Instructions regarding the examination may be given verbally, but if at all possible it is preferable to provide the patient with a set of printed do's and dont's in order to avoid any misunderstanding. Such an instruction sheet might touch upon the following:

Fasting

1. For morning examination, it is usually advisable to have the patient fast after midnight because:

(a) Fasting blood sugar or certain other blood chemistries may be desired.

(b) Tubeless gastric analysis (see p. 75) may be performed.

(c) If a gastrointestinal series is indicated, it may be possible to do it the same day, depending on the facilities available to the doctor.

2. For afternoon examination, the patient may have a light breakfast at least 4 hours prior to his appointment.

3. It may not be necessary or desirable to have the patient fast. This decision rests with the individual physician.

Douching

Women should be instructed to abstain from douching (or the use of any vaginal medication, including suppositories) for 48 hours prior to the scheduled examination. Tub baths should also be avoided during this period. Adherence to these instructions will increase the likelihood of an adequate specimen for cytologic examination.

Bowel Preparation For Sigmoidoscopy

For the ordinary or routine detection sigmoidoscopy, bowel preparation can be quite simple. Circumstances will dictate which of the following preparations is preferable:

1. By the patient at home: On the morning of examination, the patient should take tap water enemas until the return is clear. Inexpensive plastic disposable enema units, which are available at any drugstore and which are easy to administer, may also be used by patients.

2. In the doctor's office: The disposable enema unit can be administered by the nurse at the time of examination provided adequate toilet facilities for evacuation are available in the office.

These techniques plus the use of suction at the time of examination will prepare nine out of ten patients quite satisfactorily. They are far more acceptable to patients than purgatives and, incidentally, deprive patients of an excuse for postponing or avoiding the examination.

Under other circumstances, it may be necessary to insist on stricter preparation.

For example:

1. If the above preparation fails to provide a clean bowel.

2. If the patient has any signs or symptoms suggesting lower bowel pathology. Of course, any hint of intestinal obstruction should cause the physician to weigh his recommendations carefully, especially with regard to purgation (see p. 225).

3. If previous experience with a particular patient suggests the unlikelihood of a clean bowel.

4. If office facilities are inadequate with regard to a toilet and suction apparatus.

Then if any of the circumstances just listed exist, the patient should do the following:

1. About 12 to 18 hours before his appointment (e.g., at 4 p.m. on the day prior to a morning examination) the patient should take 2 ounces (60 ml.) of castor oil. This timing is intended to allow the patient to have a night's sleep and to ensure good evacuation prior to the use of enemas.

The castor oil preparation has the additional advantage of occasionally provoking a high-lying bowel lesion to produce blood and/or mucus which is visible through the sigmoidoscope. On occasion this has been the only hint of abnormality and has led to a diagnosis of cancer which would otherwise have been missed.

An alternative to this is compound licorice powder in the amount of 3 heaping teaspoonfuls in 1/2 glass of cold water to be taken 12 to 18 hours prior to examination (e.g., at 4 p.m. the day before a morning appointment).

2. On the morning of examination, the patient should take plain tap water enemas until the return is clear. The patient should lie on his left side and avoid using too much water (e.g., more than 2 quarts) or holding the enema can too high (e.g., over 12 inches). Failure to observe these precautions may result in a great deal of water retention which will render examination unsatisfactory.

It must be emphasized that the castor oil and enema routine just outlined is the preparation par excellence for sigmoidoscopy. It has no rival in assuring a well-prepared bowel. Compromises are made solely in the interests of practicality and patient comfort and cooperation. When any pathology is suspected, however, then it is quite unwise to compromise on the quality of the preparation. Finally, the possibility of intestinal obstruction may require modification of the preparation in some patients.

3. Dietary measures, such as a low residue diet for 48 to 72 hours prior to examination, may be used in problem cases.

Self-Administered Forms

Forms may be given to the patient to be filled out at his convenience at home. These ordinarily deal only with factual items such as family history, dates of operations, hospitalization, occupation, personal habits, etc. Much of the doctor's valuable time can be saved by such a system.