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1 INTRODUCTION TO CLINICAL MEDICINE August 05, 2014

2.02
Dr. Guzman

Anus, Rectum, and Prostate

I. Anatomy and Physiology Rectal Ampulla


Anal Canal stores flatus and feces
Rectum Valves of Houston
Males
3 inward foildings in the rectal wall
Females
II. Health History lowest is sometmes palpable on the pxs left
Common and Concerning Symptoms
BPH Score Index MALES
III. Health Promotion and Counseling
IV. Techniques of Examinaton
Prostate
V. Abnormalites o has three lobes surrounding the urethra:
VI. Sample Quizzes median lobe
anterior to the urethra (not palpable)
ANATOMY AND PHYSIOLOGY lateral lobes
ANAL CANAL lie against the rectal wall
palpated as a rounded heart-shaped structure (2.5 cm long)
a short segment in which the GIT terminated
separated by a median sulcus or groove (palpable)
its angle lies on the line between the anal canal and the umbilicus
o size increases with age particularly during puberty or in
with liberal supply of somatc sensory pain nerves unlike rectum
20 years
poorly directed finger or instrument will produce pain
can become hyperplastic as its volume further expands
Seminal vesicles
rabbit ear shaped
above the prostate and is not palpable

FEMALES
Anterior rectal wall lies in contact w/ the vagina & is separated
from it by the rectovaginal septum
The cervix is usually palpable through anterior rectal wall

HEALTH HISTORY
COMMON OR CONCERNING SYMPTOMS
1. Change in bowels habits
Personal or family hx of colonic polyps, colorectal cancer or
inflammatory bowel disease inc. Risk further test and surveillance
External Margin Colon cancer: stools of thin pencil-like shape
moist and hairlaess mucosa 2. Blood in the stools
Columns of Morgagni may be from polyps/cancer, GI bleeding or local hemorrhoids
columns of mucosal tissue which lines the anal canal consider villous adenoma if with mucus
Crypts 3. Pain with defecation: rectal bleeding or ternderness
space between the column into w/c anal glands empty inquire of pain on defacation, itching, extreme tenderness in
fstula or fssure formation anus or rectum
Zona hemorrhoidalis ask for presence of mucopurolent discharge or bleeding
anastomosing veins which cross the columns forming a ring ask for ulcerations
lower segment of the anal canal contains a venous plexus that inquire of patient engages in anal intercourse
drains into the inferior rectal veins proctts: intching, anorectal pain, tenesmus, discharge or bleeding
internal and external hemorrhoids (gonorrhea, Chlamydia, anal intercourse, ulceratons of herpes
simplex chancre of primary syphilis)
Muscles: Sphincters
consider pinworm infestaton in young patients for itching
Concentric ring of muscles that hold the anal canal closed
4. Anal warts (HPV) or fssure (proctitis or crohns)
o Internal: involuntary control
5. Weak stream of urine (BPH in men)
o External: voluntary control
difculty starting or holding back urine stream
Innervation
weak flow
o Lower half: somatc sensory nerves (painful) LoSoPain
polyuria at night
o Upper half: autonomic nerves (insensitive) UpAu
bloody semen or urine with ejaculation
Anorectal Junction
frequent pain or stifness in the lower back, hips or upper
also known as dentate line/ pectinate line
boundary between somatic and visceral nerve supplies thighs
visible on proctoscopic exam as saw tooth-like edge but not 6. Burning in urination (prostatitis in men)
palpable
BPH Score Index (American Urological Association)
RECTUM
superior to the anus, 12 cm with proximal end is continuous w/
sigmoid colon
balloons out and turns posterior into the hollow of coccyx and
sacrum above the anorectal junction
most parts accessed by digital examinaton are usually lacking of
peritoneal surface
if tender: peritoneal inflammation or nodularity (peritoneal
matastases)

