(15) Anus, Rectum, Prostate Flashcards
rectum
- lies against the cerum and coccyx then merges w/ the short segment of anal canal
- extends from rectosigmoid junction, anterior to S3 vertebra, to the anorectal junction at the tip of coccyx
external margin of anal canal
poor demarcated
- moist hairless appearance usually distinguishes it form the surrounding perineal skin
internal anal sphincter
an extension of the muscular coat of the rectal wall
what holds the anal canal closed?
multiple actions of the voluntary external anal sphincter and the involuntary internal anal sphincter
anal canal
- angle is on a line roughly between anus and umbilicus
- liberally supplied by somatic sensory nerves and a poorly directed finger or instrument wall produce pain
anorectal junction
- serrated line marking the change from skin to mucous membrane (demarcates anal canal from rectum)
- also called pectinate or dentate line
- boundary between somatic and visceral nerve supplies
- easily visible on anoscopic or endoscopic exam but no palpable
prostate gland
surrounds urethra and lies next to bladder outlet
-small in childhood, between puberty and 20y/o increases 5x in size; prostate volume further expands as gland becomes hyper plastic
- right and left lateral lobes lie against anterior rectal wall where they are palpable as a rounded, heart shaped structure approx 2.5cm long
- separated by s shallow median sulcus or groove: also palpable
- anterior and central areas of prostate cannot be examined
- seminal vesicles (shaped like rabbit ears above prostate) are also not normally palpable
in females, the ? is usually palpable through the anterior wall of the rectum
uterine cervix
valves of Houston
3 inward foldings go the rectal wall
-lowest can be sometimes be felt on pt’s left
-most of rectum that is accessible to digital exam doesn’t
t have peritoneal surface except for anterior rectum which you may be able to reach w/ tip of exam finger
rectal exam: tenderness from peritoneal inflammation or nodularity suggests ?
peritoneal masses
rectal/anus/prostate:
common/concerning symptoms and signs
- change in bowel habits
- blood in stool
- pain w/ defecation; rectal bleeding or tenderness
- anal warts or fissures
- weak urinary stream
- burning w/ urination
- blood in urine
change in stool caliber, especially pencil-thin stools, may warn of ?
colon cancer
blood in stool may be from ?
polyps
carcinoma
GI bleeding
hemorrhoids
mucus in stool may be from ?
vilois adenoma
intestinal infections
inflammatory bowel disease
irritable bowel syndrome
anorectal pain, itching, tenesmus, or discharge or bleeding from infection or rectal abscess suggests ?
proctitis
(causes include gonorrhea, chlamydia, lymphogranuloma venereum, receptive anal intercourse, ulcerations from herpes simplex, chancres of primary syphilis)
anal intching in younger patients suggests ?
pinworms
anal fissures suggests ?
proctitis
Crohn disease
genital warts may arise from ?
HPV
condylomata lata in secondary syphilis
urinary complaints r/t benign prostatic hyperplasia or prostate cancer (esp. men >70)
- difficulty starting holding back urine stream
- weak flow
- frequent pm urination
s/s acute prostatitis
sudden onset of irritative urinary tract symptoms (frequency, urgency, pain w/ urination) perineal and low back pain malaise fever chills
anal/rectal/prostate:
important topics for health promotion
- prostate cancer prevention and screening
- colorectal cancer prevention and screening
- counseling for STIs
risk factors for prostate cancer
Age: rare before 40, increase rapidly after 50, median age dx =66
Ethnicity: black
Family history: genetics, 1st degree relative (father/brother), BRCA1/2
Other: agent orange, diet high in animal fat, obesity, smoking
*BPH is not a risk factor
prostate cancer primary prevention
- no evidence that any lifestyle modification works (diet, activity, etc)
- maybe chemoprevention (5-ARIs)
prostate cancer screening
- PSA test
- digital rectal exam
- if these abnormal refer for prostate biopsy = gold standard for dx*
-use shared decision making for screenings starting between 40-50y/o until 70y/o or life expectancy <10yrs (annually)
PSA
glycoprotein produced by prostatic epithelial cells that can be elevated by cancer (also BPH, prostate infections, ejaculation)
DRE
explores for palpable abnormalities such as nodules, induration, asymmetry in peripheral posterior and lateral areas of prostate gland closest to examining finger
-unable to detect cancers in anterior and central areas of the gland
majority of cancers detected by DRE have already spread beyond prostate
for suspicion of colorectal cancer consider ?
lower endoscopy
rectal exam: male positioning
left side lying, buttocks close to edge, hips/knees flexed (esp. upper leg)
- can have standing and leaning forward w/ hips flexed but less dignified
perianal skin compared to skin on buttocks
more pigmented and coarser
anal and perianal lesions include
hemorrhoids general warts herpes syphilitic chancre carcinoma
anal/perianal linear crack or tear suggests
anal fissure from large, hard stool, IBD, to STIs
swollen, thickened, fissures perianal skin w/ excoriations suggests
pruritus ani
anal canal: tender purulent reddened mass w/ fever/chills suggests
anal abscess
abscesses tunneling to skin surface from anus to rectum may form ?
