Ppt15

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Chapter 15

The Anus, Rectum, and Prostate

Chapter 15

The Anus, Rectum, and Prostate


Anatomy Anatomy

Anatomy of the Anus, Rectum, and Prostate – Side View

Anatomy of the Anus, Rectum, and Prostate – Posterior View


Anatomy (cont.)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



• 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



• 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


Common or Concerning SymptomsCommon 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


The Health HistoryThe Health History

• Questions concerning symptoms related to the anorectal area may be classified into two categories:

– Lower gastrointestinal (GI)

– Lower genitourinary (GU)


The Health History (cont.)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?



• 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?



• 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?



• 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?


Health Promotion and CounselingHealth 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


Techniques of ExaminationTechniques 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


Techniques of Examination (cont.)Techniques of Examination (cont.)

• The male patient

– One of several patient positions may be used for examination

o The patient may stand, leaning forward with his upper body resting across the examining table and hips flexed

o The 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



• The male patient (cont.)

– Inspect the sacrococcygeal and perianal areas

o Assess for lumps, ulcers, inflammation, rashes, or excoriations

o Palpate any abnormal areas, noting lumps or tenderness




– 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


Techniques of Examination (cont.)Techniques of Examination (cont.)• The male patient (cont.)

– Examine the anus and rectum

o Lubricate a gloved index finger

o Explain what you are going to do

o Inspect the anus, noting any lesions

o Ask the patient to strain down

o Place 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




– Examine the posterior surface of the prostate gland

o Identify lateral lobes and median sulcus

o Note size, shape, and consistency of the prostate; identify any nodules or tenderness

o Normal prostate is rubbery and nontender

o If possible, extend your finger above the prostate to the region of the seminal vesicles and the peritoneal cavity; note any nodules or tenderness

o Note the color of any fecal matter on the glove, and test it for occult blood


QuestionQuestion

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


AnswerAnswer

a. Firm

• The normal prostate is rubbery.



• 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


QuestionQuestion

The 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


AnswerAnswer

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

Documents

Ppt15