UNIT 9.1: Rectum & Genitalia

1. spread the client’s buttocks

2. inspect the anal opening and surrounding area for the following:

   • lumps

   • ulcers

   • lesions

   • rashes

   • redness

   • fissures

   • thickening of the epithelium

how to inspect the perianal area

1. anal opening should appear hairless, moist, and tightly closed.

2. skin around the anal opening is coarser and more darkly pigmented.

3. surrounding perianal area should be free of redness, lumps, ulcers, lesions, and rashes.

normal findings for perianal area

1. STIs, cancer, or hemorrhoids.

2. thrombosed external hemorrhoid

3. previously thrombosed hemorrhoid

(abnormal findings for perianal area)

1. lesions may indicate..

2. ___________ appears swollen.

   • it is itchy, painful, and bleeds when the client passes stool.

3. a ____________ appears as a skin tag that protrudes from the anus.

1. perianal abscess

2. a fissure in the anal canal

3. scratching an area infected by fungi or pinworms

(abnormal findings for perianal area)

1. painful mass that is hardened and reddened suggests a..

2. swollen skin tag on the anal margin may indicate a..

3. redness and excoriation may be from..

1. anorectal fistula

2. repeated trauma from anal intercourse.

(abnormal findings for perianal area)

1. small opening in the skin that surrounds the anal opening may be an..

2. thickening of the epithelium suggests..

1. valsalva maneuver

2. no bulging or lesions appear

what to perform by straining or bearing down. Inspect the anal opening for any bulges or lesions.

• what is the normal finding

1. rectal prolapse

2. hemorrhoids or an anal fissure

(abnormal finding for valsalva maneuver)

• bulges of red mucous membrane may indicate a..

• ____________ may also be seen

1. inspect this area for any signs of swelling, redness, dimpling, or hair.

2. NF: area is normally smooth and free of redness and hair.

how to inspect the sacrococcygeal area and normal findings

pilonidal cyst

(abnormal findings for inspecting the sacrococcygeal area)

• reddened, swollen, or dimpled area covered by a small tuft of hair located midline on the lower sacrum suggests a..

1. inform the client

2. explain that it may feel like their bowels are going to move but that this will not happen.

3. lubricate your gloved index finger;

4. ask the client to bear down.

5. place the pad of your index finger on the anal opening and apply slight pressure

6. this will cause relaxation of the sphincter.

7. when you feel the sphincter relax, insert your finger gently with the pad facing down

how to palpate the anus

this causes the sphincter to tighten, and, if forced into the rectum, may cause pain.

in palpating the anus, never use your fingertip because..

1. spread the gluteal folds with your hands in close approximation to the anus and attempt to visualize a lesion that may be causing the pain.

2. if tension is maintained on the gluteal folds for 60 seconds, the anus will dilate normally. Ask the client to tighten the external sphincter; note the tone.

3. rotate finger to examine the muscular anal ring. Palpate for tenderness, nodules, and hardness.

(how to palpate the anus)

• if the sphincter does not relax and the client reports severe pain..

1. sphincter relaxes, permitting entry.

2. examination finger enters anus.

3. client can normally close the sphincter around the gloved finger.

4. anus is normally smooth, nontender, and free of nodules and hardness.

normal findings for palpating the anus

1. sphincter tightens, making further examination unrealistic.

2. examination finger cannot enter the anus.

3. poor sphincter tone may be the result of a spinal cord injury, previous surgery, trauma, or a prolapsed rectum. Tightened sphincter tone may indicate anxiety, scarring, or inflammation.

abnormal findings for palpating the anus

1. spinal cord injury, previous surgery, trauma, or a prolapsed rectum.

2. anxiety, scarring, or inflammation.

3. hemorrhoids, fistula, or fissure.

4. polyps or cancer.

5. scarring or cancer.

(abnormal findings for palpating the anus)

1. poor sphincter tone may be the result of a..

2. tightened sphincter tone may indicate..

3. tenderness may indicate..

4. nodules may indicate..

5. hardness may indicate..

1. insert your finger further into the rectum as far as possible

2. turn your hand clockwise then counterclockwise.

3. this allows palpation of as much rectal surface as possible.

