ANUS, RECTUM, AND PROSTATE

2.2
August 6, 2014

Dr. Tengco
REFERENCE:
Previous trans
Bates

Dr. Guzmans words of wisdom

OUTLINE:
I. Anatomy and Physiology
A. Anus (Anal Canal)
B. Rectum
C. Prostate Gland
D. Cervix
II.
Rectal and Genital Examination
A. Health History
1. Common Symptoms
B. Rectal Examination
1. Positions
2. Procedure
3. Alternate Approach
III.Screening for Prostate Cancer
A. Risk Factors
B. Common Methods of Screening
C. Chemoprevention
D. Counseling Men about Prostate Cancer
IV. Screening for Colorectal Cancer
V. Counselling for STIs
VI. Abnormalities of Anus, Surrounding Skin and
Rectum
VII.
Abnormalities of Prostate

I. ANATOMY AND PHYSIOLOGY

A. ANUS (ANAL CANAL)
Terminal portions of the GIT
Anal canal: 2.5 4 cm, opens onto the perineum
o External margin of the anus is poorly demarcated but
is distinguished by moist, hairless mucosa
o Juncture with the perianal skin: increased pigmentation
and (+) hair
o Concentric ring of muscles: internal & external
sphincters hold the anal canal closed

Internal -involuntary autonomic control

-extension of the muscular coat of the
rectal wall

External voluntary control

o Lower half: supplied w/ somatic sensory nerves
(painful, a poorly directed finger or instrument will
produce pain)
o Upper half: autonomic control (insensitive)
o Lined by columns of mucosal tissue (columns of
Morgagni)
o Crypts: space between the column into which anal
glands empty fistula or fissure formation
o Anastomosing veins cross the columns, forming a ring
called zona hemorrhoidalis: internal hemorrhoids
o Lower segment of the anal canal contains a venous
plexus that drains into the inferior rectal veins:
external hemorrhoids
o Angle of the anal canal: on a line roughly between the
anus and umbilicus
Pectinate or dentate line
o Anorectal junction
o Serrated line marking the change from skin to mucous
membrane demarcates the anal canal from rectum
o Boundary between somatic and visceral nerve supplies
o Visible on proctoscopic examination but not palpable

Figure 1. Anatomy of the anal canal

Figure 2. Coronal section of the anus and rectum, posterior view, showing at the
anterior wall.

B. RECTUM
Superior to the anus, 12 cm
Balloons out above the anorectal junction and turns posteriorly
into the hollow of coccyx and sacrum
Proximal end is continuous w/ sigmoid colon
Distal end, anorectal junction, visible on proctoscopic exam as
saw tooth-like edge, but it is non palpable
Rectal ampulla: stores flatus & feces
3 semilunar transverse folds (Houston valves)
o Three inward foldings found in the rectal wall
o Lowest can sometimes be felt on the patients left
o Most surface that is accessible to digital examination
does not have a peritoneal surface except for the
anterior rectum
o Anterior rectum can be reached with the tip of your
examining finger and if there are peritoneal metastases,
tenderness (due toinflammation) or nodularity is present
Anterior rectal wall lies in contact with the vagina and is
separated from it by the rectovaginal septum

Figure 3. Coronal section of the anus and rectum, posterior view, showing at the
anterior wall.

ELI

C. PROSTATE GLAND
Located at the base of bladder, surrounds the urethra
Muscular & glandular tissue
4 x 3 x 2 cm
Posterior surface is in contact w/ anterior rectal wall,
accessible by digital exam
Convex, divided by median sulcus into R & L lateral lobe,
median lobe is non palpable
In males, 3 lobes of prostate gland surround the urethra
small during childhood
Increases roughly fivefold in size between puberty and approx.
20 years
Volume expands as the gland becomes hyperplastic
Two lateral lobes lie against the anterior rectal wall and are
palpable as a rounded, heart-shaped structure approx. 2.5
cm long
Median sulcus or groove separates the 2 lateral lobes
Third (median) lobe is anterior to the urethra and cannot be
examined

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ANUS, RECTUM, AND PROSTATE

ANUS, RECTUM AND PROSTATE
Seminal vesicles shaped like rabbit ears above the
prostate are not normally palpable

