Colon

You are about to perform a rectal examination of an older adult.

What are the steps to examine this patient?
Explain your rationale.
What are some findings you can have while assessing the rectal sphincter?
Describe the differences during the rectal examination of acute prostatitis and benign prostatic hypertrophy.
What findings would expect on physical examination of acute prostatitis and benign prostatic hypertrophy?

Submission Instructions:

Your initial post should be at least 500 words, formatted and cited in proper current APA style with support from at least 2 academic sources.

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Jarvis, C. (2019).
- Chapter 26
- Elsevier. (n.d.). Colon and rectal cancer. Evolve: Jarvis: Physical examination & health assessment, 6th edition – Clinical reference – Health promotion guide. Elsevier.com. https://coursewareobjects.elsevier.com/objects/elr/Jarvis6e/clinicalreference_health/?ch=25

Chapter 26

Anus, Rectum, and Prostate

Anal canal

Outlet of gastrointestinal tract; lined with modified skin; no hair or sebaceous glands

Surrounded by two concentric layers of muscle, the sphincters

Under voluntary control; except for passing feces and gas, sphincters keep anal canal tightly closed

Anal columns, or columns of Morgagni, are folds of mucosa.

Each anal column contains an artery and a vein.

Rectum

Distal portion of large intestine

Rectal interior has three semilunar transverse folds, called valves of Houston.

Structure and Function:
Anal Canal and Rectum

Anus and Rectum

Peritoneum covers only upper two thirds of rectum.

In male, anterior part of peritoneum reflects down to anal opening, forming rectovesical pouch and then covers bladder.

In female, it is termed the rectouterine pouch.

Structure and Function:
Peritoneal Reflection

Lies in front of anterior wall of rectum and 2 cm behind symphysis pubis

Surrounds bladder neck and urethra and has 15 to 30 ducts that open into urethra

Two seminal vesicles project above prostate.

Secrete a fluid rich in fructose, which nourishes sperm, and contains prostaglandins

Two bulbourethral Cowper’s glands located inferior to prostate on either side of urethra secrete a clear, viscid mucus.

Structure: Prostate Gland

Anatomy of the Prostate Gland and Seminal Vesicles

Uterine cervix, in females, lies in front of anterior rectal wall and may be palpated through it.

Combined length of anal canal and rectum is about 16 cm in adult.

Sigmoid colon, S-shaped course in pelvic cavity

Regional Structures

Infants

Meconium: First stool passed by newborn is dark green; occurs within 24 to 48 hours of birth, indicates anal patency

Gastrocolic reflex: wave of peristalsis in response to eating

Infant passes stools by reflex.

Children and adults

At male puberty, prostate gland undergoes a very rapid increase to more than twice its prepubertal size; during young adulthood size remains fairly constant.

Prostate gland commonly starts to enlarge during middle adult years; increases with age.

Benign prostatic hypertrophy (BPH) present in 80% of men over 60 years of age

Developmental Competence

Most frequently diagnosed cancer in men

Known risk factors:

Increasing age, African ancestry, family history, and inherited mutation of BRCA1 and BRCA2 genes

Ethnic/geographic variation is seen in terms of occurrence.

Incidence higher for black men than other racial groups, and more likely to be diagnosed at advanced stage

Mortality rates are two times higher for black men.

Diets heavy in red meat or high-fat dairy products may be factor

Some evidence suggests that prostate cancer may increase with obesity.

Follow screening recommendations relative to identified risk

Culture and Genetics:
Prostate Cancer

Colorectal cancer also has racial variation.

Ethnic/geographic variation is seen in terms of occurrence.

Screening and treatment differences that occur along racial/ethnic lines and to insurance status

Age paradox seen with increased incidence in younger population and increased death rate in older population

Screening recommendations relative to age and risk

Hereditary factors that lead to increased CRC:

Family history, inherited genetic syndromes, personal history of inflammatory bowel disease, or type 2 diabetes

Culture and Genetics:
Colorectal Cancer (CRC)

Usual bowel routine

Change in bowel habits

Rectal bleeding, blood in stool

Medications: laxatives, stool softeners, iron

Rectal conditions: pruritus, hemorrhoids, fissure, fistula

Family history

Patient-centered care: diet of high-fiber foods, most recent examinations

Subjective Data

Usual bowel routine: ask about

frequency, characteristics of stool, straining or pain with movement.

change in bowel habits, constipation versus diarrhea, onset and duration.

associated clinical symptoms—pain/nausea/vomiting.

r/t foods ingested and/or occurrence in other family/group members.

Rectal bleeding: ask about

presence of blood in stool—quantity/color/odor, onset, duration and frequency.

spotting or out right passing of blood with stool.

characteristics: clay-colored, pus or mucus, frothy.

accompanied by flatus.

Subjective Data Questions (1 of 2)

Medication: ask about

Rx or OTC, laxatives or stool softeners, iron pills.

use of enemas to move bowels.

Rectal conditions: ask about

rectal area problems—itching, pain, or burning.

hemorrhoids—presence and treatment.

fistula—presence and treatment.

Family history: ask about

polyps, or cancer in colon or rectum.

inflammatory bowel disease or prostate cancer.

Patient-centered care: ask about

usual amount of high-fiber foods in diet.

number of glasses of water taken daily.

fate of last diagnostic testing as well as PSA for males.

Subjective Data Questions (2 of 2)

Have you ever noticed any irritation in your child’s anal area, such as redness, raised skin, or frequent itching?

How are your child’s bowel movements? How frequent are they? Are there any problems or pain or straining with bowel movement?