4. note tenderness, irregularities, nodules, and hardness.

how to palpate the rectum

rectal mucosa is normally soft, smooth, nontender, and free of nodules.

normal finding for palpating the rectum

1. scarring or cancer

2. polyps or cancer

(abnormal finding for palpating the rectum)

1. hardness and irregularities may be from..

2. nodules may indicate..

1. sit on a stool with the client facing you and standing

2. client to raise their gown or drape

3. note pubic hair growth pattern and any excoriation, erythema, or infestation at the base of the penis and within the pubic hair.

how to inspect the penis (base of the penis and pubic hair)

1. pubic hair is coarser than scalp hair.

2. normal pubic hair pattern in adults is hair covering the entire groin area, extending to the medial thighs, and up the abdomen toward the umbilicus.

3. base of the penis and the pubic hair are free of excoriation, erythema, and infestation

4. pubic hair may be gray and sparse in older adult clients.

5. penis becomes smaller and the testes hang lower in the scrotum in older adult clients.

normal findings for inspecting the penis

1. absence or scarcity of pubic hair

   • receiving chemotherapy.

2. lice or nit (eggs) infestation

abnormal findings for inspecting the penis

1. pediculosis pubis

2. “crabs.”

(abnormal findings for inspecting the penis)

1. lice or nit (eggs) infestation at the base of the penis or pubic hair is known as ____________

2. commonly referred to as _____

1. observe for rashes, lesions, or lumps

how to inspecting the skin of the shaft

1. skin of the penis is wrinkled and hairless and is normally free of rashes, lesions, or lumps.

2. genital piercing is becoming more common, and nurses may see male clients with one or more piercings of the penis.

3. pubertal rites =

   • slitting the penile shaft (penile subincision),

   • leaving an opening that may extend the entire length of the shaft

normal findings for inspecting the skin of the shaft

1. rashes, lesions, or lumps may indicate STI or cancer

2. drainage around piercings indicates infection.

abnormal findings for inspecting the skin of the shaft

1. palpate any abnormalities noted during inspection.

2. also note any hardened or tender areas

how to palpate the shaft

penis, in a nonerect state, is usually soft, flaccid, and nontender.

normal findings for palpating the shaft

tenderness may indicate inflammation or infection.

abnormal findings for palpating the shaft

1. observe for color, location, and integrity of the foreskin in uncircumcised men.

how to inspect the foreskin

1. circumcised, intact and uniform in color with the penis

normal findings for inspecting the foreskin

discoloration of the foreskin may indicate scarring or infection.

abnormal findings for inspecting the foreskin

1. observe for size, shape, and lesions or redness.

how to inspect the glans

1. size and shape of the glans vary, appearing rounded, broad, or even pointed.

2. the surface of the glans is normally smooth and free of lesions and redness

3. if the client is not circumcised, ask them to retract their foreskin (if the client is unable to do so, the nurse may retract it) to allow observation of the glans. This may be painful.

4. foreskin retracts easily

normal findings for inspecting the glans

smegma

(normal findings for inspecting the glans)

• small amount of whitish material, called ________, normally accumulates under the foreskin.

1. chancres (red, oval ulcerations) from syphilis, genital warts, and pimplelike lesions from herpes are sometimes detected on the glans

abnormal findings for inspecting the glans

phimosis

(abnormal findings for inspecting the glans)

• tight foreskin that cannot be retracted is called..

paraphimosis

(abnormal findings for inspecting the glans)

• foreskin that, once retracted, cannot be returned to cover the glans is called..

urinary meatus

slitlike and normally found in the center of the glans.

1. hypospadias

2. epispadias

abnormal findings for urinary meatus

1. squeeze the glans between your index finger and thumb

how to palpate for urethral discharge and normal findings

1. gonorrhea

2. urethritis.

(abnormal findings for urethral discharge)

1. yellow discharge is usually associated with..

2. clear or white discharge is usually associated with..

3. any discharge should be cultured

1. the client to hold their penis out of the way.

2. observe for swelling, lumps, or bulges

3. NF: scrotal sac hangs below or at the level of the penis.

4. NF: left side of the scrotal sac usually hangs lower than the right side.

how to inspect the size, shape, and position of the scrotum & normal findings

1. hydrocele

2. hematocele

3. hernia

4. cancer

(abnormal findings for inspecting the size, shape, and position of the scrotum)

1. enlarged scrotal sac may result from fluid..

