Anus, Rectum, and Prostate
Chapter 23
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Health History: Risk Factors
Colorectal cancer
• Age: highest incidence—middle age/older
– About 90% of new cases—>50
• History:
– Personal: colorectal cancer, adenomatous polyps, or
inflammatory bowel disease
– Family: strong for colon cancer (member of family
with hereditary colorectal cancer) or polyps
• Lifestyle: smoking, excessive alcohol intake, and
sedentary lifestyle
• Diet: obesity; high-fat, low-fiber diet
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Health History: Risk Factors
Prostate cancer
• Age: older men; 75% new cases—males >65
• Family history: 1st degree relative with prostate
cancer
• Ethnicity: African-American men—highest
incidence, twice as high as white men
• Worldwide, highest prevalence in North America
and northwestern Europe
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Health History:
Present Health Status
• Any chronic illnesses? Describe.
• Medications currently taking? Use
laxatives/stool softeners? How often?
• Kinds of foods eaten? Routinely eat high-
fiber foods? Fluid drunk each day? Types
of beverages?
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Health History:
Present Health Status
• Have had a test examining stool/visual
exam of rectum/colon? If so, when?
Results?
• Men: Last prostate exam? Have had a
prostate-specific antigen (PSA) blood
test? When? Results?
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Health History
Bowel Elimination Pattern
• Pattern of bowel movements: How often?
Regular? Describe. Hard? Soft? Color?
• Ever use enema? If so, how often?
• Rely on morning coffee, tea, or nicotine to
stimulate bowel movement?
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Health History
Anal Sex
• Engage in anal sex? If so, how often?
Men: Recipient? Include oral-anal or
genital-anal sex?
• How many partners in last year?
Lubrication? Condoms?
• Did sex include inanimate objects inserted
into anus/rectum? Types of objects used?
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Health History:
Past Medical History
• Past medical problems? Diagnosed with
medical condition related to rectum (e.g.,
hemorrhoids, warts, polyps, infection)?
When? How treated?
• Problem with prostate such as enlarged
prostate, infection of prostate (prostatitis),
or cancer?
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Health History: Family History
• Has anyone in family had colon or rectal
cancer? Polyps in rectum or colon?
Inflammatory bowel disease?
• Men: Anyone in family had prostate
cancer? If so, who? What age?
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Problem Based History
Change in Bowel Function
• First notice change? Sudden or gradual? What
might be causing change?
• Describe change. Number of stools per day?
Consistency? Appearance? Pain?
• Increased gas (flatus), pain, fever, nausea,
vomiting, abdominal pain or cramping, diarrhea,
or discomfort after eating? Connection with
specific foods? Anyone else in family have
same symptoms?
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Problem Based History
Rectal Bleeding
• First start? Constant or come and go?
• Describe color of blood. How much blood
noticed? Blood alone, mixed with stool, or
both? Odd odor accompanying bloody
stool?
• Presence of mucus in stools with blood?
Accompanying abdominal cramping or
pain? Have you been constipated?
• Other symptoms such as fatigue?
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Problem Based History
Rectal Discomfort: Pain, Itching
• When begun? Feels like? Constant or come and
go? Localized or radiate?
• How severe is pain? Rate pain on a scale of
1-10. Does it interfere with daily activities?
• Which makes it worse—activity or bowel
movement? What reduces pain, if anything?
• Have hemorrhoids? If so, bleed? How treated?
• Sores on your anus or surrounding skin? What
do they look like?
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Problem Based History
Changes in Urinary Function: Men
• What changes noticed? When did it begin?
Worse? Constant or come and go?
• Difficult beginning urinating? Urine stream
weak? Dribble? Have to urinate but can’t?
Get up in middle of night to urinate?
