1. Usual bowel routine.

 •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?

Assess usual bowel routine.

Constipation is

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

Dyschezia.

(hemorrhoid, fissure) or constipation.

2. Change in bowel habits.

change

bowel habits?

 •Eaten at a restaurant recently?

Anyone else in your group or family have the same symptoms?

•Traveled to a foreign country during the past 6 months?

•Stools have a hard consistency? When did this start?

Diarrhea occurs with

gastroenteritis,

colitis,

irritable colon syndrome.

Consider food poisoning.

Consider parasitic infection.

Constipation.

3. Rectal bleeding, blood in the stool.

 •Ever had clay-colored stools?

 •Ever had mucus or pus in stool?

 •Frothy stool?

•Need to pass gas frequently?

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.

Clay color indicates absent bile pigment.

Steatorrhea

Flatulence.

4. Medications.

What medications do you take—prescription and over-the-counter? Laxatives or stool softeners?

Which ones? How often? Iron pills?

Do you ever use enemas to move your bowels? How often?

5. Rectal conditions.

•Ever had a problem controlling your bowels?

Pruritus.

Fecal incontinence.

Mucoid discharge and soiled underwear occur with

prolapsed hemorrhoids.

6. Family history.

family history:

Risk factors for colon cancer,

rectal cancer,

 prostate cancer.

7. Self-care behaviors.

high-fiber foods

 •Date of last: digital rectal examination,

stool blood test, colonoscopy, (for men) prostate-specific antigen blood test.

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.

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.

²

INSPECT THE PERIANAL AREA

Spread the buttocks wide apart and 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.

Inspect the sacrococcygeal area.

Normally, it appears smooth and even.

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

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.

Inflammation. Lesions or scars.

Linear split—fissure.

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

Small round opening in anal area

—fistula

Inflammation or tenderness, swelling, tuft of hair, or dimple at tip of coccyx may indicate pilonidal cyst

Appearance of fissure or hemorrhoids.

Circular red doughnut of tissue—rectal prolapse

PALPATE THE ANUS AND RECTUM

Drop lubricating jelly onto your gloved index finger.

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

Place the pad of your index finger gently against the anal verge (Fig. 25-4).

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.

Rotate your examining finger to palpate the entire muscular ring.

 The canal should feel smooth and even. Note the intersphincteric groove circling the canal wall.

To assess tone, ask the person to tighten the muscle. The sphincter should tighten evenly around your finger with no pain to the person.

Use a bi-digital palpation with your thumb against the perianal tissue (Fig. 25-5).

 Press your examining finger toward it.

 This maneuver highlights any swelling or tenderness and helps assess the bulbourethral glands.

Decreased tone.

Increased tone occurs with inflammation and anxiety.

Tenderness.

anus and rectum cont.

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

Insert your finger farther and explore all around the rectal wall.

It normally feels smooth with no nodularity.

Promptly report any mass you discover for further examination.

Internal hemorrhoid above anorectal junction is not palpable unless thrombosed.

A soft, slightly movable mass may be a polyp.

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

Prostate Gland.

into

Size—2.5 cm long by 4 cm wide; should not protrude more than 1 cm into the rectumv

Surface—smooth

Consistency—elastic, rubbery

Mobility—slightly movable

Sensitivity—nontender to palpation

Enlarged or atrophied gland.

Flat with no groove.

Nodular.

Hard; or boggy, soft, fluctuant.

Fixed.

Tender.

Enlarged, firm, smooth gland with central groove obliterated suggests benign prostatic hypertrophy.

Swollen, exquisitely tender gland accompanies prostatitis.

Any stone-hard, irregular, fixed nodule indicates carcinoma

In the female, palpate the cervix through the anterior rectal wall.

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.

Withdraw your examining finger; normally, no bright red blood or mucus is on the glove.

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

Examination of Stool.

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

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.

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

A patient collects the stool specimen at home and mails it to the laboratory.

 The guaiac-based fecal occult blood test has long been in use but it requires three separate stool samples to yield a sensitivity of 92%.¹⁶

Also, false positives can occur due to ingestion of red meat and other foods and certain medications.

Evidence shows the newer fecal immunochemical test is easier and requires only one stool sample.

It detects antibodies specific for human hemoglobin and is sensitive to invasive cancers and precancerous lesions.

¹

Jelly-like mucus shreds mixed in stool indicate inflammation.

Bright red blood on stool surface indicates rectal bleeding.

Bright red blood mixed with feces indicates possible colonic bleeding.

Black tarry stool with distinct malodor ind

icates upper GI bleeding with blood partially digested.

(Must lose more than 50 mL from upper GI tract to be considered melena.)

Black stool—also occurs with ingesting iron or bismuth preparations.

Gray, tan stool—absent bile pigment (e.g., obstructive jaundice).

Pale yellow, greasy stool—increased fat content (steatorrhea), as occurs with malabsorption syndrome.

Occult bleeding usually indicates cancer of the colon.

The Aging Adult

As an aging person performs the Valsalva maneuver,

you may note relaxation of the perianal musculature and decreased sphincter control.

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

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.

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.

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.

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.

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.

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.

absess

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.

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.

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.

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.

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.

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.

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.