2. blood..

3. bowel..

4. tumor..

1. varicocele

(abnormal findings for inspecting the size, shape, and position of the scrotum)

1. __________ is an enlargement of the veins within the scrotum, which may cause low sperm production and decreased sperm quality, which can cause infertility

1. observe color, integrity, and lesions or rashes.

2. to perform an accurate inspection, you must spread out the scrotal folds (rugae) of skin

3. lift the scrotal sac to inspect the posterior skin.

how to inspect the scrotal skin

1. scrotal skin is thin and rugated (crinkled), with little hair dispersion.

2. color is slightly darker than that of the penis.

3. lesions and rashes are not normally present.

4. sebaceous cysts (small, yellowish, firm, nontender, benign nodules) are a normal finding.

normal findings for inspecting the scrotal skin

1. rashes, lesions, and inflammation

abnormal findings for inspecting the scrotal skin

1. palpate each testis and epididymis between your thumb and first two fingers

2. note size, shape, consistency, nodules, masses, and tenderness.

3. do not apply too much pressure to the testes because this will cause pain.

how to palpate the scrotal contents

1. testes are ovoid, approximately 3.5–5 cm long, 2.5 cm wide, and 2.5 cm deep, and equal bilaterally in size and shape.

2. they are smooth, firm, rubbery, mobile, free of nodules, and rather tender to pressure.

3. the epididymis is nontender, smooth, and softer than the testes.

normal findings for palpating the scrotal contents

1. cryptorchidism (an undescended testicle)

2. cancer

3. acute orchitis, torsion of the spermatic cord, a strangulated hernia, or epididymitis

(abnormal findings for palpating the scrotal contents)

• absence of a testis suggests..

• painless nodules may indicate..

• tenderness and swelling may indicate..

epididymitis

(abnormal findings for palpating the scrotal contents)

• if the client has ________, passive elevation of the testes may relieve the scrotal pain (prehn sign).

1. spermatic cord will lie between your thumb and finger

2. note any nodules, swelling, or tenderness

3. NF: spermatic cord and vas deferens should feel uniform on both sides.

   • the cord is smooth, nontender, and ropelike.

how to palpate each spermatic cord and vas deferens from the epididymis to the inguinal ring & normal findings

1. varicocele

2. infection or cysts

3. hydrocele of the spermatic cord

(abnormal findings for palpating each spermatic cord and vas deferens from the epididymis to the inguinal ring)

1. palpable, tortuous veins suggest..

2. beaded or thickened cord indicates..

3. cyst suggests..

transillumination

• darken the room and shine a light from the back of the scrotum through the mass.

• look for a red glow.

if an abnormal mass or swelling was noted during inspection and palpation of the scrotum, perform __________

1. normally scrotal contents do not transilluminate.

normal findings for transillumination of the scrotum

1. hydrocele, spermatocele

2. tumor, hernias, or varicocele

(abnormal findings for transillumination of the scrotum)

1. swellings or masses that contain serous fluid

   • light up with a red glow.

2. swellings or masses that are solid or filled with blood

   • not light up with a red glow.

1. ask the client to lie down

2. note whether the mass disappears.

3. if it remains, auscultate it for bowel sounds.

4. finally, gently palpate the mass and try to push it upward into the abdomen (unless client complains of extreme tenderness or nausea)

5. NF: are not expected.

how to palpate for scrotal mass and normal findings

1. no scrotal hernia is present

2. hydrocele

3. presence of bowel and thus a scrotal hernia

4. an incarcerated hernia

5. hernia

(abnormal findings for scrotal mass)

• If the bulge disappears, _________, but the mass may result from something else.

• if the mass remains, place your fingers above the scrotal mass. If you can get your fingers above the mass, suspect..

• bowel sounds auscultated over the mass indicate..

  will not be heard over a hydrocele.

• if you cannot push the mass into the abdomen, suspect..

• A ________ is strangulated when its blood supply is cut off.

1. inspect for bulges

2. client to turn head and cough or to bear down as if having a bowel movement, and continue to inspect the areas.