B. RECTAL EXAMINATION
Generally uncomfortable & embarrassing
Be calm, slowly paced, & gentle in your touch
Explain what will happen step by step & let the patient
know what to expect
Inspection and palpation ONLY

D. CERVIX
In females, palpable through the anterior wall of the
rectum
II. RECTAL AND GENITAL EXAMINATION
If they have not already done so, ask the patient to
remove their underwear.
This examination is probably easier to perform and yields
more information if it is done with the patient standing
while you are seated in front of them.
In this position, it is easier to examine the testes, evaluate
for inguinal hernias and perform the rectal exam.
However, if the patient is unable to stand/unsteady on
their feet, it can be performed while they lie on the
exam table.
A. HEALTH HISTORY
1. COMMON SYMPTOMS
Change in bowel habits
o Ask: change in pattern of bowel function, size and
caliber of stool, diarrhea or constipation, abnormal
stool color
o Colon cancer: thin pencil-like shape stool
o Villous adenoma: mucus in stool
Blood in the stool
o May range from black stools (melena), to red blood
(hematochezia), to bright-red per rectum
o (+) blood in stool: present in polyps, cancer, GI
bleeding or local hemorrhoids
o Ask: personal or family history of colonic polyps,
colorectal CA, or IBD
Pain with defecation; rectal bleeding or tenderness
o Ask: pain on defecation, itching, tenderness in
anus and rectum, mucopurulent discharge,
ulcerations and any history of anal intercourse
o Proctitis: itching, anorectal pain, tenesmus or
discharge or bleeding from infection or rectal
abscess

gonorrhea, chlamydia, lymphogranuloma

venereum, herpes simplex,syphilis
Anal warts or fissures
o Anal warts: HPV, secondary syphilis (condylomata
lata)
o Anal fissures: proctitis, Crohns disease
Weak stream of urine
o Ask: difficulty starting/ holding back urine stream,
weak flow, urinary frequency, nocturia, dysuria,
hematuria, pain on ejaculation, pain or stiffness in
the lower back, hips, or upper thighs
o May suggest urethral obstruction, BPH, or prostate
CA
Burning urination

ELI

Possible prostatitis if accompanied by malaise,

fever or chills

I.
II.
III.
IV.

1. POSITIONS
Knee-chest
Left lateral with hips & knees flexed

Satisfactory, allows good visualization of the

perianal and sacrococcygeal areas
Standing w/ the hips flexed & upper body supported
by the examining table
Females: lithotomy

Figure 4. Rectal exam positions

I.standing w/ the hips flexed & upper body supported by the
examining table; II.Knee-chest; III. Lithotomy; IV.left lateral with hips
& knees flexed

NOTE: No matter how you position the patient, you will

not be able to examine the full length of the rectum. If
rectosigmoid CA is suspected, consider sigmoidoscopy or
colonoscopy
2. PROCEDURE
Have the patient stand and learn forward, resting his
hands on the examining table.
2. Place a small amount of lubricant on your gloved
index finger.
3. Place your finger at the anus and wait for reflex
sphincter relaxation.
push one side to let the finger slide in (Guzman)
examine the anal sphincter (for the tone) first
before palpating the rectal wall
4. Gently insert your finger and examine as much of the
rectal wall as possible.
5. Sequentially examine the right lateral, posterior and
left lateral surfaces feeling for pelvic structures.
6. Evaluate the prostate gland in men along anterior
wall.
7. Examine the posterior surface of the prostate.
8. Evaluate the lateral lobes and the sulcus.
9. Note the size, shape, consistency and tenderness.
10. Note the rectal contents.
1.

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ANUS, RECTUM, AND PROSTATE

ANUS, RECTUM AND PROSTATE
11. Remove finger and evaluate the faeces on the gloved
finger and save it for Guaic testing

15.

