Assess: Anus, Rectum, Prostate

Technique for anorectal exam: Inspection of the perianal area *abnormal findings*

*Abnormal findings*: Lesions may indicate STI's, cancer or hemorrhoids. A thrombosed external hemorrhoid appears swollen. It is itchy, painful and bleeds when client passes stool. A previously thrombosed hemorrhoid appears as a skin tag that protrudes from the anus. A painful mass that is hardened and reddened suggests a perianal abscess. A swollen skin tag on the anal margin may indicate a fissure in the anal canal. Redness and excoriation may be from scratching an area infected fungi or pinworms. A small opening in the skin that surrounds the anal opening may be an anorectal fistula. Thickening of the epithelium suggests repeated trauma from anal intercourse.

2. Examine the questions and answers in the Subjective nursing history section. What questions might you add, and why? (lecture slides)

*Bowel patterns*: again, we compare with the client's normal; changes in bowel patterns is one of the warning signs of cancer - evaluate further Constipation or diarrhea - dietary counseling, obstruction, impaction, medications, dehydration, infection Fecal incontinence - GI infection, neurologic disorders *Stool*: iron, pepto bismol - black stool also bleeding; bleeding may indicate ulcers, cancer, hemmorhoids; clay colored stool - liver disease Mucus stool: steatorrhea (too much fat in the stool) *Itching/pain*: hemmorhoids, cancer, trauma, STDs, pinworms, Surgeries: helpful to know in doing a thorough assessment; may affect changes in the anatomy Occult blood: once a year starting at 50 - detects polyps and colorectal cancer - really improves survival rates - red meat within 3 days of test as well as too much vitamin C, and large quantities of fresh fruits and vegetables can all cause a false positive Colonoscopy: start at 50 and then every 3 to 5 years DRE: masses, prostate enlargement, prostate nodules - start at 40 and then every year PSA: biologic marker for prostate cancer - every year starting at 50 (has been found recently to be less effective than originally thought) Use of laxatives and stool softeners can really mess the body up. They may cause chronic constipation or diarrhea Anal sex - can cause trauma to the anus and increases risk for HIV and StDs Prostate medication: usually because of voiding problems High fiber diet is good to keep colorectal cancer away High fat diet is a controversial risk factor for colorectal cancer Exercise: reduces risk for colorectal cancer HRT: reduced risk for colorectal cancer Usual bowel routine Dyschezia = pain during a bowel movement Change in bowel habits Rectal bleeding or blood in stool Black stools = GI bleed Clay color = absent bile pigment Steatorrhea = excessive fat in stool Medications (laxatives, stool softeners, iron) Rectal conditions (pruritis, hemorrhoids, fissure, fistula) Family history Risk factors: colon cancer, rectal cancer, prostate cancer Self-care behaviors (diet of high-fiber foods, most recent examinations) High-fiber foods = beans, prunes, barley, carrots, broccoli, cabbage (from lecture slides)

Discuss the collection of stool specimens:

*Bright red* = possible colonic bleeding *Black stool* = ingestion of iron or bismuth preps, or GI bleed *Gray*, *tan*, or *clay colored* stool = absent bile pigment; obstructive jaundice *Pale yellow*, *greasy stool* = increased fat content (steatorrhea); malabsorption syndrome *Occult* - not visible - testing?? Once a year starting at 50. Detects polyps and colorectal cancer, really improves survival rates. red meat within 3 days of test as well as too much vitamin C, large quantities of fresh fruits and vegetables can all cause a false positive.

Technique for anorectal exam: Inspection of the perianal area *normal findings*

*Normal findings*: the anal opening should appear hairless, moist and tightly closed. The skin around the anal opening is more coarse and more darkly pigmented. The surrounding perianal area should be free of redness, lumps, ulcers, lesions, and rashes.

fistula

A fistula is an abnormal connection between an organ, vessel, or intestine and another structure. Fistulas are usually the result of injury or surgery. It can also result from infection or inflammation. Inflammatory bowel disease, such as ulcerative colitis or Crohn's disease, is an example of a disease that leads to fistulas between one loop of intestine and another. Injury can lead to fistulas between arteries and veins source: http://www.nlm.nih.gov/medlineplus/ency/article/002365.htm

Describe the technique for prostate examination: abnormal findings

A swollen, tender prostate may indicate acute prostatitis. An enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests benign prostatic hypertrophy (BPH). A hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest cancer.

