Chapter 15 (Anus, Rectum and Prostate)

Dawn is a 55-year-old woman who comes in today for her yearly wellness examination. You carefully perform the rectal examination in the lithotomy position and feel a mass against the bowel wall which is firm and immobile. Which of the following is most likely? A) Colon cancer B) Hemorrhoid C) Anal fissure D) Valve of Houston

Ans: A Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: This examination should make you think of colon cancer because the mass is firm, nonmobile, and nontender. Hemorrhoids are not firm and are frequently visible externally, although some may be internal as well. An anal fissure would be a palpable linear lesion in the anal canal that may be tender. Valves of Houston are sometimes palpable but are not firm.

An elderly woman with dementia is brought in by her daughter for a "rectal mass." On examination you notice a moist pink mass protruding from the anus, which is nontender. It is soft and does not have any associated bleeding. Which of the following is most likely? A) Rectal prolapse B) External hemorrhoid C) Perianal fistula D) Prolapsed internal hemorrhoid

Ans: A Chapter: 15 Page and Header: 568, Table 15-2 Feedback: Rectal prolapse is occasionally seen in chronic constipation. It represents actual rectal tissue which has protruded through the anus. In young children it is associated with cystic fibrosis as well as other conditions. An external hemorrhoid or a prolapsed internal hemorrhoid is not moist and does not have the same mucosa. A perianal fistula represents a connection from the bowel to the exterior apart from the anus and can be associated with inflammatory bowel disease, especially Crohn's disease.

. A 55-year-old retired property manager comes to your clinic, concerned that she may have a tumor in her rectum. When asked why, she states that after straining at a bowel movement she felt a mass around her rectum. She denies any blood in her stool, black stools, or pain with defecation. She admits to having had chronic constipation for 30 years. She often uses laxatives to be able to have a bowel movement. She denies any recent weight gain, weight loss, fever, or night sweats. Her past medical history consists of hypothyroidism, and she has had two spontaneous vaginal deliveries. Her mother died recently of colon cancer and her father has high blood pressure but is otherwise healthy. She denies any smoking and only occasionally drinks alcohol. On examination she seems nervous. Her blood pressure is 140/90 and her pulse is 100. Her cardiac, lung, and abdominal examinations are normal. On visualization of her anus, no inflammation, masses, or fissures are noted. When she is asked to bear down, you see a rosette of red mucosa prolapsing from the anus. On digital rectal examination there are no masses and no blood is found on the glove. What disorder of the anus or rectum is this likely to be? A) Prolapse of the rectum B) Internal hemorrhoids C) Anorectal cancer D) Prostate cancer

Ans: A Chapter: 15 Page and Header: 568, Table 15-2 Feedback: Unless someone is bearing down, such as during a bowel movement, the red mucosa is not seen. This is common when there is heavy straining during a bowel movement. This finding in a young child or infant may lead you to suspect cystic fibrosis.

A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for the last several months. He believes the problem is steadily getting worse. When asked he says he has a very weak stream and it feels like it takes 10 minutes to empty his bladder. He also has the urge to go to the bathroom more often than he used to. He denies any blood or sediment in his urine and any pain with urination. He has had no fever, weight gain, weight loss, or night sweats. His medical history includes type 2 diabetes and high blood pressure treated with medications. He does not smoke but drinks a six pack of beer weekly. He has been married for 35 years. His mother died of a myocardial infarction in her 70s and his father is currently in his 80s with high blood pressure and arthritis. On examination you see a mildly obese male who is alert and cooperative. His blood pressure is 130/70 with a heart rate of 80. He is afebrile and his cardiac, lung, and abdominal examinations are normal. On visualization of the anus you see no inflammation, masses, or fissures. Digital rectal examination reveals a smooth, enlarged prostate. No discrete masses are felt. There is no blood on the glove or on guaiac testing. An analysis of the urine shows no red blood cells, white blood cells, or bacteria. What disorder of the anus, rectum, or prostate is this most likely to be? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer

Ans: A Chapter: 15 Page and Header: 570, Table 15-3 Feedback: BPH becomes more prevalent during the fifth decade and is often associated with the urinary symptoms of hesitancy in starting a stream, decreased strength of stream, nocturia, and leaking of urine. On examination an enlarged, symmetric, firm prostate is palpated. The anterior lobe cannot be felt. These patients may also develop UTIs secondary to the obstruction.

