Transcript Chapter 7 Body Systems

Anus, Rectum, and Prostate
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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
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Physical Examination
Preview
(Cont.)
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 Inspect the sacrococcygeal and perianal area for the
following:
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Skin characteristics
Lesions
Pilonidal dimpling and/or tufts of hair
Inflammation
Excoriation
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Physical Exam Preview
(Cont.)
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 Inspect the anus for the following:
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Skin characteristics and tags
Lesions, fissures, hemorrhoids, or polyps
Fistulae
Prolapse
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Physical Examination
Preview
(Cont.)
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 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
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Physical Examination
Preview
(Cont.)
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 In males, palpate the posterior surface of the
prostate gland through the anterior rectal wall for the
following:
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Size
Contour
Consistency
Mobility
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Physical Examination
Preview
(Cont.)
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 In females, palpate the cervix and uterus through the
anterior rectal wall for the following:
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Size
Shape
Position
Smoothness
Mobility
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Physical Examination
Preview
(Cont.)
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 Have the patient bear down and palpate deeper for
the following:
 Tenderness
 Nodules
 Withdraw the finger and examine fecal material for
the following:
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Color
Consistency
Blood or pus
Occult blood by chemical test if indicated
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Anal Canal
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 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
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Anal Canal (Cont.)
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 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
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Anal Canal (Cont.)
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 Anal canal
 Normally kept securely closed by concentric rings of
sphincter muscles
 Internal
 Smooth muscle
 Involuntary
 External
 Striated
 Voluntary
 Controls defecation
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Anal Canal (Cont.)
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 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
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Anal Canal (Cont.)
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 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
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Rectum
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 Rectum: 12 cm long
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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
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Prostate
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 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
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Infants and Children
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 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
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Pregnant Women
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 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
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Older Adults
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 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
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History of Present
Illness
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 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
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History of Present
Illness(Cont.)
 Anal discomfort: itching, pain, stinging, burning
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Relation to body position and defecation
Straining at stool
Blood and mucus
Interference with activities of daily living and sleep
Medications: hemorrhoid preparations
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History of Present
Illness(Cont.)
 Rectal bleeding
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Color: bright or dark red, black
Relation to defecation
Amount
Changes in stool
Associated symptoms
Medications: iron, fiber additives
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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
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Past Medical History
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 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
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Family History
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 Rectal polyps
 Colon cancer or familial cancer syndromes
 Prostatic cancer
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Personal and Social
History
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 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
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Infants and Children
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 Stool characteristics
 Bowel movements accompanied by crying, straining,
bleeding
 Feeding habits
 Bowel control and potty training
 Associated symptoms
 Congenital anomaly
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Pregnant Women
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 Gestation and estimated delivery date
 Exercise
 Fluid intake and diet
 Use of complementary or alternative therapies
 Medications: prenatal vitamins, iron
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Older Adults
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 Change in bowel habits or character
 Associated symptoms
 Dietary changes
 Males: enlarged prostate and urinary symptoms
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Positioning
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 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
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Perianal Areas (Inspection)
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 Inspect for:
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Lumps
Rashes
Inflammation
Excoriation
Scars
Pilonidal dimpling
Tufts of hair at the pilonidal area
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Perianal Areas (Palpation)
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 Palpate for:
 Tenderness
 Inflammation
 Signs of:
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Perianal abscess
Anorectal fistula or fissure
Pilonidal cyst
Pruritus ani
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Anus (Inspection)
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 Inspect for:
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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.
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Sphincter (Cont.)
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 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
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Rectal Walls
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 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
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Prostate
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 Via anterior rectal wall
 Size
 Contour
 Median sulcus
 Lateral lobes
 Consistency
 Mobility
 Tenderness
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Uterus and Cervix
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 Retroflexed or retroverted uterus is usually palpable
through rectal examination.
 Cervix may be palpable through the anterior rectal
wall.
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Stool
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 Characteristics
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Color
Blood
Pus
Mucus
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Infants and Children
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 Inspect anus, perineum, and buttocks
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Redness or irritation
Masses
Discharge or bleeding
Perirectal protrusion
Rectal abscesses
Texture and tone
Anal contraction
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Infants and Children
(Cont.)
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 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
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Infants and Children
(Cont.)
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 Rectal examination is not routine for infants and
children; do rectal examination for:
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Pain
Bleeding
Rectal protrusion or abscesses
Stool abnormalities
 Rectal examination is routine for adolescents.
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Pregnant Women
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 Inspect and palpate for expected changes.
 Stool changes
 Iron preparations
 Hemorrhoids
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Size
Extent
Location (internal or external)
Discomfort to the patient
Signs of infection or bleeding
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Older Adults
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 Inspect and palpate for:
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Decreased sphincter tone
Stool character
Enlarged prostate
Polyps
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Abnormalities (Anus and Rectum
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 Pilonidal cyst
 Loose hairs penetrate the skin in the sacrococcygeal
area.
 Anal warts (condyloma acuminata)
 Result of infection with the human papillomavirus
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Abnormalities (Anus and Rectum)
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 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
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Abnormalities (Anus and Rectum)
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 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
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Abnormalities (Anus and Rectum)
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 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
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Abnormalities (Anus and Rectum)
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 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
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Abnormalities (Anus and Rectum)
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 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
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Prostate (Cont.)
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 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
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Children
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 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.
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