assessment of the anus and rectum including the prostate.

1. Assessment of Anus
and Rectum
Maria Carmela L. Domocmat, RN, MSN
Instructor, Nursing Health Assessment
School of Nursing
Northern Luzon Adventist College

2. Objectives:
At the end of the lecture the student will be able
to:
Specify the important anatomy and physiology
of the anus, rectum, and prostate.
Enumerate at least three interview
topics/questions.
Identify normal assessment findings in the
anus, rectum, and prostate.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 2

3. ANUS AND RECTUM
Anatomy and Physiology
Techniques of Examination
Related Abnormalities

4. Anatomy and
Physiology
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 4

5. Female
Male
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 5

6. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 6

7. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 7

8. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 8

9. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 9

10. Collecting
Subjective Data
History of present health concern
Past Health History
Family History
Lifestyle and Health Practices

11. Collecting Subjective Data
Provide clues to client’s overall health
and whether he is at risk for diseases
and disorders of the anus, rectum, or
prostate.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 11

12. Collecting Subjective Data
A good time to teach client about the risk
factors related to diseases, such as
colorectal or prostate cancer, and about
ways to decrease those risks.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 12

13. Collecting Subjective Data
Note:
Can be embarrassing to both the examiner
and the client. It is important to ease the
client’s anxiety as much as possible
Ask questions in straightforward manner,
and let the client voice any concerns
throughout assessment. RN, MSN
6/26/2011 Maria Carmela L. Domocmat, 13

14. Collecting Subjective Data
Note:
In some cultural groups, only nurses of the
same gender will be considered acceptable
assessors of intimate bodies.
Client’s comfort and privacy
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 14

15. History of present health
concern
COLDSPA
Bowel patterns:
What is your usual bowel pattern?
Have you noticed any recent change in the
pattern?
Any pain while passing a bowel movement?
Do you experience Domocmat, RN, MSN
6/26/2011 Maria Carmela L. constipation? 15

16. History of present health
concern
Do you experience constipation?
Do you experience diarrhea? Is the diarrhea
associated with any nausea and vomiting?
Do you have trouble controlling your
bowels?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 16

17. History of present health
concern
Stool
What is the color of your stool? Hard or soft?
Have you noticed any blood on or in your
stool? If so, how much?
Have you noticed any mucus in your stool?
Itching and Pain
Do you experience any itching or pain in the
rectal area?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 17

18. History of present health
concern
Pattern of urination
Do you have any difficulty starting the urine
stream? Or holding back urine? Is the flow
weak? What about frequent urination,
especially at night? Or pain or burning as
you pass out urine?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 18

19. History of present health
concern
Pattern of urination
Do you notice blood in your urine or semen
or pain with ejaculation? Is there frequent
pain or stiffness in the lower back, hips, or
upper thighs?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 19

20. Past Health History
Have you ever had anal or rectal trauma
or surgery? Were you born with any
congenital deformities of the anus or
rectum? Have you had prostate surgery?
Have you had hemorrhoids or surgery for
hemorrhoids?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 20

21. Past Health History
When was the last time you had a stool
test to detect blood?
Have you ever had
proctosigmoidoscopy?
When was the last time you had DRE by
a physician?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 21

22. Past Health History
Have you ever had blood taken for a
prostate screening, which measures the
level of prostate-specific antigen (PSA) in
prostate-
your blood? When was the test and what
was the result?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 22

23. Family History
Is there a history of polyps, colon, or
rectal cancer, or prostate cancer in your
family?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 23

24. Lifestyle and Health
Practices
Do you use any laxatives, stool
softeners, enemas, or other bowel
movement-
movement-enhancing medications?
Do you engage in anal sex?
Do you take any medications for your
prostate?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 24

25. Lifestyle and Health
Practices
How much high-fiber food and roughage
high-
do you consume everyday? Do you eat
foods high in saturated fat?
Do you engage in regular exercise?
Do you use calcium supplements?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 25

26. Lifestyle and Health
Practices
For postmenopausal women: do you use
hormone replacement therapy?
Has any anal or rectal problem affected
your normal activities of daily living
(working and engaging in recreation)?
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 26

27. Important topics for health
promotion and counseling
Screening for prostate cancer
Screening for polyps and colorectal
cancer
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 27

28. Collecting Objective
Data: Techniques of
Examination

29. Preparing the client
Client positioning
Standing
Knee-
Knee-chest
Squatting
Left lateral
Lithotomy
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 29

30. Techniques of
Examination
Inspection of Perineum and
Sacrococcygeal Area

31. Positions for
Rectal
Examination
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 31

32. Equipments needed
Gloves
Lubricant
Guaiac Testing Equipment
Tissue
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 32

33. Inspection of Perineum and
Sacrococcygeal Area
Inspect the buttocks and sacral region for
lesions, swelling, inflammation, and
tenderness.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 33

34. Male
Female
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 34

35. Normal Findings
Area should be smooth and free of
lesions, swelling, inflammation, and
tenderness.
There should be no evidence of feces or
mucus on the perianal skin.
No additional opening
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 35