A 42-year-old house painter comes to your clinic, complaining of pain with defecation and profuse bleeding in the toilet after a bowel movement. He was in his usual state of health until 2 weeks ago, when he was injured in a car accident. After the accident he began taking prescription narcotics for the pain in his shoulder. Since then he has had very few bowel movements. His stool is hard and pebble-like. He states he has always been "regular" in the past, with easy bowel movements. His diet has not changed but he states that he is exercising less since the accident. His past medical history includes hypertension and he is on a low-dose diuretic. He has had no other chronic illnesses or surgeries. He has a family history of hypertension, coronary heart disease, and diabetes but no cancer. He is divorced and has three children. He smokes two packs of cigarettes per day and quit drinking more than 10 years ago. He has had no recent weight loss, weight gain, fever, or night sweats. On examination he appears muscular and healthy; he is afebrile. His blood pressure is 135/90 with a pulse of 80. His cardiac, lung, and abdominal examinations are normal. He is wearing a sling on his left arm. On observation of his anus you find a swollen bluish ovoid mass that appears to contain a blood clot. Digital rectal examination is extremely painful for the patient. No other mass is palpated within the anus or rectum. What disorder of the anus is this patient likely to have? A) Anal fissure B) External hemorrhoid C) Anorectal cancer D) Internal hemorrhoid

Ans: B Chapter: 15 Page and Header: 568, Table 15-2 Feedback: A swollen, bluish ovoid mass is most likely a thrombosed external hemorrhoid. These can cause brisk bleeding with defecation. Hemorrhoids are often caused by low-fiber diets, dehydration, lack of exercise, and anything that causes constipation leading to increased straining with defecation. Narcotics can cause severe constipation, leading to this disorder.

A 24-year-old graduate student comes to your clinic, complaining of burning during urination and increased urinary frequency. He has had a low-grade fever (100.5 degrees) and does not feel very well. He is very worried about sexually transmitted diseases because he had a drunken encounter 2 weeks ago and did not use a condom. He has had no recent weight loss, weight gain, or night sweats. His past medical history includes knee surgery in high school and genital warts in college. He does not smoke but drinks six beers every Friday and Saturday night. He denies using any IV drugs but has tried marijuana in the past. His father has high cholesterol but his mother is healthy. On examination he appears tired. His temperature is 99.5 degrees and his blood pressure is 110/70. His abdominal examination is normal. Visualization of the anus shows no masses, inflammation, or fissures. Digital rectal examination reveals a warm, boggy, tender prostate. No discrete masses are felt and there is no blood on the glove. The scrotum and penis appear normal. Urinalysis shows moderate amounts of white blood cells and bacteria. What disorder of the anus, prostate, or rectum best describes this situation? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Epididymitis

Ans: B Chapter: 15 Page and Header: 570, Table 15-3 Feedback: Prostatitis generally causes increased frequency of urination, pain with urination, and lower back pain. On digital rectal examination a warm, tender, boggy prostate will be palpated. In young men the etiology is often a sexually transmitted disease such as chlamydia or gonorrhea. This man's substance abuse problem should also be discussed with him, and you should consider further questions and screening for HIV.

Which is true of the pectinate or dentate line? A) It is a palpable landmark. B) It demarcates the areas supplied by the central nervous system from the peripheral nervous system. C) It is the border between the anal canal and the rectum. D) It is not visible on proctoscopic examination.