What are signs and symptoms of prostate cancer?

A weak or slow urinary stream A feeling of incomplete bladder emptying Difficulty starting urination Frequent urination Urgency to urinate Getting up frequently at night to urinate A urinary stream that starts and stops Straining to urinate Continued dribbling of urine Returning to urinate again minutes after finishing (http://www.webmd.com/men/prostate-enlargement-bph/features/enlarged-prostate-bph-complex-problem)

What are the risk factors for prostate cancer?

African-American Older than 60 Having a father or brother with prostate cancer Exposure to Agent Orange Excessive alcohol consumption Working on a farm, in a tire plant, with paint, with cadmium Diet high in fat, especially in animal fat. Note that prostate cancer is less common in people who do not eat meat (vegetarians)

perianal abscess

An anal abscess is a painful condition in which a collection of pus develops near the anus. Most anal abscesses are a result of infection from small anal glands. The most common type of abscess is a perianal abscess. This often appears as a painful boil-like swelling near the anus. It may be red in color and warm to the touch. Anal abscesses located in deeper tissue are less common and may be less visible

Anus and Rectum structure and function (lecture slides)

Anal canal -Outlet of the GI tract Sphincters -Muscles around anal canal Anal columns -Folds of mucosa Anorectal junction -Not palpable, visible on proctoscopy Anal valve Anal crypt Rectum -12 cm long -Distal portion of the large intestine Valves of Houston -Hold feces as flatus passes

Technique for anorectal exam: Inspection of the perianal area (perform *Valsalva's maneuver*)

Ask the client to perform Valsalva's maneuver by straining or bearing down. Inspect the anal opening for any bulldogs or lesions.

Technique for palpating the *anus* continued... pg 600

Ask the client to tighten the external sphincter; note the tone. Rotate finger to examine the muscular anal ring. Palpate for tenderness, nodules, and hardness.

benign prostatic hyperplasia/hypertrophy

Benign prostatic hyperplasia (BPH), also called benign enlargement of the prostate (BEP), adenofibromyomatous hyperplasia and benign prostatic hypertrophy (technically incorrect usage), is a benign increase in size of the prostate. source: http://en.wikipedia.org/wiki/Benign_prostatic_hyperplasia

Technique for anorectal exam: Inspection of the perianal area (perform *Valsalva's maneuver*) *abnormal findings*

Bulges of red mucous membrane may indicate a rectal prolapse. Hemorrhoids or an anal fissure may also be seen.

Technique for palpating the *anus* normal findings

Client's sphincter relaxes, permitting entry Examination finger enters anus

pilonidal cyst

Hair-containing cyst located in the midline over the coccyx or lower sacrum (from lecture slides)

Technique for palpating the *anus*

In from the client that you are going to perform the internal examination at this point. Explain that it may feel like his bowels are going to move but that this will not happen. Lubricate your gloved index finger; ask client the client to bear down. As the client bears down, place the pad of your index finger on the anal opening and apply slight pressure; this will cause relaxation of the sphincter. *Never use your finger tip*- this causes the sphincter to tighten and if forced in to the rectum, may cause pain. When you feel the sphincter relax, insert your finger gently with the pad facing down. *If severe pain prevents your entrance to the anus*, do not force the examination. If the sphincter does not relax and the client reports severe pain, spread the gluteal folds with your hands in close approximation to the anus and attempt to visualize a lesion that may be causing the pain. If tension is maintained on the gluteal folds for 60 seconds, the anus will dilate normally.

Structure and function of Prostate gland (lecture slides)

In front of the anterior wall of the rectum Elastic and rubbery consistency; 2 lobes, separated by groove 2 cm behind the symphysis pubis Secretes a thin, milky fluid that helps sperm viability and motility; neutralizes acidic female vaginal secretions

Technique for anorectal exam: inspect the sacrococcygeal area

Inspect this area for any signs of swelling, redness, dimpling or hair. *Normal findings*: area is normally smooth, and free of redness and hair. *Abnormal findings*: A reddened, swollen, or dimpled area covered by a small tuft of hair located midline on the lower sacrum suggests a pilonindal cyst. pg 599

Structure and Function of Seminal Vesicles

Located on either side of the prostate gland. Secrete a fluid that is rich in fructose; nourishes the sperm and contains prostaglandins, normally not palpable

Technique for anorectal exam: Inspection of the perianal area (perform *Valsalva's maneuver*) *normal findings*

No bulging or lesions appear

fissure

Painful tear in mucosa at anal margin Occurs from passing large, hard stool or diarrheal stools (from lecture slides)

What are the risk factors for colorectal cancer?

