Anus, Rectum, Prostate

Question 1

Describe the structure of the anal canal

Answer 1

The anal canal is the outlet of the gastrointestinal (GI) tract, and it is about 3.8cm long in the adult. It is lined with modified skin (having no hair or sebaceous glands) that merges with rectal mucosa at the anorectal junction.

Question 2

describe the position of the anal canal

Answer 2

The canal slants forward toward the umbilicus, forming a distinct right angle with the rectum, which rests back in the hollow of the sacrum.

Question 3

What type of nerve are in the rectal/anus region?

Answer 3

Although the rectum contains only autonomic nerves, numerous somatic sensory nerves are present in the anal canal and external skin, so a person feels sharp pain from any trauma to the anal area.

Question 4

Differentiate between internal sphincter and external sphincter

Answer 4

• The internal sphincter is under involuntary control by the autonomic nervous system. - The external sphincter surrounds the internal sphincter but also has a small section over the tip of the internal sphincter at the opening. It is under voluntary control.
• Except for the passing of feces and gas, the sphincters keep the anal canal tightly closed.

Question 5

The intersphincteric groove separates what?

Answer 5

the internal and external sphincters and is palpable.

Question 6

what are the anal columns? (columns of Morgagni)

Answer 6

• folds of mucosa that extend vertically down from the rectum and end in the anorectal junction.
• This junction is not palpable, but it is visible on proctoscopy. Each anal column contains an artery and a vein.

Question 7

How does a hemorrhoid form?

Answer 7

Under conditions of chronic increased venous pressure, the vein in the anal columns may enlarge, forming a hemorrhoid.

Question 8

Describe the rectum

Answer 8

The rectum, which is 12cm long, is the distal portion of the large intestine. It extends from the sigmoid colon, at the level of the third sacral vertebra, and ends at the anal canal. Just above the anal canal, the rectum dilates and turns posteriorly, forming the rectal ampulla. The rectal interior has three semilunar transverse folds called the valves of Houston.

Question 9

Valves of Houston

Answer 9

The rectal interior has three semilunar transverse folds called the valves of Houston.

• These cross one-half the circumference of the rectal lumen. Their function is unclear, but they may serve to hold feces as the flatus passes.
• The lowest is within reach of palpation, usually on the person’s left side, and must not be mistaken for an intrarectal mass.*

Question 10

rectovesical pouch

Answer 10

The peritoneum covers only the upper two thirds of the rectum. In the male, the anterior part of the peritoneum reflects down to within 7.5cm of the anal opening to form the rectovesical pouch and then covers the bladder

Question 11

recto-uterine pouch

Answer 11

• in females

- extends down to within 5.5cm of the anal opening.

Question 12

The prostate gland

Answer 12

• lies in front of the anterior wall of the rectum and 2cm behind the symphysis pubis.
• It surrounds the bladder neck and the urethra and has 15 to 30 ducts that open into the urethra. T
• secretes a thin, milky, alkaline fluid that helps sperm viability.
• It is 2 lobed structure with a round or heart shape. It measures 2.5cm long and 4cm in diameter.

Question 13

Seminal vesicles

Answer 13

The two seminal vesicles project like rabbit ears above the prostate. The seminal vesicles secrete a fluid that is rich in fructose, which nourishes the sperm and contains prostaglandins.

Question 14

Bulbourethral (Cowper) glands

Answer 14

each the size of a pea and are located inferior to the prostate on either side of the urethra. They secrete a clear, viscid mucus.

Question 15

prevalence of prostate cancer

Answer 15

more common in North America and northwestern Europe and is less common in Central and South America, Africa, and Asia. The incidence of PC is higher for African-American men than for men of other racial groups; African-American men are more likely to be diagnosed at an advanced stage of the disease, and mortality rates are two times higher for African-American men than for white men

Question 16

risk factors for prostate cancer

Answer 16

• Family history is positively associated; men with one first-degree relative (father or brother) are 2 to 3 times more likely to develop PC.
• Genetic factors contribute some risk: BRCA2 mutations
• Environmental factors may account for more risk than genetics because migration studies show men of Asian and African heritage living in the United States have a higher risk for PC than their counterparts living in Asia and Africa.
• Environmental factors include diet. Diets high in red meat and processed meat, animal and saturated fats, and dairy products may increase risk, whereas diets high in fiber, fruits, and vegetables may lower risk

Question 17

Age for prostate screening

Answer 17

• Men at average risk for PC should receive information at 50 years; at higher risk (African Americans and positive family history) at 45 years; and at very high risk (multiple family members with PC) at 40 years.
• Screening includes the blood test for prostate-specific antigen (PSA) and a physical examination (i.e., a digital rectal exam