1.
2.
3.
4.
5.
6.
7.
8.
-

9.
o
o
10.
11.
12.
13.
14.
-

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3. ALTERNATE APPROACH (from Bates)

Ask the patient to lie on his left side, his buttocks
close to the edge of the examining table near you.
Flex the patients hips & knees especially in the
upper leg to stabilize his/her position and improves
visibility.
Drape the patient appropriately exposing the buttocks
adequately.
Glove your hands and spread the buttocks apart.
Inspect the sacrococcygeal & perianal areas for
lumps, ulcers, inflammation, rashes, and excoriations
Adult perianal skin is normally more pigmented and
somewhat coarser than the skin over the buttocks
Anal lesions: hemorrhoids, venereal warts, herpes,
syphilitic chancre, carcinoma
Causes of anal fissure: large, hard stools, IBD, STI
Pruritus ani- swollen, thickened, fissured perianal
skin with excoriations
Ask the patient to strain: inspect the anus for any
lesions, fissures & hemorrhoids
Anorectal fistula tender, purulent, reddened mass
with fever or chills and abscess tunneling to the skin
Place the pad of your lubricated index finger over the
anus
As the sphincter relaxes, gently insert your fingertip
into the anal canal (direction is toward the
umbilicus)
If you feel the sphincter tighten, pause and reassure
the patient. When the sphincter relaxes, proceed.
If there is severe tenderness, place your fingers on
both sides of the anus and gently spread the orifice
then ask the patient to strain down look of lesions
causing the tenderness
Note for sphincter tone, any tenderness, induration
and nodules
Sphincter tone
Tightness: anxiety, inflammation, or scarring
Laxity: neurologic disease (S2-S4 cord lesion)
Induration-may be caused by inflammation, scarring
or malignancy
Insert your examining finger into the rectum as far as
possible
Rotate your hand clockwise to palpate as much of
the rectal surface as possible on the patients right
side
Rotate your hand counterclockwise to palpate the
surface posteriorly and on the patients left side
Again note for any tenderness, induration or
irregularities and nodules
Rotate your hand further counterclockwise so that
your finger can examine the posterior surface of
the prostate gland
By turning your body somewhat away from the
patient, you can feel this area more easily.

16.
17.
18.

19.
20.
21.

Tell the patient that examining his prostate gland may

prompt an urge to urinate.
Sweep your finger gently over the prostate gland
identifying its lateral lobes and the median sulcus
between them
Note the size, shape & consistency of the prostate
Identify any nodules or tenderness
If possible, extend your finger above the prostate to
the region of the seminal vesicles and peritoneal
cavity and sweep the anterior wall. Note for any
nodule or tenderness
Gently withdraw your finger
Note any fecal material or blood on the withdrawn
examining finger
Note the color and test for occult blood
Wipe the patients anus or give him tissues to do it
himself

NOTE: the technique of rectal exam in the female is the

same. The cervix is usually felt readily through the
anterior rectal wall. Sometimes, a retroverted uterus is
also palpable.
The rectum is usually examined after the female genital,
usually in lithotomy position. This position allows to
conduct the bimanual examination and delineate possible
adnexal or pelvic mass. It also allows the examiner to test
the integrity of the rectovaginal wall and may help in
palpating a cancer high in the rectum.
III. SCREENING FOR PROSTATE CANCER
Prostate cancer is the leading cancer diagnosed in US
men and the second leading cause of death in men
after lung cancer
A. RISK FACTORS
1. Age

After 50 years of age, the risk increases sharply with

each advancing decade
2. Ethnicity

Incidence is higher in African American than

Caucasian men
3. Family history

One affected first degree relative = 2-3x likely to have

cancer

Two or more affected relatives = 3-5x risk

Genetic: mutation with BRCA2 mutation

4. Diet

There is a study that suggests association between

prostate cancer and the high intake of saturated fat
from dairy and animal sources but evidence is
inconclusive

Recent study found that there is no evidence of

decreased risk from selenium or vitamin E
B. COMMON METHODS OF SCREENING
1. Prostate Specific Antigen (PSA)

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ANUS, RECTUM, AND PROSTATE

ANUS, RECTUM AND PROSTATE

PSA is a glycoprotein produced by prostate epithelial

cells

Biomarker for early detection of prostate cancer

Has a number of limitations as a screening test

Elevated in a number of benign conditions:

o False
positive:
hyperplasia,
prostatitis,
ejaculation, and urinary retention
o False negative: some men with prostate cancer
will not have elevated PSA

Common cutpoint for proceeding to biopsy:

4.0ng/mL

Does not distinguish small volume indolent cancers

from aggressive life threatening disease

Extends lead time (time that the screening alone

advances diagnosis) by 5 to 7 years.

