid colon or suspicions of these changes are indications for rectoscopy.
Contraindications to the use of rectoscopy:
- The appearance of profuse bleeding from the intestines.
- The presence of acute inflammation in the anal area – hemorrhoids, paraproctitis, and so on.
- Existing acute inflammatory processes in the abdominal cavity.
- The appearance of an acute anal fissure in the patient.
- The occurrence of narrowing of the lumen of the anal canal due to various reasons - congenital or acquired. Usually, such symptoms are one of the signs of a rectal tumor.
- The appearance of traumatic lesions in the anal area. For example, as a result of chemical or thermal burns.
- History of heart disease in the decompensation stage.
- The emergence of a serious condition of the patient of a general nature or the manifestation of acute forms of diseases.
- Existing menstrual bleeding in women.
The rectoscopy procedure allows detecting various types of neoplasms of the rectum and some sections of the sigmoid colon even at precancerous stages, when the tumor condition is reversible. In addition to visual examination, it is possible to take a biopsy (i.e. a piece of tissue) of the area of the rectal wall that is suspicious. Subsequently, the pathological piece of the intestine undergoes histological examination for the presence of altered cells.
The reliability of rectoscopy is high due to the fact that the specialist can not only notice neoplasms on the mucous membrane of the rectum, but also examine them in detail.
Rectoscopy can be used not only to examine the patient's intestines, but also to remove small tumors. This procedure is quick and non-traumatic and saves the patient from abdominal surgery, which causes great inconvenience to patients.
Also, with the help of rectoscopy, it is possible to stop existing bleeding that has arisen from the intestinal mucosa using special electrodes.
The importance of diagnostics using rectoscopy currently seems very great. Recently, in modern society, there has been a constant increase in the number of tumor diseases of the colon. The possibilities of medicine currently allow us to treat this terrible disease, but only in the early stages. But the initial stages of cancer of the colon, like many other tumors, are practically asymptomatic. Therefore, there is no diagnosis and timely treatment of this disease in the early stages. And only at a late stage of the disease does the tumor manifest itself through strong symptoms, but during this period, treatment becomes ineffective.
Rectoscopy of the rectum
Rectoscopy of the rectum is recorded using a standardized procedure that allows recording pathological changes in the intestine. To record the data obtained as a result of examining the anal opening and perineum, a clock face diagram is used. The circumference of the anus is divided into areas that correspond to the markings on the clock face. The projection is carried out in such a way that the “12 o’clock” mark is on the scrotal suture or genital slit, the “6 o’clock” mark is on the anococcygeal line, “9 o’clock” is to the right of the anus, and “3 o’clock” is to the left of the anus. The line that connects the markings has a conditional passage along the middle of the anus, and also delimits the anus into two semicircles - anterior and posterior. It should be taken into account that the patient is lying on his back.
Is it painful to have a rectoscopy?
Before undergoing a rectoscopy, patients usually ask themselves: is it painful to undergo a rectoscopy?
The rectoscopy procedure is completely painless. Both the visual examination of the intestines, and the taking of a biopsy, and the method of stopping bleeding with the help of electrodes are characterized by a complete absence of pain.
There are no side effects after a rectoscopy. In some cases, a feeling of bloating and pressure in the abdomen occurs after the examination. These symptoms occur due to the presence of air that enters the intestines during the diagnosis. Such symptoms disappear after a short period of time and no longer bother the patient.
In some very rare cases, bleeding or perforation of the colon may occur. If these complications occur, it is necessary to seek emergency medical care.
This diagnostic examination is considered safe, since the severe complications mentioned above are extremely rare. Therefore, this procedure is recommended for both pregnant women and children. But in these cases, rectoscopy should be performed only according to existing indications and with great caution.
If pain occurs during rectoscopy, this means that the patient has some extraintestinal formations or the large intestine has a slightly different anatomical structure from the usual one. A thorough examination of the patient when pain occurs, in order to clarify the cause of its occurrence, is performed after the tube is removed.
Price of rectoscopy
The price of a rectoscopy procedure varies depending on the location where the examination is performed.
In some medical institutions the cost of the procedure is 120 - 125 UAH, in other medical institutions you need to pay 180 UAH for a rectoscopy.
The stated cost of diagnostics includes a consultation with a proctologist to establish a diagnosis, a physical examination of the patient, a digital examination of the anus and rectum, and the rectoscopy procedure itself. Currently, many medical institutions perform video anoscopy in parallel with rectoscopy, which is included in the cost of diagnostics.