1. Anus, Rectum, and Prostate.

2.   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 Anus, Rectum, and Prostate

3.   Inspect the sacrococcygeal and perianal area for the following:  Skin characteristics  Lesions  Pilonidal dimpling and/or tufts of hair  Inflammation  Excoriation 3 Physical Examination Preview (Cont.)

4.   Inspect the anus for the following:  Skin characteristics and tags  Lesions, fissures, hemorrhoids, or polyps  Fistulae  Prolapse 4 Physical Exam Preview (Cont.)

5.   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.)

6.   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.)

7.   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.)

8.   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 Physical Examination Preview (Cont.)

9.   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

10.   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.)

11.   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.)

12.   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.)

13.   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 Anal Canal (Cont.)

14.   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 Rectum

15.   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 Prostate

16.   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 Infants and Children

17.   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 Pregnant Women

18.   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 Older Adults

19.   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

20.   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.)

21.   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.)

22.   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 History of Present Illness (Cont.)

23.   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 Past Medical History

24.   Rectal polyps  Colon cancer or familial cancer syndromes  Prostatic cancer 24 Family History

25.   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 Personal and Social History

26.   Stool characteristics  Bowel movements accompanied by crying, straining, bleeding  Feeding habits  Bowel control and potty training  Associated symptoms  Congenital anomaly 26 Infants and Children

27.   Gestation and estimated delivery date  Exercise  Fluid intake and diet  Use of complementary or alternative therapies  Medications: prenatal vitamins, iron 27 Pregnant Women

28.   Change in bowel habits or character  Associated symptoms  Dietary changes  Males: enlarged prostate and urinary symptoms 28 Older Adults

29.   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 Positioning

30.   Inspect for:  Lumps  Rashes  Inflammation  Excoriation  Scars  Pilonidal dimpling  Tufts of hair at the pilonidal area 30 Perianal Areas (Inspection)

31.   Palpate for:  Tenderness  Inflammation  Signs of:  Perianal abscess  Anorectal fistula or fissure  Pilonidal cyst  Pruritus ani 31 Perianal Areas (Palpation)

32.   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 Anus (Inspection)

33.   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 Sphincter (Cont.)

34.   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 Rectal Walls

35.   Via anterior rectal wall  Size  Contour  Median sulcus  Lateral lobes  Consistency  Mobility  Tenderness 35 Prostate

36.   Retroflexed or retroverted uterus is usually palpable through rectal examination.  Cervix may be palpable through the anterior rectal wall. 36 Uterus and Cervix

37.   Characteristics  Color  Blood  Pus  Mucus 37 Stool

38.   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

39.   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.)

40.   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 Infants and Children (Cont.)

41.   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 Pregnant Women

42.   Inspect and palpate for:  Decreased sphincter tone  Stool character  Enlarged prostate  Polyps 42 Older Adults

43.   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

44.   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)

45.   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)

46.   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)

47.   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)

48.   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 Abnormalities (Anus and Rectum)

49.   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 Prostate (Cont.)

50.   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 Children