Mosby's Guide to Physical Examination, 7th Edition

CHAPTER 16. Anus, Rectum, and Prostate

EQUIPMENT

image Gloves

image Water-soluble lubricant

image Light source

image Drapes

image Fecal occult blood testing materials if indicated

EXAMINATION

Have patient in knee-chest or left lateral position with hips and knees flexed, or standing with hips flexed and upper body supported by examining table. Drape patient appropriately.

TECHNIQUE

FINDINGS

Wear gloves on both hands

Inspect and palpate sacrococcygeal and perianal area

imageSkin characteristics

EXPECTED:Smooth and uninterrupted.

UNEXPECTED:Lumps, rashes, tenderness, inflammation, excoriation, pilonidal dimpling, or tufts of hair.

Inspect anus

Spread patient’s buttocks.

Examine, using penlight or lamp if needed, with patient relaxed as well as with patient bearing down.

 

imageSkin characteristics

EXPECTED:Skin coarser and darker than on buttocks.

UNEXPECTED:Skin lesions, skin tags or warts, external or internal hemorrhoids, fissures and fistulas, rectal prolapse, or polyps. Describe any irregularities and locate using clock referents (12 o’clock ventral midline/6 o’clock dorsal midline).

Inspect, palpate, assess sphincter tone

Put water-soluble lubricant on index or middle finger; press pad against anal opening, and ask patient to bear down to relax external sphincter. As relaxation occurs, slip tip of finger into anal canal, as shown in figure below. (Assure patient that although he or she may feel the urgency of a bowel movement, it will not occur.) Ask patient to tighten external sphincter around finger.

EXPECTED:Even sphincter tightening.

UNEXPECTED:Patient discomfort. Lax or extremely tight sphincter, tenderness.

image

Palpate muscular anal ring

Rotate finger.

EXPECTED:Smooth, even with consistent pressure exerted.

UNEXPECTED:Nodules or other irregularities.

Palpate lateral and posterior rectal walls

Insert finger farther, and rotate to palpate lateral, then posterior, rectal walls. (If helpful, perform bidigital palpation with thumb and finger by lightly pressing thumb against perianal tissue and bringing finger toward thumb.)

EXPECTED:Smooth, even, uninterrupted.

UNEXPECTED:Nodules, masses, polyps, tenderness, or irregularities. (Internal hemorrhoids not ordinarily felt unless thrombosed.)

Males: Palpate posterior surface of prostate gland through anterior rectal wall

Rotate finger and palpate anterior rectal wall and posterior surface of prostate gland. (Alert patient that he may feel urge to urinate but will not.)

 

imageConsistency and characteristics of anterior rectal wall

EXPECTED:Smooth, even, uninterrupted.

UNEXPECTED:Nodules, masses, polyps, tenderness, or irregularities.

imageConsistency, contour, characteristics of prostate

EXPECTED:Surface firm and smooth, lateral lobes symmetric, median sulcus palpable, seminal vesicles not palpable.

UNEXPECTED:Rubberiness, bogginess, fluctuant softness, stony hard nodularity, tenderness, obliterated sulcus, or palpable seminal vesicles.

imageMobility of prostate gland

EXPECTED: Slightly movable.

imageSize of prostate gland

EXPECTED:4 cm diameter with less than 1 cm protruding into rectum.

 

UNEXPECTED:Protrusion greater than 1 cm (note distance of protrusion).

UNEXPECTED:Discharge that appears at urethral meatus (collect specimen for microscopic examination).

Females: Palpate uterus through anterior rectal wall

Attempt to palpate uterus and cervix through anterior rectal wall.

 

imagePosition

EXPECTED:Midline, retroflexed or retroverted.

UNEXPECTED:Deviation to right or left.

imageSurface characteristics

EXPECTED:Smooth.

UNEXPECTED:Irregular.

Have patient bear down, and palpate deeper

Ask patient to bear down while you reach farther into rectum.

Females: Explore in cul-de-sac.

Males: Explore above prostate.

UNEXPECTED:Tenderness of peritoneal area or nodules.

Withdraw finger, and examine fecal material

imageColor and consistency

EXPECTED:Soft and brown.

UNEXPECTED:Blood; pus; or light tan, gray, or tarry black stool. If indicated, fecal material can be tested for blood using a chemical guaiac procedure.

AIDS TO DIFFERENTIAL DIAGNOSIS

ABNORMALITY

DESCRIPTION

Anal warts (condyloma acuminata)

Subjective Data:Growths on the anus and genitalia.