Question 18

Incidence rates for Colorectal Cancer

Answer 18

• The incidence rates are almost 20% higher for African-American women and men than for whites, and the mortality rates are almost 50% higher for African Americans than for whites.
• Because colorectal cancer can largely be prevented by removal of adenomatous polyps, guidelines for average-risk adults start at age 50 years and include health teaching about options for screening. Options include a colonoscopy every 10 years with bowel preparation and conscious sedation, and an annual guaiac-based fecal occult blood test or fecal immunochemical test

Question 19

Subjective data includes:

Answer 19

1) Usual bowel routine
2) Change in bowel habits
3) Rectal bleeding, blood in the stool
4) Medications (laxatives, stool softeners, iron)
5) Rectal conditions (pruritus, hemorrhoids, fissure, fistula)
6) Family history
7) Self-care behaviors (diet of high-fiber foods, most recent examinations)

Question 20

Usual bowel routine?

Answer 20

Bowels move regularly? How often? Usual color? Hard or soft?
•Any straining at stool, incomplete evacuation, urge to have bowel movement but nothing comes?
•Eat breakfast? (This increases colon motility and prompts a bowel movement in many.)
•Pain while passing a bowel movement?

Question 21

Constipation is less than __ bowels/week and common in _____ ______

Answer 21

Constipation is ≤ 3 stools/week and is a common concern among aging adults.

Question 22

Any straining at stool, incomplete evacuation, urge to have bowel movement but nothing comes? (What does this question ask for?)

Answer 22

Dyschezia= Pain due to a local condition (hemorrhoid, fissure) or constipation.

Question 23

Change in bowel habits?

Answer 23

Loose stools or diarrhea? When did this start? Is the diarrhea associated with nausea and vomiting, abdominal pain, something you ate recently?

Question 24

Diarrhea occurs with…..?

Answer 24

Diarrhea occurs with gastroenteritis, colitis, irritable colon syndrome.

Question 25

Blood in stool or bloody stool?

Answer 25

Rectal bleeding, blood in the stool. Ever had black or bloody stools? (abnormal–>Melena)
When did you first notice blood in the stools? What is the color, bright red or dark red-black?
How much blood: spotting on the toilet paper or outright passing of blood with the stool? Do the bloody stools have a particular smell?

Question 26

Melena and/or red blood in stools. What does this suggest?

Answer 26

Melena.
- Black stools may be tarry due to occult blood (melena) from GI bleeding or nontarry from ingestion of iron medications.

-Red blood in stools occurs with GI bleeding or local bleeding around the anus and with colon and rectal cancer.

Question 27

Ever had clay-colored stools?

•Ever had mucus or pus in stool?

Answer 27

Clay color indicates absent bile pigment.

Question 28

Frothy stool? (suggests Steatorrhea, which is?)

Answer 28

Steatorrhea is excessive fat in the stool as in malabsorption of fat.

Question 29

Mucoid discharge and soiled undies suggests what?

Answer 29

Prolapsed hemorrhoid (abnormal)

Question 30

what do you ask to assess self-care behaviors in regard to diet?

Answer 30

. What is the usual amount of high-fiber foods in your daily diet: cereals, apples or other fruits, vegetables, whole-grain breads? How many glasses of water do you drink each day?
*High-fiber foods of the soluble type (beans, prunes, barley, carrots, broccoli, cabbage) lower cholesterol, whereas insoluble fiber foods (cereals, wheat germ) reduce risk for colon cancer. Also, fiber foods fight obesity, stabilize blood sugar, and help some GI disorders.

Question 31

What do you ask to assess self-care behaviors in regard to cancer prevention?

Answer 31

Date of last: digital rectal examination, stool blood test, colonoscopy, (for men) prostate-specific antigen blood test.
*Early detection for cancer: DRE performed annually after age 50 years; fecal occult blood test annually after age 50 years; sigmoidoscopy every 5 years or colonoscopy every 10 years after age 50 years; PSA blood test annually for men older than 50 years, except Black men beginning at age 45 years.

Question 32

Inspecting anus- normal findings

Answer 32

observe the perianal region. The anus normally looks moist and hairless, with coarse, folded skin that is more pigmented than the perianal skin. The anal opening is tightly closed. No lesions are present.

Question 33

Inspecting perianal region- abnormalities

Answer 33

Inflammation. Lesions or scars.

Linear split—fissure.

Flabby skin sac—hemorrhoid. Shiny blue skin sac—thrombosed hemorrhoid.

Small round opening in anal area—fistula

Question 34

sacrococcygeal area normally is

Answer 34

smooth and even

*Abnormal- inflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx may indicate pilonidal cyst

Question 35

When the nurse instructs the patient to bear down and perform the Valsalva maneuver, what should be observed?