Ans: C Chapter: 15 Page and Header: 555, Anatomy and Physiology Feedback: The pectinate or dentate line marks the division between the anal canal and rectum. It is not palpable but is visible on proctoscopy. It also marks the areas supplied by the visceral and peripheral nervous systems.

. A 56-year-old homosexual man presents with itching, anorectal pain, and tenesmus of 1 week's duration. Rectal examination reveals generalized tenderness without frank prostate abnormalities. Which of the following is most likely? A) Acute prostatitis B) External hemorrhoid C) Proctitis D) Colon cancer

Ans: C Chapter: 15 Page and Header: 557, The Health History Feedback: The combination of itching, anorectal pain, and tenesmus in a homosexual man should make one consider proctitis. This may be caused by a sexually transmitted infection such as gonorrhea, chlamydia, or lymphogranuloma venereum. A careful history should be taken, and counseling regarding protection from these diseases should be offered. While pain and itching are associated with hemorrhoids, the internal tenderness on examination makes this less likely than proctitis in this patient. Acute prostatitis does not usually cause itching and is usually associated with examination findings. Most colon cancers do not cause any symptoms, which is why screening for asymptomatic disease is so important.

A 36-year-old married bank teller comes to your office, complaining of pain with defecation and occasional blood on the toilet paper. She states that last week she had food poisoning with nausea, vomiting, and diarrhea. She had runny stools but no black or bloody stools. Ever since her illness, she has continued to have severe pain with bowel movements. She now tries to put off defecation as long as possible. Although she is having constipation she denies any further diarrhea or leakage of stool. She has a past medical history of hypothyroidism and two spontaneous vaginal deliveries. She has had no other chronic illnesses or surgeries. She does not smoke and rarely drinks. She has two children. There is no family history of breast or colon cancer. She has had no weight gain, weight loss, fever, or night sweats. On examination she is afebrile, with a blood pressure of 115/70 and a pulse of 80. On abdominal examination she has active bowel sounds, is nontender in all quadrants, and has no hepatosplenomegaly. Inspection of the anus reveals inflammation on the posterior side with erythema. Digital rectal examination is painful for the patient but no abnormalities are palpated. Anoscopic examination reveals no inflammation or bleeding. What is the anal disorder that best describes her symptoms? A) Anorectal fistula B) External hemorrhoids C) Anal fissure D) Anorectal cancer

Ans: C Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: Anal fissures often occur after severe diarrhea or constipation. They cause bright blood on the toilet paper and are extremely painful during defecation. A small ulceration or fissure is observed proximal to the anus.

A 22-year-old nurse comes to your clinic, complaining of severe constipation and pain during defecation. She has also seen blood on the toilet paper. She states that she eats a healthy diet and does some light exercising. She is currently at the beginning of her third trimester of an unremarkable pregnancy. Her past medical history is unremarkable. Her mother has high cholesterol but her father is in good health. She does not smoke, drink alcohol, or use illegal drugs. She is married and expecting her first child. On examination she appears healthy and is afebrile, with a blood pressure of 110/60. Her abdominal examination reveals a gravid uterus but is otherwise unremarkable. On visualization of the anus there is a slight red, moist-appearing protrusion from the anus. As you have her bear down, the protrusion grows larger. On digital rectal examination you can feel an enlarged tender area on the posterior side. There is some blood on the glove after the examination. What disorder of the anus or rectum best fits this presentation? A) Anal fissure B) External hemorrhoids C) Internal hemorrhoids D) Anorectal fistula

Ans: C Chapter: 15 Page and Header: 568, Table 15-2 Feedback: Internal hemorrhoids are common during pregnancy. A red, swollen, moist mass is seen prolapsing through the anus, which worsens with bearing down. These are not usually palpable on rectal examination if not prolapsed.