3. NF: normally free from bulges.

how to inspect for inguinal and femoral hernia and normal findings

hernia

(abnormal findings for inspecting for inguinal and femoral hernia)

• bulges that appear at the external inguinal ring or at the femoral canal when the client bears down may signal...

1. shift their weight to the left for palpation of the right inguinal canal and vice versa

2. place your right index finger into the client’s right scrotum and press upward

3. palpate up the spermatic cord until you reach the triangular-shaped, slitlike opening o

4. push your finger through the opening

5. continue palpating up the inguinal canal

6. client to bear down or cough

7. feel for bulges against your finger.

8. repeat the procedure on the opposite side

9. NF: bulging or masses are not normally palpated.

10. AF: bulge or mass may indicate a hernia.

how to palpate for inguinal hernia and nodes and normal and abnormal findings

1. if nodes are palpable, note size, consistency, mobility, or tenderness

2. NF: no enlargement or tenderness

3. AF: enlarged or tender lymph nodes may indicate an inflammatory process or infection of the penis or scrotum.

how to palpate for inguinal lymph nodes and normal and abnormal findings

1. palpate on the front of the thigh in the femoral canal area.

2. client to bear down or cough.

3. feel for bulges

4. NF: not palpable

5. AF: bulge or mass palpated as client bears down or coughs.

how to palpate for femoral hernia and normal and abnormal findings

1. palpated on the anterior surface of the rectum by turning the hand fully counterclockwise so that the pad of your index finger faces toward the client’s umbilicus

2. move your body away from the client to achieve the proper angle for examination.

3. client that they may feel an urge to urinate

4. move the pad of your index finger over the prostate gland, trying to feel the sulcus between the lateral lobes.

5. note the size, shape, and consistency of the prostate, and identify any nodules or tenderness.

how to palpate the prostate

1. normally nontender and rubbery.

2. it has two lateral lobes that are divided by a median sulcus.

3. the lobes are normally smooth, 2.5 cm long, and heart-shaped.

normal findings for prostate

1. acute prostatitis

2. BPH

3. cancer

(abnormal findings for prostate)

1. swollen, tender prostate may indicate..

2. enlarged smooth, firm, slightly elastic prostate that may not have a median sulcus suggests..

3. hard area on the prostate or hard, fixed, irregular nodules on the prostate suggest..

1. wash your hands and put on gloves.

2. note the distribution of pubic hair.

3. also be alert for signs of infestation.

how to inspect the mons pubis

1. pubic hair is distributed in an inverted triangular pattern and there are no signs of infestation.

2. older clients may have gray, thinning pubic hair.

3. some clients may have piercing of the genital area.

normal findings for inspecting the mons pubis

1. shaving pubic hair

2. lice or nits (eggs) at the base of the pubic hairs indicate pediculosis pubis infestation.

   • this condition, commonly referred to as “crabs,”

   • is most often transmitted by sexual contact.

abnormal findings for inspecting the mons pubis

1. NF: no enlargement or swelling of the lymph nodes

2. AF: enlarged inguinal nodes infection or may be the result of irritation from hair removal.

normal findings and abnormal findings for palpating the inguinal lymph nodes

1. observe the labia majora and perineum for lesions, swelling, and excoriation

how to inspect the labia majora and perineum

1. labia majora are equal in size and free of lesions, swelling, and excoriation

2. healed tear or episiotomy scar may be visible

3. labia of a woman who has not delivered offspring vaginally will meet in the middle

4. labia of a woman who has delivered vaginally will not meet in the middle and may appear shriveled

5. remove clitoris (cultures)

6. piercings

normal findings for inspecting the labia majora and perineum

1. herpes or syphilis

2. scratching or self-treatment of the lesions.

(abnormal findings for inspecting the labia majora and perineum)

1. lesions may be from an infectious disease, such as..

2. excoriation and swelling may be from..

3. evaluate all lesions and refer the client to a primary care provider for treatment.

1. gloved hand to separate the labia majora

2. inspect for lesions, excoriation, swelling, and/or discharge

how to inspect the labia minora, clitoris, urethral meatus, and vaginal opening.

