1. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 15 The Anus, Rectum, and Prostate

2. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy Anatomy of the Anus, Rectum, and Prostate – Side View Anatomy of the Anus, Rectum, and Prostate – Posterior View

3. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) The gastrointestinal tract terminates in a short segment, the anal canal –Normally, the anal canal is held in a closed position by two muscles, the voluntary external anal sphincter and involuntary internal anal sphincter –The angle of the anal canal lies on a line roughly between the anus and umbilicus –The anal canal is liberally supplied by somatic sensory nerves

4. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) A serrated line demarcates the anal canal from the rectum The anorectal junction (often called the pectinate or dentate line) is the boundary between somatic and visceral nerve supplies

5. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Anatomy (cont.) In the male, the prostate gland lies against the anterior rectal wall –It is rounded, heart-shaped, and normally 2.5 cm long –Only the lateral lobes and median sulcus are palpable In the female, the uterine cervix usually is palpable through the anterior wall of the rectum

6. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Common or Concerning Symptoms Change in bowel habits Blood in the stool Pain with defecation; rectal bleeding or tenderness Anal warts or fissures Weak stream of urine Burning upon urination

7. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History Questions concerning symptoms related to the anorectal area may be classified into two categories: –Lower gastrointestinal (GI) –Lower genitourinary (GU)

8. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History (cont.) Lower GI concerns –Is there any change in the pattern of bowel function? –Any change in the size or caliber of the stool? –Any diarrhea or constipation? –What color is the stool? –Any obvious blood or mucus in the stool?

9. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History (cont.) Lower GI concerns (cont.) –Any pain on defecation? –Any itching? –Any extreme tenderness in the anus or rectum? –Any purulent discharge or bleeding? –Any history of anal warts, ulcerations, or fissures? –Any involvement in anal intercourse ?

10. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History (cont.) Lower GU concerns (for men) –Is there any difficulty starting or holding back the urine stream? –Is the urine flow weak? –Is there frequent urination, especially at night? –Is there any pain or burning upon urination or ejaculation?

11. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Health History (cont.) Lower GU questions (for men) (cont.) –Any blood in the urine or semen? –Any pain or stiffness in the lower back, hips, or upper thighs? –Any discomfort or heaviness at the base of the penis with associated malaise, fever, or chills?

12. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Health Promotion and Counseling Screen for prostate cancer –Prostate cancer is the leading cancer diagnosed in men in the United States, and the third leading cause of death –The primary risk factors are age, ethnicity, and family history (although a series of studies have suggested an association between intake of dietary fat and risk of prostate cancer) Screen for polyps and colorectal cancer Provide counseling about sexually transmitted diseases

13. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination The anorectal and prostate examinations are usually the least popular segments of the physical examination A skillfully performed examination should not be truly painful Successful examination requires a calm demeanor, explanation to the patient of what he or she may feel, gentleness, and slow movement of your finger In asymptomatic adolescents, it is appropriate to defer the rectal exam

14. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The male patient –One of several patient positions may be used for examination oThe patient may stand, leaning forward with his upper body resting across the examining table and hips flexed oThe patient may lie on his left side with his buttocks close to the edge of the exam table near you; flex the patients hips and knees, especially the top leg

15. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The male patient (cont.) –Inspect the sacrococcygeal and perianal areas oAssess for lumps, ulcers, inflammation, rashes, or excoriations oPalpate any abnormal areas, noting lumps or tenderness

16. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The male patient (cont.) –Occasionally, severe tenderness prevents entry and internal examination –Instead, place your fingers on both sides of the anus, gently spread the orifice, and ask the patient to bear down –Look for a lesion, such as an anal fissure, that might explain the tenderness

17. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The male patient (cont.) –Examine the anus and rectum oLubricate a gloved index finger oExplain what you are going to do oInspect the anus, noting any lesions oAsk the patient to strain down oPlace finger pad over the anus and gently insert your fingertip into the anal canal; proceed with insertion upon relaxation of the sphincter  Assess for sphincter tone of the anus, tenderness, induration, irregularities, or nodules

18. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The male patient (cont.) –Examine the posterior surface of the prostate gland oIdentify lateral lobes and median sulcus oNote size, shape, and consistency of the prostate; identify any nodules or tenderness oNormal prostate is rubbery and nontender oIf possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity; note any nodules or tenderness oNote the color of any fecal matter on the glove, and test it for occult blood

19. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question A 65-year-old male presents to clinic for a routine examination. The following is the documentation of his prostate examination. Which statement would be of concern? a.Firm b.Heart-shaped c.2.5 cm long d.Median sulcus palpable

20. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer a.Firm The normal prostate is rubbery.

21. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Techniques of Examination (cont.) The female patient –The rectum is usually examined after the female genitalia, while the woman is in the lithotomy position; this position is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall and may also help to palpate a cancer high in the rectum –If the rectum only requires examination, the side- lying position affords a much better view to the perianal and sacrococcygeal areas –Use the same techniques for examination that are used for men

22. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question T he female patient may remain in a lateral position for examination of which of the following: a.Adnexal mass b.Perianal fissure c.Integrity of the rectovaginal wall d.Pelvic mass

23. Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer b.Perianal fissure The rectum is usually examined while the woman is in the lithotomy position, which is also ideal for conducting the bimanual examination and is suitable for testing the integrity of the rectovaginal wall; it may also help to palpate a cancer high in the rectum If the rectum only requires examination, the side-lying position affords a much better view to the perianal and sacrococcygeal areas