A 45-year-old African-American minister comes to your clinic for a general physical examination. He has not been feeling very well for about 3 months, including night sweats and a chronic low-grade fever of 100 to 101 degrees. He denies any upper respiratory symptoms, chest pain, nausea, constipation, diarrhea, blood in his stool, or urinary tract symptoms. He has had some lower back pain. He has a past history of difficult-to-control high blood pressure and high cholesterol. He has had no surgeries in the past. His mother has diabetes and high blood pressure. He knows very little about his father because his parents divorced when he was young. He knows his father died in his 50s, but he is unsure of the exact cause. The patient denies smoking, drinking, or drug use. He is married and has three children. On examination he appears his stated age and is generally fit. His temperature is 99.9 degrees and his blood pressure is 160/90. His head, ears, nose, throat, and neck examinations are normal. His cardiac, lung, and abdominal examinations are also normal. On visualization of the anus there is no inflammation, masses, or fissures. Digital rectal examination elicits an irregular, asymmetric, hard nodule on the otherwise normal posterior surface of the prostate. Examination of the scrotum and penis are normal. Laboratory results are pending. What disorder of the anus, rectum, or prostate is mostly likely in this case? A) Benign prostatic hyperplasia (BPH) B) Prostatitis C) Prostate cancer D) Anorectal cancer

Ans: C Chapter: 15 Page and Header: 570, Table 15-3 Feedback: Prostate cancer often presents with few symptoms and can sometimes be found on routine digital rectal examination. It is more common at a younger age in African-American men, and PSA screening, if indicated, begins at age 40, ten years earlier than in other races. Palpation on digital rectal examination can reveal a hard, irregular, asymmetric nodule, but can also reveal an asymmetry in texture between the two lobes.

Mr. Jackson is a 50-year-old African-American who has had discomfort between his scrotum and anus. He also has had some fevers and dysuria. Your rectal examination is halted by tenderness anteriorly, but no frank mass is palpable. What is your most likely diagnosis? A) Prostate cancer B) Colon cancer C) Prostatitis D) Colonic polyp

Ans: C Chapter: 15 Page and Header: 570, Table 15-3 Feedback: The above examination, associated with a history of dysuria, frequency, and incomplete voiding, should lead you to suspect acute prostatitis. Prostate cancer, colon cancer, and polyps should not ordinarily cause systemic symptoms such as fever.

Which is a sign of benign prostatic hyperplasia? A) Weight loss B) Bone pain C) Fever D) Nocturia

Ans: D Chapter: 15 Page and Header: 557, The Health History Feedback: Benign prostatic hyperplasia (BPH) is usually not associated with systemic symptoms such as weight loss or fever. Bone pain is associated with prostate cancer, which often metastasizes to the lower axial skeleton. Nocturia, sensation of incomplete voiding, weak stream, and difficulty initiating urination are also common symptoms of prostate cancer.

. Which is true of prostate cancer? A) It is commonly lethal. B) It is one of the less common forms of cancer. C) Family history does not appear to be a risk factor. D) Ethnicity is a risk factor.

Ans: D Chapter: 15 Page and Header: 558, Health Promotion and Counseling Feedback: Although prostate cancer is the most commonly diagnosed cancer in men, biologic risk and mortality are only 3%. Lung and colon cancers are more common causes of mortality. Genetics appear to account for 42% of cases in one study. The rate of prostate cancer is almost double in African-American men, which is one of the reasons to begin screening at 40 years of age rather than the standard recommendation of 50.

Important techniques in performing the rectal examination include which of the following? A) Lubrication B) Waiting for the sphincter to relax C) Explaining what the patient should expect with each step before it occurs D) All of the above

Ans: D Chapter: 15 Page and Header: 561, Techniques of Examination Feedback: Lubricating the entire finger (yet removing excess lubricant), being patient while the anal sphincter relaxes, and preparing the patient for each step are key parts of a good rectal examination. The examination itself, while it may be awkward for a patient, should never cause pain in a normal person.