Answer 35

No break in skin integrity or protrusion through the anal opening should be present. Describe any abnormality in clock-face terms, with the 12 o’clock position as the anterior point toward the symphysis pubis and the 6 o’clock position toward the coccyx.

Question 36

a circular red donut of tissue indicates ____ ______?

Answer 36

Rectal prolapse

Question 37

Never approach the anus with your finger in a ____ _____, instead go in with your finger ______

Answer 37

Never approach the anus with your finger in a right angle*, instead go in with your finger flexed.
* Place the pad of your index finger gently against the anal verge. You will feel the sphincter tighten and then relax. As it relaxes, flex the tip of your finger and slowly insert it into the anal canal in a direction toward the umbilicus. Never approach the anus at right angles with your index finger extended. Such a jabbing motion does not promote sphincter relaxation and is painful.

Question 38

Palpating the anus and rectum: palpating the muscular ring

Answer 38

• rotate finger to palpate the entire muscular ring. The canal should feel smooth and even
• To assess tone, ask the person to tighten the muscle. The sphincter should tighten evenly around your finger with no pain to the person.
  Abnormal finding: Decreased tone. Increased tone occurs with inflammation and anxiety

Question 39

Use a ______ _______ with your thumb against the ______ ______. Press your examining finger toward it. This maneuver highlights any _______ or _______ and helps assess the _________ ______.

Answer 39

bi-digital palpation
perianal tissue
Swelling or tenderness
bulbourethral glands

Question 40

when palpating the rectal wall, how should it feel?

Answer 40

explore all around the rectal wall. It normally feels smooth with no nodularity. Promptly report any mass you discover for further examination.

Question 41

An internal hemorrhoid above anorectal junction is not palpable unless _________.

Answer 41

Thrombosed

Question 42

A soft, slightly movable mass may be a _______

Answer 42

polyp

Question 43

A firm or hard mass with irregular shape or rolled edges may signify ________

Answer 43

carcinoma

Question 44

The nurse palpates something that feels elastic and bulging on the anterior wall in a male. What is it?

Answer 44

The prostate gland

Question 45

How should the nurse palpate the prostate gland?

Answer 45

Palpate the entire prostate in a systematic manner, but note that only the superior and part of the lateral surfaces are accessible to examination.

• Press into the gland at each location, because when a nodule occurs, it will not project into the rectal lumen.
• The surface should feel smooth and muscular; search for any distinct nodule or diffuse firmness.

Question 46

Note these characteristics when palpating the prostate gland:

Answer 46

Size—2.5cm long by 4cm wide; should not protrude more than 1cm into the rectum
(Abnormal= Enlarged or atrophied gland.)

Shape—heart shape, with palpable central groove
(Abnormal= Flat with no groove.)

Surface—smooth
(abnormal=Nodular.)

Consistency—elastic, rubbery
( Abnormal= Hard; or boggy, soft, fluctuant.)

Mobility—slightly movable
(abnormal=Fixed.)

Sensitivity—nontender to palpation
(Abnormal= Tender.)

Question 47

Enlarged, firm, smooth gland with central groove obliterated suggests………?

Answer 47

benign prostatic hypertrophy

Question 48

Swollen, exquisitely tender gland accompanies…..?

Answer 48

prostatitis

Question 49

Any stone-hard, irregular, fixed nodule indicates…..?

Answer 49

carcinoma

Question 50

how should the cervix feel when palpated?

Answer 50

It normally feels like a small, round mass. You also may palpate a retroverted uterus or a tampon in the vagina. Do not mistake the cervix or a tampon for a tumor.

Question 51

Jelly-like mucus shreds mixed in stool indicate ….?

Answer 51

inflammation

Question 52

Bright red blood on stool surface indicates….

Answer 52

rectal bleeding

Question 53

Bright red blood mixed with feces indicates possible….

Answer 53

colonic bleeding

Question 54

Occult blood test

Answer 54

A negative response is normal. If the stool is Hematest positive, it indicates occult blood. Note that a false-positive finding may occur if the person has ingested significant amounts of red meat within 3 days of the test.

Question 55

Black tarry stool with distinct malodor

Answer 55

Indicates upper GI bleeding with blood partially digested. (Must lose more than 50mL from upper GI tract to be considered melena.)

Question 56

Black stool

Answer 56

allso occurs with ingesting iron or bismuth preparations.

Question 57

Gray, tan stool

Answer 57

absent bile pigment (e.g., obstructive jaundice).

Question 58

Pale yellow, greasy stool

Answer 58

increased fat content (steatorrhea), as occurs with malabsorption syndrome.

Question 59

Occult bleeding

Answer 59

usually indicates cancer of the colon

Question 60

Pilonidal Cyst or Sinus

Answer 60

A hair-containing cyst or sinus located in the midline over the coccyx or lower sacrum. Often opens as a dimple with visible tuft of hair and, possibly, an erythematous halo. Or, may appear as a palpable cyst. When advanced, has a palpable sinus tract. Although it is a congenital disorder, the lesion is first diagnosed between the ages of 15 and 30 years.

