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Anus, Rectum, and Prostate . Anus, Rectum, and Prostate Examination of the anus and rectum is performed: As part of an annual well-person examination for both men and women And, in men, includes examination of the prostate When the patient has a specific concern or problem 2 Physical Examination Preview (Cont.) Inspect the sacrococcygeal and perianal area for the following: Skin characteristics Lesions Pilonidal dimpling and/or tufts of hair Inflammation Excoriation 3 Physical Exam Preview (Cont.) Inspect the anus for the following: Skin characteristics and tags Lesions, fissures, hemorrhoids, or polyps Fistulae Prolapse 4 Physical Examination Preview (Cont.) Insert finger and assess sphincter tone. Palpate the muscular ring for the following: Smoothness Evenness of pressure against examining finger Palpate the lateral, posterior, and anterior rectal walls for the following: Nodules, masses, or polyps Tenderness Irregularities 5 Physical Examination Preview (Cont.) In males, palpate the posterior surface of the prostate gland through the anterior rectal wall for the following: Size Contour Consistency Mobility 6 Physical Examination Preview (Cont.) In females, palpate the cervix and uterus through the anterior rectal wall for the following: Size Shape Position Smoothness Mobility 7 Physical Examination Preview (Cont.) Have the patient bear down and palpate deeper for the following: Tenderness Nodules Withdraw the finger and examine fecal material for the following: Color Consistency Blood or pus Occult blood by chemical test if indicated 8 Anal Canal Anal canal: 2.5 to 4 cm long Opens onto the perineum Visible tissue at the external margin of the anus is moist, hairless mucosa Juncture with the perianal skin is characterized by increased pigmentation and, in the adult, the presence of hair 9 Anal Canal (Cont.) Anal canal Lower half of the canal is supplied with somatic sensory nerves. Sensitive to pain Upper half is under autonomic control. Relatively insensitive to pain 10 Anal Canal (Cont.) Anal canal Normally kept securely closed by concentric rings of sphincter muscles Internal Smooth muscle Involuntary External Striated Voluntary Controls defecation 11 Anal Canal (Cont.) Anal canal Lined by columns of mucosal tissue (columns of Morgagni) Spaces between the columns are called crypts Anal glands empty Inflammation of the crypts can result in fistula or fissure formation 12 Anal Canal (Cont.) Anal canal Anastomosing veins cross the columns Zona hemorrhoidalis Internal hemorrhoids Lower segment of the anal canal contains a venous plexus that drains into the inferior rectal veins External hemorrhoids 13 Rectum Rectum: 12 cm long Rectum lies superior to the anus. Proximal end is continuous with the sigmoid colon. Rectal ampulla stores flatus and feces. Rectal wall contains three semilunar transverse folds (Houston valves). Lowest of these folds can be palpated 14 Prostate Prostate: 4 × 3 × 2 cm Located at the base of the bladder and surrounds the urethra Posterior surface accessible by digital examination Anterior rectal wall Three lobes Median sulcus: left and right lateral lobes Median lobe: not palpable Contains active secretory alveoli that contribute to ejaculatory fluid 15 Infants and Children First meconium stool is ordinarily passed within the first 24 to 48 hours after birth and indicates anal patency. Common for newborns to have a stool after each feeding (the gastrocolic reflex) Control of external anal sphincter by 18 to 24 months Myelination complete Prostate undeveloped until puberty 16 Pregnant Women Decreased GI tract tone and motility produce constipation Dietary habits and hormonal changes Pressure in the veins below the enlarged uterus increases Development of hemorrhoids Aggravated by labor Protrusion and inflammation 17 Older Adults Degeneration of afferent neurons in the rectal wall: Interferes with the process of relaxation of the internal sphincter Increased pressure sensation threshold in rectum Stool retention Loss of external sphincter tone Fecal incontinence Prostate Fibromuscular structures of the prostate gland atrophy Often obscured by benign hyperplasia of the glandular tissue Loss of function of the secretory alveoli 18 History of Present Illness Changes in bowel function Character: number, frequency, consistency of stools; presence of mucus or blood; color Onset and duration Accompanying symptoms Medications: iron, laxatives, stool softeners 19 History of Present Illness(Cont.) Anal discomfort: itching, pain, stinging, burning Relation to body position and defecation Straining at stool Blood and mucus Interference with activities of daily living and sleep Medications: hemorrhoid preparations 20 History of Present Illness(Cont.) Rectal bleeding Color: bright or dark red, black Relation to defecation Amount Changes in stool Associated symptoms Medications: iron, fiber additives 21 History of Present Illness(Cont.) Males: Changes in urinary function History of enlarged prostate or prostatitis Symptoms: hesitancy, urgency, nocturia, dysuria, change in force or caliber of stream, dribbling, urethral discharge Medications: antihistamines, anticholinergics, tricyclic antidepressants, 5-alpha-reductase-inhibitors 22 Past Medical History Hemorrhoids Spinal cord injury Males: prostatic hypertrophy or cancer Females: episiotomy or fourth-degree laceration during delivery Colorectal cancer or related cancers: breast, ovarian, endometrial 23 Family History Rectal polyps Colon cancer or familial cancer syndromes Prostatic cancer 24 Personal and Social History Travel history: