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Chapter 20 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 Physical Examination Preview 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 Physical Exam Preview (Cont.) Inspect the anus for the following: Skin characteristics and tags Lesions, fissures, hemorrhoids, or polyps Fistulae Prolapse 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 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 Physical Examination Preview (Cont.) In females, palpate the cervix and uterus through the anterior rectal wall for the following: Size Shape Position Smoothness Mobility 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 Anatomy and Physiology Anal Canal and Rectum 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 Anal Canal and Rectum (Cont.) Anal Canal and Rectum (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 Anal Canal and Rectum (Cont.) Anal Canal and Rectum (Cont.) Anal canal (Cont.) Normally kept securely closed by concentric rings of sphincter muscles Internal Smooth muscle Involuntary External Striated Voluntary Controls defecation Anal Canal and Rectum (Cont.) Anal canal (Cont.) 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 Anal Canal and Rectum (Cont.) Anal canal (Cont.) 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 Anal Canal and Rectum (Cont.) 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 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 Prostate (Cont.) Prostate Three lobes Median sulcus: left and right lateral lobes Median lobe: not palpable Contains active secretory alveoli that contribute to ejaculatory fluid 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 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 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 Older Adults (Cont.) Prostate Fibromuscular structures of the prostate gland atrophy Often obscured by benign hyperplasia of the glandular tissue Loss of function of the secretory alveoli Review of Related History 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 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 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 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-alphareductase-inhibitors 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 Family History Rectal polyps Colon cancer or familial cancer syndromes Prostatic cancer 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 Infants and Children Stool characteristics Bowel movements accompanied by crying, straining, bleeding Feeding habits Bowel control and potty training Associated symptoms Congenital anomaly Pregnant Women Gestation and estimated delivery date Exercise Fluid intake and diet Use of complementary or alternative therapies Medications: prenatal vitamins, iron Older Adults Change in bowel habits or character Associated symptoms Dietary changes Males: enlarged prostate and urinary symptoms Examination and Findings Equipment Gloves Lubricant Penlight Drapes Test for occult blood 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 Sacrococcygeal and Perianal Areas Inspect for: Lumps Rashes Inflammation Excoriation Scars Pilonidal dimpling Tufts of hair at the pilonidal area Sacrococcygeal and Perianal Areas (Cont.) Palpate for: Tenderness Inflammation Signs of: Perianal abscess Anorectal fistula or fissure Pilonidal cyst Pruritus ani Anus 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. Sphincter 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. Sphincter (Cont.) Rectal pain is almost always indicative of a local disease. Irritation, rock-hard constipation, rectal fissures, or thrombosed hemorrhoids Anal Ring Tone and texture Smooth and exerts even pressure Nodes or irregularities 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 Prostate Via anterior rectal wall Size Contour Median sulcus Lateral lobes Consistency Mobility Tenderness Uterus and Cervix Retroflexed or retroverted uterus is usually palpable through rectal examination. Cervix may be palpable through the anterior rectal wall. Stool Characteristics Color Blood Pus Mucus Infants and Children Inspect anus, perineum, and buttocks Redness or irritation Masses Discharge or bleeding Perirectal protrusion Rectal abscesses Texture and tone Anal contraction 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 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. 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 Older Adults Inspect and palpate for: Decreased sphincter tone Stool character Enlarged prostate Polyps Abnormalities Anus, Rectum, and Surrounding Skin Pilonidal cyst Loose hairs penetrate the skin in the sacrococcygeal area. Anal warts (condyloma acuminata) Result of infection with the human papillomavirus Anus, Rectum, and Surrounding Skin (Cont.) 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 Anus, Rectum, and Surrounding Skin (Cont.) 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 Anus, Rectum, and Surrounding Skin (Cont.) 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 Anus, Rectum, and Surrounding Skin (Cont.) 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 Anus, Rectum, and Surrounding Skin (Cont.) Polyps Occur anywhere in the intestinal tract May be malignant or benign Anus, Rectum, and Surrounding Skin (Cont.) 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 Prostate Prostatitis Inflammation of the prostate gland Prostate (Cont.) 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 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. Question 1 The internal anal canal is lined with mucosal tissue that fuse to form the anorectal junction. This is called: A. Columns of Morgani B. Houston valves C. Gastrocolic reflex D. Zona hemorrhoidalis Question 2 In males, which surface of the prostate gland is accessible by digital examination? A. Median lobe B. Posterior C. Superior D. Anterior Question 3 In the infant, the internal and external anal sphincters are under involuntary control because: A. The prostate is small and inactive B. Myelination of the spinal cord is incomplete C. Degeneration of the afferent nerves D. Encopresis Question 4 An expected anal or rectal finding late in pregnancy is the presence of: A. Rectal prolapse B. Skin tags C. Polyps D. Hemorrhoids Question 5 During the digital rectal examination have the patient bear down to: A. Spread the buttocks B. Examine the prolapse of hemorrhoids C. Relax the internal sphincter D. Relax the external sphincter