Personal history of polyps or cancer Inflammatory bowel diseases Genetics Ashkenazi Jewish descent High fat/protein diet Physical inactivity Obesity Alcohol (mod. to heavy) (from lecture slides)

Technique for palpating the *anus* continued... pg 600 *abnormal findings*

Poor sphincter tone may be the result of a spinal cord injury, previous injury, trauma, or prolapsed rectum. Tightened sphincter tone may indicate anxiety, scarring, or inflammation. Tenderness may indicate hemorrhoids, fistula or fissure. Nodules may indicate polyps or cancer. Hardness may indicate scarring or cancer. Hardness or irregularities may be from scarring or cancer. Nodules may indicate polyps or cancer.

prolapse

Rectal prolapse is a condition in which the rectum (the lower end of the colon, located just above the anus) becomes stretched out and protrudes out of the anus. Weakness of the anal sphincter muscle is often associated with rectal prolapse at this stage, resulting in leakage of stool or mucus. While the condition occurs in both sexes, it is much more common in women than men. source: http://www.fascrs.org/patients/conditions/rectal_prolapse/ Rectal: Rectal mucous membrane protrudes through the anus (from lecture slides)

polyps

Rectal: Protruding growth from the rectal mucous membrane Colon polyps are growths on the inner lining of the colon and are very common. Colon polyps are important because they may be, or may become malignant (cancerous). They also are important because based on their size, number, and histology, they can predict which patients are more likely to develop further polyps and colon cancer. source: http://www.medicinenet.com/colon_polyps/article.htm

Risk reduction for Colorectal cancer

Risk reduction Occult blood test yearly Endoscopy Screening High fiber, fruits, and veggies diet Low fat and animal protein Raisins/grapes every day Regular exercise HRT for post menopause Know the symptoms of colorectal cancer

Structure and Function of Bulbourethral glands

Size of a pea Located inferior to the prostate on either side of the urethra Secrete a clear, viscid mucus

Technique for palpating the *anus* abnormal findings

Sphincter tightens, making further examination unrealistic. Examination finger cannot enter the anus. pg 599

Technique for anorectal exam: Inspection of the perianal area

Spread the client's buttocks and inspect the anal opening and surrounding area for the following: lumps ulcers lesions rashes redness fissures thickening of the epithelium

Technique for palpating the *anus* continued... pg 600 *normal findings*

The client can normally close the sphincter around the gloved finger. The anus is normally smooth, nontender, and free nodules and hardness. The rectal mucosa is normally soft, smooth, nontender, and free of nodules.

Describe the technique for prostate examination

The prostate can be palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so that the pad of your index finger faces toward the client's umbilicus. You may need to move your body away from the client to achieve the proper angle for examination. Tell the client that he may feel an urge to urinate but that he will not. Move the pad of your index finger over the prostate gland, trying to feel the sulcus between the lateral lobes. Note the size, shape and consistency of the prostate, and identify any nodules or tenderness.

Describe the technique for prostate examination: normal findings

The prostate is normally nontender and rubbery. It has two lateral lobes that are divided by a median sulcus. The lobes are normally smooth, 2.5 cm long, and heart-shaped.

Technique for palpating the *anus* Palpate the peritoneal cavity

This area may be palpated in men above the prostate gland in the area of the seminal vesicles on the anterior surface of the rectum. Note tenderness or nodules. *Normal findings*: the area is normally smooth and nontender. *Abnormal findings*: A peritoneal protrusion into the rectum, called a real shelf may indicate a cancerous lesion or peritoneal metastasis. Tenderness may indicate peritoneal inflammation.

What is a side effect of anal or rectal exam for which you must be especially watchful?

Valsalva maneuver - carefully with cardiac patients! This can stimulate the vagus nerve, causing heart to slow down.

What are signs and symptoms of colorectal cancer?