Additional History:
Infants and Children

Preparation

Perform rectal examination on all adults and particularly for those in middle and late years.

Place patient in best position relative to gender.

Males: Left lateral decubitus, standing, or lithotomy

Females: Lithotomy for examining genitalia or left lateral decubitus for exam of rectum alone

Equipment

Penlight

Lubricating jelly

Glove

Guaiac test container

Objective Data:
Preparation and Equipment

Rectal Examination Positions

Spread buttocks wide apart and inspect perianal region.

Anus normally looks moist and hairless, with coarse folded skin more pigmented than perianal skin.

Anal opening tightly closed; no lesions present

Inspect sacrococcygeal area; normally appears smooth and even.

Instruct a person to hold breath and bear down by performing a Valsalva maneuver.

No break in skin integrity or protrusion through anal opening should be present.

Describe any abnormality in clock-face terms, with 12:00 as the anterior point toward symphysis pubis and 6:00 toward coccyx.

Inspect Perianal Area

Instruct the person that palpation is not painful but may feel like needing to move bowels.

Drop lubricating jelly onto gloved index finger; place pad of index finger gently against anal verge.

Rotate examination finger to palpate entire muscular ring.

Above anal canal, rectum turns posteriorly, following curve of coccyx and sacrum.

Promptly report any mass you discover for further examination.

Palpate Anus and Rectum

On anterior wall in male, note elastic, bulging prostate gland.

Palpate entire prostate in a systematic manner; note that only superior and part of lateral surfaces is accessible to examination.

Note the following characteristics:

Size

Shape

Surface

Consistency

Mobility

Sensitivity

Prostate Gland

Palpate cervix in female through anterior rectal wall.

Withdraw examination finger; normally no bright red blood or mucus is on glove.

To complete examination, offer the person tissues to remove lubricant and help the person to comfortable position.

Cervical Examination

Inspect any feces remaining on glove.

Normally color is brown and consistency is soft.

Test any stool on glove for occult blood using specimen container that your agency directs.

If stool Hematest is positive, it indicates occult blood.

Note that false-positive finding may occur if the person has ingested red meat within 3 days of test.

Enhance self-care by providing the average risk patient an at-home collection kit to screen for asymptomatic colorectal cancer and precancerous lesions.

Examination of Stool

Newborn and infant

Confirm a patent rectum and anus by noting passage of first meconium stool within 24 to 48 hours of birth.

Check anal reflex to assess sphincter tone; gently stroke anal area and note quick contraction of sphincter.

Mongolian spot is a common variation of hyperpigmentation in African American, American Indian, Mediterranean, and Asian newborns.

Children

Inspect perennial area of school-age child and adolescent during genitalia exam.

Developmental Competence:
Infants and Children

As an aging person performs Valsalva maneuver, you may note relaxation of perianal musculature and decreased sphincter control.

Otherwise, full examination proceeds as that described for younger adult.

Developmental Competence:
Aging Adult

Prostate cancer, colorectal cancer (CRC) and HPV

PSA—effective earl screening test

Screening for CRC starts at age 50 with recommended colonoscopy

FIT—Fecal Immunochemical test—start at age 40

HPV vaccine—Men under 26 years of age

Health Promotion Teaching

Pilonidal cyst or sinus

Fissure

Hemorrhoids

Pruritus ani

Fecal impaction (FI)

Anorectal fistula

Anal Region Abnormalities

Rectum

Abscess

Rectal polyp

Anorectal fistula

Carcinoma

Prostate

Benign prostatic hypertrophy (BPH)

Prostatitis

Carcinoma

Abnormalities:
Rectum and Prostate

Inspect anus and perineal area

Inspect during valsalva maneuver

Palpate anal canal and rectum on all adults

Test stool for occult blood

Summary Checklist: Anus,
Rectum, and Prostate

Colon and Rectal Cancer: What Is Your Risk?

Screening for colon and rectal cancer can find cancer, if present, at an early stage with a better chance for a cure.

Reporting any symptoms immediately to your doctors is also important, but cancer screening can help find cancer before

symptoms even appear.

Risk Factors

A close relative (a parent, sibling, or child) who has had colon or rectal cancer or polyps at an age younger than

60, or having two close relatives who have had colon or rectal cancer at any age

A known family history of hereditary colorectal cancer conditions

A personal history of colon or rectal cancer, adenomatous polyps, or chronic inflammatory bowel disease

Several screening options are available for early detection of colon and rectal cancer. The American Cancer Society

recommends one of the following five options for men and women beginning at 50 years of age:

A fecal occult blood test (FOBT) every year

Flexible sigmoidoscopy every 5 years, OR

A fecal occult blood test every year PLUS flexible sigmoidoscopy every 5 years (recommended by the

American Cancer Society, 2002)

Other Options

Double-contrast barium enema every 5 to 10 years, OR

Colonoscopy every 10 years

Any positive fecal occult blood tests should be followed up with a colonoscopy.

If you have one or more of the risk factors for colon or rectal cancer, your health care provider may recommend screening

more often.

FOR MORE INFORMATION:

• MEDLINEplus Resource Page: http://www.nlm.nih.gov/medlineplus/colorectalcancer.html

• The National Cancer Institute: http://www.nci.nih.gov/cancer_information/cancer_type/colon_and_rectal/

• Colon Cancer Alliance: http://www.ccalliance.org (1-877-422-2030)

• American Cancer Society: http://www.cancer.org (1-800-ACS-2345)

Source: American Cancer Society 2002.

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