36. Palpation of Coccygeal
Area
Palpate the coccygeal area
Normal Finding
No tenderness
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 36

37. Pilonidal Sinus
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 37

38. Inspection of Anal Mucosa
Spread the buttocks apart
with both hands, exposing
the anus.
Examine the anus for
color, appearance,
lesions, inflammation,
rash, and masses.
Instruct the client to bear down as though
moving the bowels (Valsalva maneuver)
(Valsalva
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 38
Watch video

39. Normal Findings
Deeply pigmented,
coarse, moist, and
hairless.
Free of lesions,
inflammation, rash,
masses and additional
openings. The anal
opening should be
closed.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 39

40. Normal Findings
There should not be
any tissue protrusion
No leakage of feces
or mucus from the
anus while straining
No tissue perfusion
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 40

41. Let’s Watch:
Examining the Anus
and Anal Sphincter

42. Abnormal Findings
Imperforate Anus Hemorrhoid
Skin Tag Venereal Warts
Anorectal Fistula Herpes
Anal Fissure Gonococcal Proctitis
Rectal Prolapse Carcinoma

43. Imperforate Skin Tag
anus
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 43

44. Fistula-in-
Fistula-in- Anorectal
ano fistula
Fistula-In-Ano: External opening of fistulus tract
is apparent in photo above. Proximal opening This patient presented with "just a little blood when I wipe."
would be at level of crypts, within the anal canal. When anoscopy revealed no anal pathology, closer inspection
Maria Carmela L. Domocmat, RN, MSNidentify this papular area. The wooden
Fistulas are frequently associated with perirectal
6/26/2011 allowed the physician to 44
abscesses, though none are present in this case. end of a cotton-tipped applicator was inserted 3 cm confirming a
fistula, and the patient was referred for surgery.

45. Anal Fissure Rectal Prolapse
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 45

46. External
hemorrhoid
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 46

47. Prolapsed Internal Thrombosed
Hemorrhoid External
Hemorrhoid
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 47

48. Condylomata Perianal
acuminatum herpes
(Venereal warts)
Rectal HSV infection with
perianal ulcers
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 48

49. Gonococcal proctitis
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 49

50. Anal Carcinoma
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 50

51. Palpation of Anus and
Rectum

52. Palpation of Anus and
Rectum
Reassure the client
that sensations of
urination and
defecation are
common during the
rectal assessment.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 52

53. Palpation of Anus and
Rectum
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 53

54. Palpation of Anus and
Rectum
While the client strains, place gloved
and lubricated finger at anal opening
as sphincter relaxes
Slowly insert the flexed tip of your
finger into the anal sphincter pointing
toward client’s umbilicus
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 54

55. Digital
Pressure is
applied against
anal verge
until the
external
sphincter is
felt to yield
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 55

56. The gloved,
lubricated
finger is
slowly
flexed and
introduced in
the direction
of the
umbilicus
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 56

57. Avoid this
incorrect
approach
at a right
angle to
the
sphincter
It causes discomfort for the client
Does not promote relaxation
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 57

58. If the client tightens the sphincter,
remove your finger, reassure the client,
and try again, using a relaxation
technique such as deep breathing
Feel the sphincter relax. Insert as far as
it will go.
Note anal sphincter tone.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 58

59. Subcutaneuos portion of the external
sphincter is palpated between thumb
and index finger
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 59

60. Digital exploration of the deep
external sphincter
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 60

61. Palpation of the levator ani
muscle
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 61

62. Palpate the lateral,
posterior, and
anterior walls of the
rectum in a
sequenced manner.
The lateral walls felt
by rotating the
finger along the
sides of the rectum
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 62

63. Palpate for
nodules,
irregularity,
masses, and
tenderness.
Ask the client to
bear down again
(which may help to
palpate masses.)
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 63

64. Normal Findings
Smooth
No mass, nodules,
tenderness
Even pressure on finger
Continuous, smooth
surface with minimal
discomfort to client
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 64

65. Normal Findings
Rectum should accommodate
the index finger.
Sphincter tightens evenly
around finger with minimal
discomfort to client
Good sphincter tone at rest
and with bearing down.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 65

66. Normal Findings
No excessive pain,
tenderness, induration,
irregularities, or nodules
in the rectum or rectal
wall.
Anal canal is
approximately 2.5 cm
long. It is bordered by
the external and internal
sphincters, which are
normally firm and
smooth
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 66

67. Let’s Watch:
Palpating Posterior
and Lateral Rectal
Walls

68. Anoscopy
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 68

69. Abnormal Findings
Rectal polyps
Pedunculated
Sessile

70. Pedunculated polyps
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 70

71. Sessile, multilobulated polyp
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 71
On biopsy, turned out to be a benign tubular
adenoma.