Warning signs: change in bowel habits (diarrhea, constipation, narrowing of stool, lasting more than a few days); blood in the stool, cramping or steady abdominal pain, weakness and fatigue; loss of appetite; jaundice (lecture slides)

Internal hemorrhoids

lie far enough inside the rectum that you can't see or feel them. They don't usually hurt because there are few pain-sensing nerves in the rectum. Bleeding may be the only sign that they are there. Sometimes internal hemorrhoids prolapse, or enlarge and protrude outside the anal sphincter. When this happens, you may be able to see or feel them as moist, pink pads of skin that are pinker than the surrounding area. Prolapsed hemorrhoids may hurt because the anus is dense with pain-sensing nerves. They usually recede into the rectum on their own; if they don't, they can be gently pushed back into place.

External hemorrhoids

lie within the anus and are usually painful. If an external hemorrhoid prolapses to the outside (usually in the course of passing stool), you can see and feel it. Blood clots sometimes form within prolapsed external hemorrhoids, causing an extremely painful condition called a thrombosis. If an external hemorrhoid becomes thrombosed, it can look rather frightening, turning purple or blue, and could possibly bleed. Despite their appearance, thrombosed hemorrhoids are usually not serious but can be painful. They will resolve themselves in a couple of weeks. If the pain is unbearable, your health care provider can remove the thrombosed hemorrhoid, which stops the pain. Anal bleeding and pain of any sort should be evaluated by a qualified health care provider; it can indicate a life-threatening condition, such as colorectal cancer. However, hemorrhoids are the No. 1 cause of anal bleeding and are rarely dangerous, but a definite diagnosis from your health care provider is important source: http://www.webmd.com/a-to-z-guides/understanding-hemorrhoids-basics

Document any abnormalities by

noting position in relation to a face of a clock

prostatitis

often described as an infection of the prostate. It can also be an inflammation with no sign of infection. Just 5% to 10% of cases are caused by bacterial infection. It does not raise the risk of getting prostate cancer.

2. Examine the questions and answers in the Subjective nursing history section. What questions might you add, and why? (from book)

pg 586-589

What would you teach your client about screenings for colorectal cancer?

pg 591 client education

What would you teach your client about screenings for prostate cancer?

pg 591 table 26-2 the benefits do not outweigh the risks when routine screening is done for prostate cancer. There, the current recommendation is AGAINST routine screening with PSA test for men that do not have symptoms that are highly suspicious for prostate cancer, regardless of age, race or family history.

hemorrhoid (internal, external)

swollen blood vessels of the rectum. The hemorrhoidal veins are located in the lowest area of the rectum and the anus. Sometimes they swell so that the vein walls become stretched, thin, and irritated by passing bowel movements. Hemorrhoids are classified into two general categories: internal and external. Painless, flabby papules Can be internal or external Result from increased pressure; straining to stool Cause pain with bowel movements (from lecture slides)

Anus and Rectum structure and function (book)

the anal canal is the final segment of the digestive system. It begins at the anal sphincter and ends at the anorectal junction. It is lined with skin that contains no hair or sebaceous glasses, but does contain many somatic sensory nerves, making it susceptible to painful stimuli. The anal opening can be destined from the perianal skin by it's hairless, moist appearance. The anal verge (opening) extends interiorly, overlying the external anal sphincter. Within the anus are two sphincters that normally hold the anal canal closed except when passing gas and feces. The external sphincter is composed of skeletal muscle and is under voluntary control. The internal sphincter is composed of smooth muscle and is under involuntary control by the autonomic nervous system. Dividing the two sphincters is the palpable intersphincteric groove. The anal canal proceeds upward toward the umbilicus. Just above the internal sphincter is the anorectal junction, the dividing point of the anal canal and the rectum. The recut is lined with folds of mucosa. The rectum is the lowest portion of the large intestine and is approx 12 cm long, extending from the end of the sigmoid colon to the anorectal junction. pg 584

Structure and function of Prostate gland (book)

the gland surrounds the neck of the bladder and urethra. This chestnut or heart shaped organ can be palpated through the anterior wall of the rectum. Located on either side of the gland are the seminal vesicles.

The most frequently used position for inspection and palpation of the anus, rectum and prostate is

the left lateral position. This position allows adequate inspections and palpation and is usually more comfortable for the client. However, some examiners find it easiest to perform the male anus, rectum and prostate examination while client stands and bends over the examining table with his hips flexed. pg 592

Palpating the prostate gland prior to drawing to PSA (prostate-specific antigen)

will raise PSA level.