Transcriber: Santander Page 1 of 5


1.1 INTRODUCTION TO CLINICAL MEDICINE

Mild symptoms that dont bother you (AUA score 0 to 7)


watchful waitng is the best opton
get regular checkups to make sure that complicatons are not
developing
Moderate to severe symptoms that dont bother you (AUA score of 8 or
more)
watchful waitng
if symptoms start to interfere: medicatonand a minimally invasive
procedure, or surgery should be sought
Moderate to severe symptoms (AUA score of 8 or more) with 5. Inspect the sacrococcygeal and perianal areas for lumps, ulcers,
complicatons: inflammaton, rashes, or excoriations.
symptoms are bothersome and have developed complicatons such
Adult perianal skin is normally more pigmented and somewhat coarser
as inability to urinate
than the skin over the butocks
catheter, surgery, or another treatment. Anal and perianal lesions include hemorrhoids, venereal warts, herpes,
syphilitc chancre, and carcinoma
HEALTH PROMOTION AND COUNSELING A linear crack or tear suggests anal fissure from large, hard stools,
inflammatory bowel disease, or STIs
Screening for prostate cancer
Consider pruritus ani if there is swollen, thickened, fissured perianal skin
Screening for colorectal cancer with excoriations.
Counseling for sexually transmitted infections 6. Palpate any abnormal areas, noting lumps or tenderness.
Tender, purulent, reddened mass with fever or chills accompanies an
SCREENING FOR PROSTATE CANCER anal abscess
Risk Factors: Abscesses tunneling to the skin surface from the anus or rectum may
1. Age: 50 years old, risk increases for every decade. form a clogged or draining anorectal fistula
Fistulas may ooze blood, pus, or feculent mucus
2. Ethnicity: African American
Consider anoscopy or sigmoidoscopy for beter visualization
3. Family History: First degree relatves
7. Explain to the patient what you are going to do, and tell him that
4. Diet: Saturated Fat
the examination may trigger an urge to move his bowels but that
this will not occur
SCREENING FOR COLORECTAL CANCER 8. Lubricate your gloved index finger
Risk Factors: 9. Ask him to strain down
o Age 20 if with: 10. Inspect the anus, noting any lesions.
Family History 11. As the patient strains, place the pad of your gloved and
Inflammatory bowel disease lubricated index fnger over the anus
At age 50 years old (screening tests): 12. As the sphincter relaxes, gently insert your fingertip into the anal
o annual screening with high-sensitivity fecal occult blood tests canal in the direction pointing toward the umbilicus
(FOBTs) If you feel the sphincter tghten, pause and reassure the patent. When,
o sigmoidoscopy every 5 years, with high-sensitivity FOBT every 3 in a moment, the sphincter relaxes, proceed.
years
o screening colonoscopy every 10 years
Note: Patents at increased risk should undergo colonoscopy every 3 to 5
years

COUNSELING FOR SEXUALLY TRANSMITTED INFECTIONS (STIS)


Anal intercourse places men and women at risk for perianal and
rectal abrasions and transmission of HIV and other STIs
Protective measures include abstinence from high-risk behaviors, Note: Occasionally, severe tenderness prevents entry and internal
use of condoms, and good hygiene examinaton. Do not try to force it. Instead, place your fingers on both sides
of the anus, gently spread the orifice, and ask the patent to strain down.
TECHNIQUES OF EXAMINATION Look for a lesion, such as an anal fissure, that might explain the tenderness.
Rectal exam can be omitted in adolescents who have no relevant 13. If you can proceed without undue discomfort to the patient,
complaints note:
It is useful for screening and assessing symptoms in middle-aged The sphincter tone of the anus.
or older adults Normally, the muscles of the anal sphincter close snugly around your
Remember to: finger
o maintain a calm demeanor Inital restng tone reflects the integrity of the internal anal sphincter.
To check external sphincter tone, ask the patient to bear down and
o provide an explanation to the patient of what he or she squeeze the rectal muscles
may feel Sphincter tightness may occur with anxiety, inflammaton, or scarring
o be gentle and not be abrupt in moving your fnger laxity occurs in neurologic diseases (cord lesions)
Tenderness, if any
SUITABLE POSITIONS Induration
1. Standing while leaning forward with upper body resting across the may be caused by inflammation, scarring, or malignancy
examining table and hips flexed. Irregularities or nodules
2. Side-lying position is satisfactory To bring a possible lesion into reach, take your finger off the rectal
allows good visualizaton of the perianal and sacrococcygeal areas surface, ask the patent to strain down, and palpate again
14. Insert your finger into the rectum as far as possible
Note: No mater how you positon the patent, your examining finger cannot rotate your hand clockwise to palpate as much of the rectal
reach the full length of the rectum. Utlize sigmoidoscopy or colonoscopy if surface as possible on the patients right side
rectosigmoid cancer is suspected
rotate your hand counterclockwise next to palpate the surface
posteriorly and on the patients lef side.
RECTAL AND ANAL EXAMINATION IN MALES the prostate gland can be palpated in this manner and also made
1. Ask the patient to lie on his lef side with his buttocks close to the easier by turning your body away from the patient
edge of the examining table near you. tell the patient that examining his prostate gland may prompt an
2. Flex the patients hips and knees, especially in the upper leg, urge to urinate!!!
stabilizes his position and improves visibility. 15. Sweep your finger carefully over the prostate gland, identifying
3. Drape the patient appropriately and adjust the light for the best its lateral lobes and the median sulcus between them
view. Note the size, shape, and consistency of the prostate, and
4. Glove your hands and spread the buttocks apart. identify any nodules or tenderness
The normal prostate is rubbery and nontender
1.1 INTRODUCTION TO CLINICAL MEDICINE