Increases overdiagnosis (diagnosis in men who

would not have clinical symptoms during their
lifetime) by an estimated 23-43%

Can lead to harm from overtreatment due to

indolent curative surgery or radiation for cancer

Modifications of PSA such as PSA density, PSA

velocity, and PSA doubling time have not been
shown to improve health outcomes
2. Digital Rectal Exam (DRE)

Low sensitivity 59% and specificity of 94%

Detects tumors on posterior and lateral aspects of

the gland but misses the 25% to 35% of tumors
arising in other areas

Suspicious findings of nodules, asymmetry, and

induration should be pursued
3. PSA and DRE

US Prostate, Lung, Colorectal, and Ovarian (PLCO)

Cancer Screening Trial study showed no benefit from
screening in reducing mortality.
o Men were offered either:
1. Annual PSA testing for 6 years and DRE for 4
years
2. Usual care

Prostate-Cancer Mortality in a Randomized

European Study (ERSPC)showed 20% reduction in
mortality in men ages 55 to 69 years old.
o Men were offered PSA screening once every 4
years

In 2010, a meta-analysis of 6 randomized controlled

studies showed screening leads to early diagnosis
but has no significant effect on prostate cancer
mortality. The said study has a significant limitations
in study methodology, ranging from inadequate
concealment of randomization before or after
recruitment, termed allocation concealment, to
short length of follow-up
C. CHEMOPREVENTION
Inhibits conversion of testosterone to principal intracellular
androgen DHT (via 5 reductase)

ELI

Shrinks or inhibit growth of existing CA rather than

preventingthem
1. Finasteride-inhibits 5 reductase type 2
2. Dutasteride-inhibits5 reductase type 1 and type 2
D. COUNSELING MEN ABOUT PROSTATE CANCER
Ask-Tell-Ask Approach
Ask : Clinicians ask first to assess a patients desire for
information
Tell : Filling in the info requested by the patient, keeping
the patients educational level in mind and using
appropriate decision aids
Ask : Ask if the patient is ready to make a decision to
undergo screening
IV.SCREENING FOR COLORECTAL CANCER
Identify patients at average risk, ideally by age 20, but
earlier if there are high risk factors such as IBD or a
family history of an inherited polyposis syndrome
Offer patients at average risk with screening options
(starting 50yo)
1. High sensitivity fecal occult blood test (FOBTs)
annually
2. Sigmoidoscopy every 5 years with FOBT every 3
years
3. Screening colonoscopy every 10 years
4. Double-contrast barium enema or computed
tomography colonography every 5 years
Note: FOBT should involve at-home collection of 6
samples over a 2-3 day period
Patients at increased risk should undergo colonoscopy
every 3 to 5 years
V. COUNSELING FOR SEXUALLY TRANSMITTED
INFECTIONS (STIs)
Anal intercourse, places men and women at risk for
perianal and rectal abrasions and transmission of HIV
and other STIs
Preventive measures include:
o Abstinence
o Use of Condoms
o Good hygiene
REMEMBER ABCD: A-Abstinence, B-Be faithful, CCondom, D- Do not get pregnant
VI. ABNORMALITIES OF ANUS, SURROUNDING SKIN,
AND RECTUM

Pilonidal
cyst and
sinus

Common
Located midline
superficial to
coccyx or lower
sacrum
Look for opening
of sinus tract
that may exhibit

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ANUS, RECTUM, AND PROSTATE

ANUS, RECTUM AND PROSTATE

External
Hemorrhoids
(thrombosed
)

Internal
hemorrhoids
(prolapsed)

ELI

a small tuft of
hair surrounded
by a halo or
erythema
Generally
asymptomatic
Slight drainage,
abscess
formation, and
secondary sinus
tracts may
complicate the
abnormality
Dilated
hemorrhoidal
veins that
originate below
the
pectinatelineand
covered with skin
Seldom with
symptoms unless
thrombosis
occurs
Acute local pain
that increases
with defection
and sitting
Tender, swollen,
bluish, ovoid
mass is visible at
the anal margin
Enlargement of
the normal
vascular
cushions
located above
the pectineal
line
Not usually
palpable
Bright red
bleeding
May also prolapse
through the anal
canal
Appear as
reddish, moist,
protruding
masses