72. Prostatic and
Cowper’s Gland
Palpation

73. Palpation of Prostate
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 73

74. Palpate the posterior
surface of the prostate
gland.
Note the size, shape,
consistency, sensitivity
and mobility of the
prostate.
Note whether the
median sulcus is
palpable.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 74

75. Normal Findings
Approximately 4 cm
(1 ½ inches) in
diameter; projecting
less than 1 cm into
rectum. About the
size of a walnut.
Rubbery
consistency (like a
pencil eraser).
Smooth, firm and
nontender.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 75

76. If prostate protrudes into the rectal
lumen, probably enlarged. Classified
as grades 1 to 4: protruding less than
3/8 inch or 1 cm into the rectal lumen
to 1 ¼ inch or 3 cm into the rectal
lumen
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 76

77. Let’s Watch:
Palpating the
Anterior Rectal Wall
and Prostate

78. Abnormalities
Benign Prostatic Hypertrophy
Prostate Cancer

79. Benign Prostatic Hypertrophy
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 79

80. Prostrate Cancer: Single nodule
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 80

81. Prostrate Cancer: Multiple
nodules
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 81

82. Bidigital Examination of
the Bulbourethral Gland
Reassure the client that sensations of
urination and defecation are common
during the prostatic assessment.
Use a well-lubricated, gloved index
well-
finger.
Insert the gloved index finger and follow
the steps 3 to 6 above
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 82

83. Bidigital Examination of
the Bulbourethral Gland
Press your gloved thumb into the perianal
tissue while pressing your gloved index
finger toward it.
Assess for tenderness, masses, or
swelling
Release pressure of the thumb and index
finger.
Remove thumb from the perianal tissue
and advance your index finger.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 83

84. Bidigital Examination of
the Bulbourethral Gland
Photo
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 84

85. Normal Finding
Bulbourethral Gland
Nontender
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 85

86. Seminal Vesicles Palpation
Attempt to
palpate the
seminal vesicles
by extending
your index finger
above the
prostate gland.
Assess for
tenderness and
masses.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 86

87. Normal Findings
Normally, too soft
to be palpated.
Proximal portions
can sometimes
be palpated as
corrugated
structures above
the lateral to the
midpoint of the
gland.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 87

88. Let’s Watch:
Palpating the Anterior
Rectal Wall Seminal
Vesicle & Cowper’s
Gland

89. Slowly withdraw the finger; inspect
any fecal matter on your glove
and test it for occult blood.
(if not previously performed).
Offer the client tissues to wipe
off any remaining lubricant.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 89

90. Normal Findings
Stool
Brown
Soft
No mucus
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 90

91. Fecal Occult Blood Test
Stool Guaiac Test

92. Stool Guaiac Test
Other names:
Guaiac smear test
Fecal occult blood test - guaiac smear
Stool occult blood test - guaiac smear
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 92

93. Guaiac Testing Equipment
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 93

94. Stool Guaiac Test
Purpose
Finds hidden (occult) blood in the
stool.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 94

95. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 95

96. stool guaiac test
a small sample of stool is placed on a
paper card and a drop or two of testing
solution is added.
A color change is a sign of blood in the
stool.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 96

97. How to Prepare for the
Test
Do not eat red meat, any blood-containing food,
blood-
cantaloupe, uncooked broccoli, turnip, radish, or
horseradish for 3 days before the test. These foods can
sometimes interfere with the test.
test.
You may need to stop taking medicines that can
interfere with the test. These include vitamin C and
nonsteroidal anti-inflammatory medicines (NSAIDs)
anti-
such as ibuprofen and aspirin.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 97

98. 6/26/2011 Maria Carmela L. Domocmat, RN, MSN 98

99. Positive guaiac test shown on right, as would be seen for this patient.
Negative result (on left) included for comparison.
http://meded.ucsd.edu/isp/2002/desai/images/LGB46.jpg
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 99

100. Normal Finding
Negative. No blood in the stool
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 100

101. Documentation samples
“No perirectal lesions or fissures. External
sphincter tone intact. Rectal vault without
masses. Prostate smooth and nontender
with palpable median sulcus. (Or in female,
uterine cervix nontender.) Stool brown and
hemoccult negative.”
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 101

102. Documentation samples
“Perirectal area inflamed; no ulcerations,
warts, or discharge. Cannot examine
external sphincter, rectal vault, or
prostate because of spasm or external
sphincter and marked inflammation and
tenderness of anal canal.”
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 102

103. Documentation samples
“No perirectal lesions or fissures. External
sphincter tone intact. Rectal vault without
masses. Left lateral prostate lobe with 1 x 1
cm firm hard nodule; right lateral lobe
smooth; medial sulcus is obscured. Stool
brown and hemoccult negative.”
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 103

104. Sources:
Weber, Janet & Kelley, Jane. (2007). Health
assessment in nursing (3rd ed). Philadephia,
ed). Philadephia,
PA : Lippincott Williams & Wilkins.
Bickley,
Bickley, Lynn S . (2004). Bates’ Pocket guide
to physical examination and history taking
(4th ed). New York: Lippincott Williams and
ed).
Wilkins.
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 104

105. Have a blessed Day!
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 105

106. Have a blessed Day!
6/26/2011 Maria Carmela L. Domocmat, RN, MSN 106