16. If possible, extend your finger above the prostate to the region
of the seminal vesicles and the peritoneal cavity and sweep the
anterior wall
Note any nodules or tenderness
Findings include a rectal shel f of peritonea l metastases or the
tenderness of peritoneal inflammation
17. Gently withdraw your fnger, and wipe the anus or give the
patient tissues
Note the color of any fecal mater on your glove, and test it for
occult blood
A single fecal occult blood test is not an adequate screen for colon
cancer

RECTAL AND ANAL EXAMINATION IN FEMALES


1. Lithotomy position
post-vaginal examination
allows you to conduct the bimanual examination and delineate
a possible adnexal or pelvic mass
allows you to test the integrity of the rectovaginal wall
may help you to palpate a cancer high in the rectum
2. Lateral position
satisfactory if for rectal exam only
afords a much better view to the perianal and sacrococcygeal
areas
use the same techniques for examination that you use for men

Note: the cervix is readily palpated through the anterior wall. Sometimes a
retroverted uterus is also palpable. Do not mistake either of these, or a
vaginal tampon, for a tumor.
1.1 INTRODUCTION TO CLINICAL MEDICINE August 05, 2014

2.02
Dr. Guzman

Anus, Rectum, and Prostate

ABNORMALITIES OF THE ANUS, SURROUNDING SKIN AND RECTUM


fairly common
probably congenital abnormality located in the midline superficial to the coccyx or the lower
sacrum
look for the opening of a sinus tract. This opening
may exhibit a small tuf of hair surrounded by a halo of erythema.
generally asymptomatc, except perhaps for slight drainage, abscess formation and secondary
sinus tracts may complicate the picture
Pilonidal Cyst and Sinus
dilated hemorrhoidal veins that originate below the pectinate line and are covered with skin
seldom produce symptoms unless thrombosis occurs
causes acute local pain that increases with defecation and siting
tender, swollen, bluish, ovoid mass is visible at the anal margin

External Hemorrhoids (Thrombosed)


enlargements of the normal vascular cushions located above the pectinate line
not usually palpable
may cause bright-red bleeding especially during defacation
also prolapsed through the anal canal and appear as reddish, moist, protruding masses

Internal Hemorrhoids (Prolapsed)


On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may
prolapse through the anus, appearing as a doughnut or rosette of red tissue
a prolapsed involving only mucosa is relatvely small and shows radiatng folds, as illustrated
when the entre bowel wall is involved, the prolapse is larger and covered by concentrically circular folds

Prolapse of the Rectum


a very painful oval ulceration of the anal canal, found most commonly in the midline
posteriorly, less commonly in the midline anteriorly
its long axis lies longitudinally there may be a swollen sentinel skin tag just below it
gentle separation of the anal margins may reveal the lower edge of the fssure
the sphincter is spastic; the examination is painful
local anesthesia may be required

Anal Fissure
an inflammatory tract or tube that opens at one end into the anus or rectum and at the other
end onto the skin surface (as shown here) or into another viscus.
an abscess usually antedates such a fistula
look for the fistulous opening or openings anywhere in the skin around the anus