Prolapse of
the Rectum

Anal fissure

Anorectal
fistula

Straining for
bowel
movement, the
rectal mucosa
may prolapse
through the
anus
Doughnut or
rosette of red
tissue
Prolapse involving
only mucosa is
relatively small
and shows
radiating folds
If entire bowel
wall, larger and
covered by
concentrically
circular folds
Very painful
ulceration of the
anal canal
Most common in
the midline
posteriorly
Less common in
midline
anteriorly
Swollen sentinel
skin tag below it
Sphincter is
spastic
Painful
examination
Needs local
anesthesia
Inflammatory tract
or tube that
opens at one
end into the
anus or rectum
and the other
end onto the
skin surface
Abscess usually
antedates
Fistulous opening
anywhere in the
skin around the
anus

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ANUS, RECTUM, AND PROSTATE

ANUS, RECTUM AND PROSTATE

Polyps of the
Rectum

Fairly common
Variable in size
and number
Pedunculated
with stalk
Sessile lie on
mucosal surface
Soft and
impossible to
feel
Proctoscopy and
biopsy needed
to check if
malignant or
benign

Cancer of
the Rectum

Asymptomatic
carcinoma
Firm, nodular,
rolled edge of
an ulcerated
cancer

Rectal shelf

Widespread
peritoneal
metastases
Firm to hard
nodular rectal
shelf palpable
with the tip of
examining finger

Benign
Prostatic
Hyperplasia

Cancer of
the
Prostate

Normal in size,
feel
symmetrically
enlarged,
smooth, and
firm
Obliteration
of
median sulcus
and
more
notable
protrusion into
the
rectal
lumen
Area
of
hardness
in
the gland
Distinct
hard
nodule
that
alters
the
contour of the
gland may or
may not be
palpable
Median sulcus
may
be
obscured
As
cancer
enlarges,
it
becomes
irregular and
extend
beyond
confines of the
gland
May also result
from prostatic
stones,
chronic
inflammation,
and
other
conditions

VI. ABNORMALITIES OF THE PROSTATE

Rounded, heartshaped
2.5 cm long
Normal
Median sulcus is
Prostate
felt between 2
lateral lobes
gland
Only posterior
surface
is
palpable
Tender, swollen
boggy, and
QUIZ:
warm
1. Serrated line marking the change from skin to mucous
membrane that demarcates the anal canal from rectum
Infective
by
is also known as?
gram negative
Prostatitis
a. Pectinate line
c.
Columns
of
aerobes
or
Morgagni
sexual
b. Pectineal line
d. Houston Valves
transmission
of
Neisseria 2. Which of the following is a possible differential after
seeing a rectal fissure?
and
a. Syphilis
C. BPH
Chlamydia
b. IBD
D. Cancer

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3.

Tender, purulent, reddened mass with fever or chills

and abscess tunneling to the skin is indicative of:
a. Syphilitic chancre
c. Pruritus ani
b. Condylomata lata
d. Anorectal fistula
4. Which of the following structures is not palpable on a
rectal exam?
a. External anal sphincter
b. Retroverted uterus
c. Anterior lobe of prostate
d. Seminal vesicles
5. What is the action of the drug Finasteride?
a. Activates 5 reductase type 2
b. Inhibits 5 reductase type 2
c. Inhibits 5 reductase type 1 and 2
d. Activates 5 reductase type 1 and 2
6. Lesion that is common in the coccyx and lower sacrum
that exhibits as a small tuft of hair surrounded by a halo
or erythema?
a. Anal fissure
b. External hemorrhoids
c. Internal hemorrhoids
d. Pilonidal Cyst
7. Which of the following should be considered if a firm to
hard nodular rectal shelf palpable with the tip of
examining finger?
a. Benign prostatic hyperplasia
b. Internal hemorrhoids
c. Primary peritoneal cancer
d. Widespread peritoneal metastasis
8. Which of the following is a correct recommendation for
screening of colorectal CA?
a. FOBT every 3 years
b. Screening colonoscopy every 5 years
c. Sigmoidoscopy every 5 years with FOBT every 3
years
d. Double-contrast barium enema or computed
tomography colonography every year
9. Tender, boggy and warm prostate upon rectal exam is
indicative of
a. Normal variation
c. BPH
b. Prostatitis
d. Prostate cancer
10. A donut or rosette of red tissue seen on the anal
canal after straining is indicative of

a.
b.
c.
d.

Internal hemorrhoids
External hemorrhoids
Anal fissure
Rectal prolapse

ELI

Page
1. A
2. B