clogged or draining anorectal fistula (may ooze blood, pus, feculent mucus)
-consider anoscopy or sigmoidoscopy for better visualization
anal sphincter tightness may occur w/
anxiety
inflammation
scarring
anal sphincter laxity occurs in
neurologic diseases such as S2-S4 cord lesions
signals possible changes in urinary sphincter and detrusor muscle
-consider testing perianal sensation
anal induration may be caused by
inflammation
scarring
malignancy
rectal mass w. irregular borders suggests
rectal cancer
prostate exam may cause the patient to feel ?
urge to pee
normal prostate on palpation
rubbery
nontender
no evidence of fixity to surrounding tissues
7 parts of BPH symptoms score
- incomplete emptying
- frequency
- intermittency
- urgency
- weak stream
- straining
- nocturia
Pilondial Cyst
- fairly common, congenital, abnormality located in midline superficial to the coccyx or lower sacrum
- opening of a sinus tract sometimes w/ tuft of hair surrounded by a halo of erythema
- generally asymptomatic except for slight drainage but abscess formation and secondary sinus tacts may occur
external hemorrhoids
dilated hemorrhoidal veins that originated below the pectinate line that are covered by skin
- seldom produce symptoms unless thrombosis occurs which causes actor local pain that increases w/ defectation and sitting
- a tender, swollen, bluish, ovoid mass is visible at anal margin
internal (prolapsed) hemorrhoids
enlargements of the normal vascular cushions located above the pectinate line, usually not palpable
- may cause bright-red bleeding, especially during defectation
- may also prolapse through the anal canal and appear as reddish, moist, protruding masses, typically located in one or more of the positions illustrated
prolapse of rectum
on straining for a bowel movement, rectal mucosa, w/ or w/o muscular wall. may prolapse through anus appearing as a doughnut to rosette of red tissue
- prolapse involving only mucosa is relatively small and sows radiating folds
- when entire bowel wall is involved, the prolapse is larger and covered by concentrically circular folds
anal fissure
very painful oval ulceration of the anal canal
- most commonly found in midline posteriorly, less commonly in midline anteriorly
- its long axis lies longitudinally
- may be swollen “sentinel” skin tag just below it
- gentle separation of anal margins may reveal the lower edge of fissure
- sphincter is spastic, exam is painful (local anesthesia may be required)
anorectal fissure
inflammatory tract or tube that opens at one end into the anus or rectum and at the other end onto the skin surface or into another viscus
- an abscess usually antedates such a fistula
- look for fistulous opening or openings anywhere in the skin around the anus
polyps of rectum
- fairly common
- variable in size and number
- can develop a stalk (pedunculate) or lie on the mucosal surface (sessile)
- soft and may be difficult or impossible to feel even when in reach of the examining finger
- endoscopy and biopsy are needed for differentiation of benign from malignant lesions
cancer of rectum
-firm, nodular, rolled edge of an ulcerated cancer
rectal shelf
- widespread peritoneal metastases from any source may develop in the area of the peritoneal reflection anterior to the rectum
- a firm to hard nodular rectal “shelf” may be just palpable w/ the tip of the examining finger
- in women, this shelf of metazoic tissue develops in the rectouterine such, behind cervix and the uterus
normal prostate gland
(palpated through anterior rectal wall)
- rounded, heart-shaped structure approx 2.5cm long
- median sulcus can be palpated between 2 lateral lobes
- only posterior surface of prostate is palpable
- anterior and central lesions, including those that obstruct the urethra, are not detectable by physical exam
Acute bacterial prostatitis
presents w/ fever and urinary tract symptoms scubas frequency, urgency, dysuria, incomplete voiding, Lowe back pain
- gland feels tender, swollen, boggy, warm
- usually caused by gram- bacteria (E. coli, enterococcus, proteus) or STI (GC/Chlamydia)
chronic bacterial prostatitis
associated w/ recurrent UTIs usually from same organism
- may be asymptomatic or have dysuria or mild pelvic pain
- gland may feel normal w/o tenderness/swelling
- cultures usually show E. coli
-may be hard to distinguish from chronic pelvic pain syndrome
BPH
nonmalignant enlargement of prostate gland that increases w/ age (>50y/o)
- symptoms arise from smooth muscle contraction in prostate and bladder neck and from compression of urethra
- may be irritative (urgency, frequency, nocturia) or obstructive (decreased stream, incomplete emptying, straining) or both
- gland may be normal in size, feel enlarged, smooth, firm, slightly elastic, may be obliteration of median sulcus and more notable protrusion into rectal lumen
Prostate cancer
suggested by an area of hardness in the gland - a distinct hard nodule that alters the contour of the gland may or may not be palpable
- as the cancer enlarges it feels irregular and may extend beyond the confines of the gland
- median sulcus may be obscured
- hard areas of prostate aren’t always malignant: may be stones, chronic inflammation