 

Objective Data:Single or multiple papular lesions; may be pearly, filiform, fungating (ulcerating and necrotic) cauliflower, or plaquelike.

Perianal and perirectal abscesses

Subjective Data: Pain and tenderness in anal area.

Objective Data:Tender, swollen, fluctuant mass; may be draining.

Enterobius infestation in children

Subjective Data:Intense perianal itching, especially at night.

Objective Data:Positive tape test. Press the sticky side of cellulose tape against the perianal folds and then press the tape on a glass slide. Nematodes can be seen on microscopic examination.

Anorectal fissure

Subjective Data:Hard stools; pain, itching, bleeding.

Objective Data:Fissure most often in the posterior midline spastic internal sphincter.

Anorectal fistula

Subjective Data:Chills, fever, nausea, vomiting, and malaise.

Objective Data:Elevated, red, granular tissue at external opening, possibly with serosanguineous or purulent drainage on compression of the area; palpable indurated tract.

Hemorrhoids

Subjective Data:Itching and bleeding; discomfort.

Objective Data:May or may not be visisble; may be palpable as soft swellings. Thrombosed hemorrhoids appear as blue, shiny masses at anus.

Rectal carcinoma

Subjective Data:Bleeding; may be asymptomatic.

Objective Data:Sessile polypoid mass with nodular raised edges and areas of ulceration; consistency often stony, with irregular contour.

Prostatic carcinoma

Subjective Data:Early carcinoma asymptomatic; symptoms of urinary obstruction as carcinoma advances.

Objective Data:Hard, irregular nodule may be palpable on prostate examination; prostate asymmetric, median sulcus may be obliterated; biopsy required for diagnosis.

Prostatitis

Subjective Data:Acute: Pain, urination problems, sexual dysfunction, fever, chills, shakes. Chronic: Asymptomatic, frequent bladder infections, frequent urination, persistent pain in the lower abdomen or back.

Objective Data:Acute: Prostate enlarged, acutely tender, and often asymmetric. May have urethral discharge and fever; bacteria in the urine. Chronic: Prostate boggy, enlarged, and tender or have palpable areas of fibrosis.

Benign prostatic hypertrophy

Subjective Data:Symptoms of urinary obstruction: hesitancy, decreased force and caliber of stream, dribbling, incomplete emptying of the bladder, frequency, urgency, nocturia, and dysuria.

Objective Data:Prostate smooth, rubbery, symmetric, and enlarged; median sulcus may or may not be obliterated.

Prostate Enlargement

Prostate enlargement is classified by the amount of protrusion into the rectum:

Grade I: 1 to 2 cm

Grade II: 2 to 3 cm

Grade III: 3 to 4 cm

Grade IV: More than 4 cm

Pediatric Variations

EXAMINATION

TECHNIQUE

FINDINGS

Examine the patency of the anus and its position in all newborn infants. To determine patency, insert a lubricated catheter no more than 1 cm into the rectum.

EXPECTED:Catheter inserts; patency confirmed by passage of meconium.

UNEXPECTED:Not able to insert catheter; no evidence of stool.

Inspect perianal area.

UNEXPECTED:Parental complaints of infant’s or child’s irritability at night or evidence that child has itching in perianal area may indicate presence of parasites such as roundworms or pinworms. Specimen collection and microscopic examination are necessary to confirm findings.

Shrunken buttocks suggest a chronic debilitating disease. Asymmetric creases occur with congenital dislocation of the hips. Perirectal redness and irritation are suggestive of pinworms, Candida, or other irritants of the diaper area. Rectal prolapse results from constipation, diarrhea, or sometimes severe coughing or straining. Hemorrhoids are rare

 

in children, and their presence suggests a serious underlying problem such as portal hypertension. Small, flat flaps of skin around the rectum (condylomas) may be syphilitic in origin. Sinuses, tufts of hair, and dimpling in the pilonidal area may indicate lower spinal deformities.

SAMPLE DOCUMENTATION

Subjective.A 57-year-old male complains of nighttime urination for the past several months, at least twice per night. Restricts fluid intake after 8 pm. Notices difficulty in starting stream. No pain or bleeding on urination. No change in caliber of stream. Denies change in bowel habits or stool characteristics. No history of prostatitis or enlarged prostate.

Objective.Perianal area intact without lesions or visible hemorrhoids. An external skin tag is visible in the 6 o’clock position. No fissures or fistulas. Sphincter tightens evenly. Prostate is symmetric, smooth, boggy, with 1-cm protrusion into rectum. Median sulcus present. Nontender, no nodules. Rectal walls free of masses. Moderate amount of soft brown stool present.