Anorectal Fistula
fairly common
variable in size and number
they can develop on a stalk (pedunculated) or lie on the mucosal surface (sessile)
sof and may be difcult or impossible to feel even when in reach of the examining finger
proctoscopy and biopsy are needed for diferentiation of benign from malignant lesions

Polyps of the Rectum


asymptomatc carcinoma of the rectum makes routine rectal examination important for adults
illustrated here is the frm, nodular, rolled edge of an ulcerated cancer

Cancer of the Rectum


Widespread peritoneal metastases from any source may develop in the area of the peritoneal
reflection anterior to the rectum
A frm to hard nodular rectal shelf may be just palpable with the tip of the examining finger
in a woman, this shelf of metastatic tissue develops in the rectouterine pouch, behind the cervix and the
uterus

Rectal Shelf
1.1 INTRODUCTION TO CLINICAL MEDICINE August 05, 2014

2.02
Dr. Guzman

Anus, Rectum, and Prostate

ABNORMALITIES OF THE PROSTATE


palpated through the anterior rectal wall
rounded, heart-shaped structure approximately 2.5 cm long
median sulcus can be felt between the two lateral lobes
only posterior surface of the prostate is palpable
anterior lesions, including those that may obstruct the urethra, are not detectable by physical
examination

Normal Prostate
Acute bacterial prostatitis, illustrated here, presents with fever and urinary tract symptoms
such as frequency, urgency, dysuria, incomplete voiding, and sometimes low back pain.
The gland feels tender, swollen, boggy, and warm
examine it gently
more than 80% of infectons are caused by gram-negatve aerobes such as E. coli, Enterococcus, and
Proteus
in men younger than 35, consider sexual transmission of Neisseria gonorrhea and Chlamydia
trachomats
Chronic bacterial prostatitis is associated with recurrent urinary tract infections, usually from
the same organism
men may be asymptomatc or have symptoms of dysuria or mild pelvic pain
prostate gland may feel normal, without tenderness or swelling
cultures of prostatc fluid usually show infecton with E. coli.
Prostatitis Diferential: chronic pelvic pain syndrome
seen in up to 80% of symptomatc men who report obstructve or irritative symptoms on voiding but
show no evidence of prostate or urinary tract infection
physical examination findings are not predictable, but examination is needed to assess any prostate
induraton or asymmetry suggestve of carcinoma
afected gland may be normal in size, or may feel symmetrically enlarged, smooth, and
frm,though slightly elastic;
there may be obliteration of the median sulcus and more notable protrusion into the rectal
lumen

Benign Prostatic Hyperplasia


suggested by an area of hardness in the prostate gland
a distinct hard nodule that alters the contour of the gland may or may not be palpable
hard areas in the prostate are not always malignant
they may also result from prostatc stones, chronic inflammation, and other conditions
as the cancer enlarges, it feels irregular and may extend beyond the confnes of the gland.
the median sulcus may be obscured

Prostate Cancer

SAMPLE QUIZ
1. Where can you locate the angle of the anal canal?
2. What instruction will you give the patient in order to relax the
anal sphincter?
3. What will you remind the patient when you are about to palpate
the prostate gland?
4. A female patient underwent vaginal exam, what position should
the patient be placed on if a rectal exam is required?
5. What do you expect to see in a rectal prolapse that involved the
entire bowel wall?
6. What does a normal prostate feels?
7. Should you expect to feel the entire length of the rectum when
assuming the lateral position?
8. What should you consider if you see a swollen, thickened,
fssured perianal skin with excoriation?
9. What should you suspect when there is drainage on the perianal
area?
10. Part of the rectal wall that has contact with the vagina?
11. How do you get to assess for a rectal shelf?

Answers
1. Line between the anal canal and the umbilicus
2. Ask the patent to strain
3. Tell him that it may prompt an urge to urinate
4. Let the patent assume the same positon as the vaginal exam (lithotomy)
5. The prolapse is larger and covered by concentrically circular folds
6. Rounded, heart-shaped, median sulcus can be felt between the two lateral lobes
7. No positon wont let you.
8. Pruritus ani
9. Anorectal fistula
10. Anterior rectal wall
11. Extend your finger above the prostate to the region of the seminal vesicles and
the peritoneal cavity and sweep the anterior wall