Anatomy and Examination of the Anus, Rectum and Prostate

Chapter 15
The Anus, Rectum, and Prostate
Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins

Anatomy
Anatomy of the Anus, Rectum,
and Prostate – Side View
Anatomy of the Anus, Rectum,
and Prostate – Posterior View

Anatomy (cont.)
• The gastrointestinal tract terminates in a short
segment, the anal canal
– Normally, the anal canal is held in a closed
position by two muscles, the voluntary external
anal sphincter and involuntary internal anal
sphincter
– The angle of the anal canal lies on a line roughly
between the anus and umbilicus
– The anal canal is liberally supplied by somatic
sensory nerves

Anatomy (cont.)
• A serrated line demarcates the anal canal from the
rectum
• The anorectal junction (often called the pectinate
or dentate line) is the boundary between somatic
and visceral nerve supplies

Anatomy (cont.)
• In the male, the prostate gland lies against the
anterior rectal wall
– It is rounded, heart-shaped, and normally
2.5 cm long
– Only the lateral lobes and median sulcus
are palpable
• In the female, the uterine cervix usually is
palpable through the anterior wall of the rectum

Common or Concerning Symptoms
• Change in bowel habits
• Blood in the stool
• Pain with defecation; rectal bleeding or tenderness
• Anal warts or fissures
• Weak stream of urine
• Burning upon urination

The Health History
• Questions concerning symptoms related to the
anorectal area may be classified into two
categories:
– Lower gastrointestinal (GI)
– Lower genitourinary (GU)

The Health History (cont.)
• Lower GI concerns
– Is there any change in the pattern of bowel
function?
– Any change in the size or caliber of the stool?
– Any diarrhea or constipation?
– What color is the stool?
– Any obvious blood or mucus in the stool?

• Lower GI concerns (cont.)
– Any pain on defecation?
– Any itching?
– Any extreme tenderness in the anus or rectum?
– Any purulent discharge or bleeding?
– Any history of anal warts, ulcerations, or
fissures?
– Any involvement in anal intercourse?

• Lower GU concerns (for men)
– Is there any difficulty starting or holding back
the urine stream?
– Is the urine flow weak?
– Is there frequent urination, especially at night?
– Is there any pain or burning upon urination or
ejaculation?

• Lower GU questions (for men) (cont.)
– Any blood in the urine or semen?
– Any pain or stiffness in the lower back, hips,
or upper thighs?
– Any discomfort or heaviness at the base of the
penis with associated malaise, fever, or chills?

Health Promotion and Counseling
• Screen for prostate cancer
– Prostate cancer is the leading cancer diagnosed in
men in the United States, and the third leading
cause of death
– The primary risk factors are age, ethnicity, and
family history (although a series of studies have
suggested an association between intake of dietary
fat and risk of prostate cancer)
• Screen for polyps and colorectal cancer
• Provide counseling about sexually transmitted diseases

Techniques of Examination
• The anorectal and prostate examinations are
usually the least popular segments of the physical
examination
• A skillfully performed examination should not be
truly painful
• Successful examination requires a calm demeanor,
explanation to the patient of what he or she may
feel, gentleness, and slow movement of your finger
• In asymptomatic adolescents, it is appropriate to
defer the rectal exam

Techniques of Examination (cont.)
• The male patient
– One of several patient positions may be used
for examination
o The patient may stand, leaning forward with
his upper body resting across the examining
table and hips flexed
o The patient may lie on his left side with his
buttocks close to the edge of the exam table
near you; flex the patients hips and knees,
especially the top leg

• The male patient (cont.)
– Inspect the sacrococcygeal and perianal
areas
o Assess for lumps, ulcers, inflammation,
rashes, or excoriations
o Palpate any abnormal areas, noting lumps or
tenderness

– Occasionally, severe tenderness prevents entry
and internal examination
– Instead, place your fingers on both sides of the
anus, gently spread the orifice, and ask the
patient to bear down
– Look for a lesion, such as an anal fissure, that
might explain the tenderness

– Examine the anus and rectum
o Lubricate a gloved index finger
o Explain what you are going to do
o Inspect the anus, noting any lesions
o Ask the patient to strain down
o Place finger pad over the anus and gently insert your
fingertip into the anal canal; proceed with insertion
upon relaxation of the sphincter
 Assess for sphincter tone of the anus, tenderness,
induration, irregularities, or nodules

– Examine the posterior surface of the prostate
gland
o Identify lateral lobes and median sulcus
o Note size, shape, and consistency of the prostate;
identify any nodules or tenderness
o Normal prostate is rubbery and nontender
o If possible, extend your finger above the prostate
to the region of the seminal vesicles and the
peritoneal cavity; note any nodules or tenderness
o Note the color of any fecal matter on the glove,
and test it for occult blood

Question
A 65-year-old male presents to clinic for a routine
examination. The following is the documentation of
his prostate examination. Which statement would be
of concern?
a. Firm
b. Heart-shaped
c. 2.5 cm long
d. Median sulcus palpable

Answer
a. Firm
• The normal prostate is rubbery.

• The female patient
– The rectum is usually examined after the female
genitalia, while the woman is in the lithotomy
position; this position is also ideal for conducting the
bimanual examination and is suitable for testing the
integrity of the rectovaginal wall and may also help
to palpate a cancer high in the rectum
– If the rectum only requires examination, the side-lying
position affords a much better view to the
perianal and sacrococcygeal areas
– Use the same techniques for examination that are
used for men

Question
The female patient may remain in a lateral position
for examination of which of the following:
a. Adnexal mass
b. Perianal fissure
c. Integrity of the rectovaginal wall
d. Pelvic mass

Answer
b. Perianal fissure
• The rectum is usually examined while the
woman is in the lithotomy position, which is also
ideal for conducting the bimanual examination
and is suitable for testing the integrity of the
rectovaginal wall; it may also help to palpate a
cancer high in the rectum
• If the rectum only requires examination, the
side-lying position affords a much better view to
the perianal and sacrococcygeal areas

Anatomy and Examination of the Anus, Rectum and Prostate

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