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Examination
Preparation
• Exam of rectum/anus done on all adults
• Examination gloves worn throughout exam
• Inspection and palpation
• Anal/rectal exam same for male/female clients
• Male—prostate exam with rectal exam
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Examination
• Positioning for rectal exam depends on
client’s gender/age
– Male—left lateral position, hips and knees
flexed; knee-chest position; or standing, hips
flexed, bending over exam table, feet pointed
together
– Female—lithotomy position (if exam with
genitalia exam) or left lateral position
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Procedures and Techniques
Normal Findings
Anus and rectum
• Inspect and palpate sacrococcygeal areas for
surface characteristics and tenderness
– Skin—smooth and clear, no tenderness on palpation
• Inspect perianal area/anus for pigmentation and
surface characteristics
– Perianal skin—darker than general skin tone
– Anus—coarse, moist, hairless, more pigmented than
perianal skin; tightly closed, no lesions
– Have client bear down—inspect; no lesions
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Procedures and Techniques
Normal Findings
• Stool examination
– Examine for characteristics and occult blood
– Slowly remove finger from rectum; inspect
gloved finger for color/consistency of stool
• Brown/soft
• Guaiac for occult blood (negative)
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Age-Related Variations:
Older Adults
Anatomy and physiology
• Men, prostate gland atrophies—loss of function
– Benign enlargement of prostate—associated with
aging
– Mild enlargement—no symptoms, significant
hyperplasia obstructs bladder outlet, causing urinary
problems
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Age-Related Variations:
Older Adults
Health history
• May have elimination problems; so preoccupied
with irregularity that it alters daily living
– Clarification of symptoms is needed
– If symptoms are long-standing, ask about client’s
method of self-treatment
– Questions asked are same as for adults—pay
attention to responses concerning constipation, gas in
stomach, diarrhea, or abdominal cramping
– Medications more likely to produce changes in bowel
motility in older clients; evaluate
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Age-Related Variations:
Older Adults
Health history (cont’d)
• Older man—urinary symptoms from enlarged
prostate
– Important to ask all questions related to prostate
– American Urological Association (AUA) index
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Age-Related Variations:
Older Adults
Examination: procedures and techniques
• Client may need assistance getting into an
adequate position for examination
– If lying on back on exam table, may need assistance
turning to left lateral lying position
• Examination procedure is same as that for adult
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Age-Related Variations:
Older Adults
Normal and abnormal findings
• Findings are same as those for the adult
• Prostate hyperplasia common abnormal
finding
• Prostate may feel smooth and rubbery;
median sulcus may/may not be palpable
• May note relaxation of client’s perianal
muscles/decreased sphincter control when
bears down
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Common Problems and Conditions:
Anus and Rectum
Clinical findings
• Dimpled area, small opening with tuft of hair in
sacrococcygeal area
• Usually diagnosed in young adulthood,
occasionally at birth—depression in sacral area
• If infected, area red/tender, cyst palpable
• Cyst often drains a mucoid or purulent discharge
• May complain of pain/swelling at base of spine
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Common Problems and Conditions:
Anus and Rectum
Hemorrhoids
• Dilated veins (hemorrhoidal plexus)—
increased portal venous pressure
– Frequently caused by pregnancy, constipation,
chronic liver disease, and obesity
– Large numbers suffer condition without
seeking treatment
– Both genders affected equally
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Common Problems and Conditions:
Anus and Rectum
Hemorrhoids (cont’d)
• Clinical findings
– External hemorrhoids—outside external rectal
sphincter; flaps of tissue/skin
• If irritated/thrombosed, localized itching and
bleeding; blue or purple shiny masses at anus
– Internal hemorrhoids—-above interior
sphincter
• May be in rectum, not seen unless thrombosed,
prolapsed, or infected
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Common Problems and Conditions:
Anus and Rectum
• Clinical findings
– May/may not have symptom
– Most important symptom—rectal bleeding; if
have, better long-term outcomes
– Rectal bleeding—consistent with tumor at
early stage; more vascularized than advanced
lesion
– If tumor palpable, presents as an irregular
mass on rectal wall with nodular, raised edges
– Center of the mass often has an area of
depression
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