Question 61

Anorectal Fistula

Answer 61

A chronically inflamed gastrointestinal tract creates an abnormal passage from inner anus or rectum out to skin surrounding anus. Usually originates from a local abscess. The red, raised tract opening may drain serosanguineous or purulent matter when pressure is applied. Bi-digital palpation may reveal an indurated cord.

Question 62

Fissure

Answer 62

A painful longitudinal tear in the superficial mucosa at the anal margin. Most fissures (>90%) occur in the posterior midline area. They are frequently accompanied by a papule of hyperplastic skin, called a sentinel tag, on the anal margin below. Fissures often result from trauma (e.g., passing a large, hard stool) or from irritant diarrheal stools. The person has itching, bleeding, and exquisite pain. A resulting spasm in the sphincters makes the area painful to examine; local anesthesia may be indicated.

Question 63

Hemorrhoids

Answer 63

These painless, flabby papules are due to a varicose vein of the hemorrhoidal plexus. An external hemorrhoid originates below the anorectal junction and is covered by anal skin. When thrombosed, it contains clotted blood and becomes a painful, swollen, shiny blue mass that itches and bleeds with defecation. When it resolves, it leaves a painless, flabby skin sac around the anal orifice. An internal hemorrhoid originates above the anorectal junction and is covered by mucous membrane. When the person performs a Valsalva maneuver, it may appear as a red mucosal mass. It is not palpable. All hemorrhoids result from increased portal venous pressure, as occurs with straining at stool, chronic constipation, pregnancy, obesity, chronic liver disease, or the low-fiber diet common in Western society.

Question 64

Rectal Prolapse

Answer 64

The rectal mucous membrane protrudes through the anus, appearing as a moist red donut with radiating lines. When prolapse is incomplete, only the mucosa bulges. When complete, it includes the anal sphincters. Occurs following a Valsalva maneuver, such as straining at stool, or with exercise.

Question 65

Pruritis Ani

Answer 65

Intense perianal itching is manifested by red, raised, thickened, excoriated skin around the anus. Common causes are pinworms in children and fungal infections in adults. The area is swollen and moist, and with a fungal infection, it appears dull grayish pink. The skin is dry and brittle with psychosomatic itching.

Question 66

Abcess

Answer 66

A localized cavity of pus from infection in a pararectal space. Infection usually extends from an anal crypt. Characterized by persistent throbbing rectal pain. Termed by the space it occupies (e.g., a perianal abscess is superficial around the anal skin) and appears red, hot, swollen, indurated, and tender. An ischiorectal abscess is deep and tender to bi-digital palpation. It occurs laterally between the anus and ischial tuberosity and is uncommon.

Question 67

Rectal polyp

Answer 67

A protruding growth from the rectal mucous membrane that is fairly common. The polyp may be pedunculated (on a stalk) or sessile (a mound on the surface, close to the mucosal wall). The soft nodule is difficult to palpate. Proctoscopy is needed as well as biopsy to screen for a malignant growth.

Question 68

Fecal Impaction

Answer 68

A collection of hard, desiccated feces in the rectum. The obstruction often results from decreased bowel motility, in which more water is reabsorbed from the stool. Also occurs with retained barium from gastrointestinal x-ray examination. The person may complain of constipation or of diarrhea as a fecal stream passes around the impaction.

Question 69

Carninoma

Answer 69

A malignant neoplasm in the rectum is asymptomatic, thus the importance of routine rectal palpation. An early lesion may be a single firm nodule. You may palpate an ulcerated center with rolled edges. As the lesion grows, it has an irregular cauliflower shape and is fixed and stone-hard. Refer a person with any rectal lesion for further study because about half are malignant.

Question 70

Benign Prostatic Hypertrophy

Answer 70

S: Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia.

O: A symmetric nontender enlargement, commonly occurs in males beginning in the middle years. The prostate surface feels smooth, rubbery, or firm (like the consistency of the nose), with the median sulcus obliterated.

Question 71

Prostatitis

Answer 71

S: Fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge; dull, aching pain in perineal and rectal area.

O: An exquisitely tender enlargement is acute inflammation of the prostate gland yielding a swollen, slightly asymmetric gland that is quite tender to palpation.
*With a chronic inflammation, the signs can vary from tender enlargement with a boggy feel to isolated firm areas due to fibrosis. Or the gland may feel normal.

Question 72

Carcinoma

Answer 72

S: Frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination; continuous pain in lower back, pelvis, thighs.

O: A malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland feels stone-hard and fixed. The median sulcus is obliterated.