20 - Anus, Rectum and Prostate Flashcards
Common patient concerns
- Changes in bowel habits
- Blood in stool
- Pain with defecation; rectal bleeding or tenderness
- Anal warts or fissures
- Weak urine stream
- Burning with urination
(These make good screening questions, too.)
Melena
Black, tarry stools
Can be caused from high protein, bleeding from a high source in the GI
Stools that are black, but not tarry
Iron
Bismuth salts
Hematochezia
Red blood in stool Lower source (colon, rectum, or anus)
Hemorrhoids, etc.
Reddish, nonbloody stool
Ingestion of red foods
What is the difference between screening and diagnosing/treating?
Screening is for people who don’t have symptoms
If someone has symptoms, you are diagnosing and treating
Do you screen for prostate cancer?
No, the USPSTF ranks this screen at a D, which indicates no screening
D = “don’t screen”
What does “cancer” mean?
Social term referring to biological agent that will kill a person before their natural time of death
What does “screening” mean?
When you are looking for disease or dysfunction when the person doesn’t have symptoms
If a patient has symptoms, what are you doing when you try to find the problem?
Diagnose, NOT screen
Prostate Cancer Stats
- Leading male cancer diagnosis
- Second leading cause of death
- Risk increases after 50
- African Americans higher risk - Caucasian (earlier age, more advanced)
- Family history and diet are relevant
According to the USPSTF, what does a D mean?
Recommends against the screening service. There is a moderate or high certainty that the service has no net benefit or that the harms outweigh the benefits.
The suggestion discourages the use of screening.
What are the two ways that we can screen for prostate cancer?
PSA = prostate specific antigen DRE = digital rectal examination
What is the appropriate plan of action for prostate cancer screening?
- At 50 years, talk to patient, discuss pros and cons
- At 45 years with an at-risk male, begin screening
What makes a male at-risk?
African American
Father or brother with prostate cancer before 65
What should you NOT test with these patients?
PSA: Prostate specific antigen
Not a good representation of risk or need for intervention
What do we know about screening for prostate cancer based on screening studies?
They are commonly recommended and uncommonly useless
What do we know about PSA?
Prostate specific antigen
- Used to think it was a biomarker for early detection
- Many limitations (elevated in benign conditions, false positives, false negatives, unnecessary testing such as biopsies)
- “Over diagnosis”
- Side effects with treatment are common
What do we know about DRE?
Digital Rectal Examination
- Low sensitivity: 59%
- Specificity: 94%
- Detects tumors on the posterior and lateral aspects
- Misses 25-35% of tumors arising in other areas
- Abnormal findings need to be investigated
- Can combine prostate and colo-rectal exam
Is colorectal cancer screening recommended?
Depends on the age…
- 50-75 = grade A
- 76-85 = grade C
- Over 85 = grade D
What do we know about colorectal cancer screening?
- There is an average risk, so we screen for it
- Starting at 50 years for both male and female
- Need annual high-sensitivity fecal occult blood test (if positive, need a colonoscopy)
What increases risk for colorectal cancer?
- Inflammatory bowel disease
- Family history of an inherited polyposis syndrome
- At risk means you should have a colonoscopy every 3-5 years
When do you do a female DRE?
During pelvic exam
Be careful because the cervix, a retroverted uterus or even a tampon can mimic a tumor
DRE technique
- Position and drape
- Gloves
- Inspect sacrococcygeal and perianal areas
- Lubricate index finger
- Explain to patient may feel sense of urge
- Pad of finger on anus
- Introduce finger with relaxation
- After: Wipe or offer tissues
Common abnormalities found during DRE exam
Prostate
- Prostatitis
- Benign Prostatic hyperplasia
- Cancer
Rectum/anus
- Anal fissure
- Polyps
- Cancer
- Hemorrhoids
- Prolapse
Signs of bacterial prostatitis
Dysuria Frequency Nocturia (new) Hesitancy Suprapubic pain Painful ejaculation “Flu-like” symptoms
Classic symptoms of prostatitis
Calor (warmth)
Dolor (pain)
Rubor (swelling, redness, heat)
All of the above refer to inflammation
Tumor
What test results will you see in prostatitis?
DRE controversial
Labs: elevated WBC and positive UA
PSA would be elevated, but we don’t screen
What are the signs of benign prostatic hypertrophy?
Urgency Frequency Nocturia (gradual) Hesitancy Weak stream Hematuria (non-specific)
What are the symptoms of benign prostatic hypertrophy?
Enlarged
Nontender
Hard
Symmetrical
Is the PSA useful in benign prostatic hypertrophy?
NO
Signs of prostate cancer
Same as BPH
What are the symptoms of prostate cancer?
Nodules Nontender Induration Asymmetric Lateral lobes
Is the PSA useful in prostate cancer?
NO
Anal fissure
- Tear in skin at anus
- Acute
- Small amount blood
- May appear large
- Cause is straining or constipation
- Treat conservatively
Anal fistula
- Infected anal gland
- Above dentate line
- Chronic draining abscess
- Bypasses external sphincter
- Surgical treatment (except in Crohn’s)
Hemorrhoids (external)
Painful
Thrombose
Skin tag
Hemorrhoids (internal)
Painless
Bleed
Protrude
Prolapse
- Protruding mass
- Reducible initially
- Associated with poor bowel habits, digital disimpaction, chronic constipation
Polyps
- Polyps
- Intestinal growths
- May be asymptomatic, bleed or obstruct
- Found on DRE or colonoscopy
- Biopsy mandatory
- Classification big topic
Rectum and anal cancer
- Staged
- Screening is effective
- Risk based (symptoms, family hx)
- Surveillance for (+)
- USPSTF recommended
Anal PAP
Anal screening cytology or DNA
Goal uncertain; USPSTF NO recommendations
- Initial screening in high risk populations
- Similar reporting as PAP
Technique
- Water moistened polyester fiber
- Left lateral position
- Swab gently inserted to stop point
- Remove swab with a spiral motion
- Sample fixed with ethanol or liquid cytology