areas with high incidence of parasitic infestation, including zones in the United States Diet: inclusion of fiber and amount of animal fat Colorectal or prostate cancer risk factors Use of alcohol 25 Infants and Children Stool characteristics Bowel movements accompanied by crying, straining, bleeding Feeding habits Bowel control and potty training Associated symptoms Congenital anomaly 26 Pregnant Women Gestation and estimated delivery date Exercise Fluid intake and diet Use of complementary or alternative therapies Medications: prenatal vitamins, iron 27 Older Adults Change in bowel habits or character Associated symptoms Dietary changes Males: enlarged prostate and urinary symptoms 28 Positioning Rectal examination can be performed with the patient in any of these positions: Knee-chest Left lateral with hips and knees flexed Standing with the hips flexed and the upper body supported by the examining table 29 Perianal Areas (Inspection) Inspect for: Lumps Rashes Inflammation Excoriation Scars Pilonidal dimpling Tufts of hair at the pilonidal area 30 Perianal Areas (Palpation) Palpate for: Tenderness Inflammation Signs of: Perianal abscess Anorectal fistula or fissure Pilonidal cyst Pruritus ani 31 Anus (Inspection) Inspect for: Skin lesions Skin tags or warts External hemorrhoids Fissures Fistulae Clock referents are used to describe the location of anal and rectal findings. 12 o’clock is in the ventral midline and 6 o’clock is in the dorsal midline. 32 Sphincter (Cont.) External sphincter tone Lax sphincter may indicate neurologic deficit. Extremely tight sphincter can result from scarring, spasticity caused by a fissure or other lesion, inflammation, or anxiety about the examination. Rectal pain is almost always indicative of a local disease. Irritation, rock-hard constipation, rectal fissures, or thrombosed hemorrhoids 33 Rectal Walls Lateral and posterior Nodules, masses, irregularities, polyps, or tenderness Internal hemorrhoids not ordinarily felt unless they are thrombosed Anterior Contact with the peritoneum Peritoneal inflammation Nodularity of peritoneal metastases Shelf lesions Posterior surface of prostate 34 Prostate Via anterior rectal wall Size Contour Median sulcus Lateral lobes Consistency Mobility Tenderness 35 Uterus and Cervix Retroflexed or retroverted uterus is usually palpable through rectal examination. Cervix may be palpable through the anterior rectal wall. 36 Stool Characteristics Color Blood Pus Mucus 37 Infants and Children Inspect anus, perineum, and buttocks Redness or irritation Masses Discharge or bleeding Perirectal protrusion Rectal abscesses Texture and tone Anal contraction 38 Infants and Children (Cont.) Examine newborn for patency of anus. Lightly touch the anal opening, which should produce anal contraction (“anal wink”). Lack of contraction may indicate a lower spinal cord lesion. Routinely inspect the anal region and perineum: Redness, masses, or swelling 39 Infants and Children (Cont.) Rectal examination is not routine for infants and children; do rectal examination for: Pain Bleeding Rectal protrusion or abscesses Stool abnormalities Rectal examination is routine for adolescents. 40 Pregnant Women Inspect and palpate for expected changes. Stool changes Iron preparations Hemorrhoids Size Extent Location (internal or external) Discomfort to the patient Signs of infection or bleeding 41 Older Adults Inspect and palpate for: Decreased sphincter tone Stool character Enlarged prostate Polyps 42 Abnormalities (Anus and Rectum Pilonidal cyst Loose hairs penetrate the skin in the sacrococcygeal area. Anal warts (condyloma acuminata) Result of infection with the human papillomavirus 43 Abnormalities (Anus and Rectum) Anal cancer Most are squamous cell carcinomas, which are associated with HPV infection Adenocarcinomas originate in the glands near the anus Basal cell carcinoma and malignant melanoma Anorectal fissure Tear in the anal mucosa 44 Abnormalities (Anus and Rectum) Perianal or perirectal abscesses Infection of the soft tissues surrounding the anal canal or mucus secreting anal glands Abscess formation occurs in the deeper tissues Usually polymicrobial Anaerobes 45 Abnormalities (Anus and Rectum) Anal fistula Inflammatory tract that runs from the anus or rectum and opens onto the surface of the perianal skin or other tissue Caused by drainage of a perianal or perirectal abscess Pruritus ani Commonly caused by fungal infection in adults and by parasites in children 46 Abnormalities (Anus and Rectum) Hemorrhoids External hemorrhoids: varicose veins that originate below the anorectal line and are covered by anal skin Internal hemorrhoids: varicose veins that originate above the anorectal junction and are covered by rectal mucosa Polyps Occur anywhere in the intestinal tract May be malignant or benign 47 Abnormalities (Anus and Rectum) Rectal cancer Adenocarcinomas comprise the large majority of rectal cancers Rectal prolapse Protrusion or the rectal mucosa, with or without the muscular wall, through the anal ring 48 Prostate (Cont.) Prostatitis Inflammation of the prostate gland Benign prostatic hypertrophy (BPH) Continuing enlargement of the prostate gland Common in men older than 50 years Prostatic cancer 99% of prostate cancers are adenocarcinomas Develops from the gland cells within the prostate 49 Children Enterobiasis (roundworm, pinworm) Adult nematode (parasite) lives in the rectum or colon and emerges onto perianal skin to lay eggs while the child sleeps. Imperforate anus Rectum may end blindly, be stenosed, or have a fistulous connection to the perineum, urinary tract, or, in females, the vagina. 50