A 26-year-old woman comes to your clinic, complaining of leakage of stool despite generally normal, pain-free bowel movements. She denies any blood in her stool or on the toilet paper. She has had no recent episodes of diarrhea. Her past medical history includes a spontaneous vaginal delivery 3 months ago. She had a fourth-degree tear of the perineal area (from the vagina through the rectum) that was surgically repaired after delivery. A few days later the patient developed an abscess in the anal area that had to be incised and drained. She denies using any tobacco, alcohol, or illegal drugs. Her mother and father are both in good health. She denies any weight gain, weight loss, fever, or night sweats. She is still breast-feeding without any problems. On examination you visualize a small opening anterior to the anus with some surrounding erythema. There is not a mass or other inflammation on inspection. Digital rectal examination reveals smooth rectal walls with no blood. She has no pain during the rectal examination. Bimanual vaginal examination is also normal. What anal or rectal disorder is the most likely cause of her symptom? A) Anal fissure B) External hemorrhoids C) Internal hemorrhoids D) Anorectal fistula

Ans: D Chapter: 15 Page and Header: 568, Table 15-2 Feedback: Anorectal fistula can commonly cause a leakage of stool, even when the patient is not having a bowel movement. They are common after infections, especially after trauma to the anal musculature (such as in a fourth-degree perineal tear). With more chronic gastrointestinal symptoms, this finding may lead you to suspect Crohn's disease.

. A 50-year-old truck driver comes to your clinic for a work physical. He has had no upper respiratory, cardiac, pulmonary, gastrointestinal, urinary, or musculoskeletal system complaints. His past medical history is significant for mild arthritis and prior knee surgery in college. He is married and just changed jobs, working for a different trucking company. He smokes one pack of cigarettes a day, drinks less than six beers a week, and denies using any illegal drugs. His mother has high blood pressure and arthritis and his father died of lung cancer in his 60s. On examination, his blood pressure is 130/80 and his pulse is 80. His cardiac, lung, and abdominal examinations are normal. He has no inguinal hernia, but on his digital rectal examination you palpate a soft, smooth, nontender pedunculated mass on the posterior wall of the rectum. What anal, rectal, or prostate disorder best fits his presentation? A) Internal hemorrhoid B) Prostate cancer C) Anorectal cancer D) Rectal polyp

Ans: D Chapter: 15 Page and Header: 568, Table 15-2 Feedback: Polyps are generally symptom-free and can be found on routine rectal examinations. Proctoscopy with biopsy is necessary to see if the polyp has any potential to become cancerous. Anyone with a rectal polyp needs a colonoscopy.

A 75-year-old retired construction worker comes to your clinic, complaining of bright red blood in the toilet for the last several months. He has no pain with defecation but has occasional constipation. He states he eats a healthy diet with fruits and vegetables and walks 2 miles a day. He has had a 10-pound weight loss over the last 3 months. He denies fever or night sweats. His medical history includes high blood pressure, coronary artery disease, and arthritis. He has also had an appendectomy. He smoked for 40 years, two packs a day, but quit 15 years ago. He used to drink alcohol but doesn't now. His father died in his 60s of a heart attack and his mother had breast cancer in her 70s. On examination he appears his stated age and sits comfortably on the examining table. His blood pressure is 150/85 and his pulse is 88. He is afebrile. His cardiac, lung, and abdominal examinations are normal. Visualization of the anus shows no erythema, masses, or inflammation. Digital rectal examination elicits an irregular, firm mass on the posterior side of the rectum. After you remove your finger you notice frank blood on your glove. What anal or rectal disorder is this patient most likely to have? A) Anal fissure B) Internal hemorrhoid C) Prostate cancer D) Anorectal cancer

Ans: D Chapter: 15 Page and Header: 568, Table 15-2 Feedback: This patient has the common symptom of bright red blood in the toilet over time. He also has had weight loss and has an irregular hard mass in the rectum. It is not uncommon for these masses to be friable (bleed easily), even with gentle manipulation.