1. labia minora appear symmetric, dark pink, and moist

2. clitoris is a small mound of erectile tissue, sensitive to touch

3. urethral meatus is small and slitlike

4. vaginal opening is positioned below the urethral meatus

5. hymen may cover the vaginal opening partially or completely.

normal findings for inspecting the labia minora, clitoris, urethral meatus, and vaginal opening.

1. abcess

2. lesions, swelling, bulging in the vaginal opening, and discharge

3. the client scratching or self-treating a perineal irritation.

(abnormal findings for inspecting the labia minora, clitoris, urethral meatus, and vaginal opening.)

1. asymmetric labia may indicate..

2. ________________ are abnormal

3. excoriation may result from..

1. palpate Bartholin glands for swelling, tenderness, and discharge

2. place index finger in the vaginal opening and your thumb on the labia majora.

3. gentle pinching motion, palpate from the inferior portion of the posterior labia majora to the anterior portion.

how to palpate the bartholin glands

bartholin glands are usually soft, nontender, and drainage free

normal findings for palpating the bartholin glands

1. infection and abscess

(abnormal findings for palpating the bartholin glands.)

1. Swelling, pain, and discharge may result from..

2. if you detect a discharge, obtain a specimen to send to the laboratory for culture.

1. insert your gloved index finger into the superior portion of the vagina

2. milk the urethra from the inside, pushing up and out

how to palpate the urethra

inflammation of skene glands

(palpating the urethra)

• If the client reports urethral symptoms or urethritis or if you suspect..

1. no drainage should be noted from the urethral meatus.

2. the area is normally soft and nontender.

normal findings for palpating the bartholin glands

1. possible urethritis

2. neisseria gonorrhoeae or chlamydia trachomatis

(abnormal findings for palpating the bartholin glands.)

1. drainage from the urethra indicates..

2. any discharge should be cultured.

3. urethritis may occur with infection with..

1. unlock the speculum and slowly rotate and remove it.

2. note the vaginal color, surface, consistency, and any discharge.

3. use a cotton swab to collect the specimen of vaginal secretions from the anterior vaginal fornix or the lateral vaginal walls

4. avoid the posterior fornix, which is contaminated with cervical secretions.

5. use part of the wet mount sample to test the pH of the vaginal secretions.

how to inspect the vagina

1. should appear pink, moist, smooth, and free of lesions and irritation.

2. it should also be free of any colored or malodorous discharge.

normal findings for inspecting the vagina

1. vaginal infections, STIs, or cancer

2. infection

(abnormal findings for inspecting the vagina)

1. reddened areas, lesions, and colored, malodorous discharge are abnormal and may indicate..

2. altered pH may indicate..

1. apply water soluble lubricant to the gloved index and middle fingers of your dominant hand.

2. approach the client at the correct angle.

3. nondominant hand on the client’s lower abdomen

4. insert your index and middle fingers into the vaginal opening.

5. apply pressure to the posterior wall, and wait for the vaginal opening to relax before palpating the vaginal walls for texture and tenderness

how to palpate the vaginal wall

should feel smooth, and the client should not report any tenderness.

normal findings for palpating the vagina

infection

(abnormal findings for palpating the vagina)

• tenderness or lesions may indicate..

1. speculum inserted in position to visualize the cervix,

2. observe cervical color, size, and position.

3. also observe the surface and the appearance of the os.

4. look for discharge and lesions.

how to inspect the cervix

1. surface of the cervix is normally smooth, pink, and even.

2. midline in position and projects 1–3 cm into the vagina.

3. in pregnant clients, the cervix appears blue (Chadwick sign)

4. cervix appears pale after menopause

5. The cervical os normally appears as a small, round opening in nulliparous women and appears slitlike in parous women

normal findings for inspecting the vagina

1. cyanosis

2. anemia

3. inflammation

4. polyps, cancer, or infection

5. prolapse or tumor, and further evaluation is needed

(abnormal findings for inspecting the cervix)

1. nonpregnant woman, a bluish cervix may indicate..

2. nonmenopausal woman, a pale cervix may indicate..

3. redness may be from..

4. asymmetric, reddened areas, strawberry spots, and white patches are also abnormal

5. cervical lesions may result from..

6. cervical enlargement or projection into the vagina more than 3 cm may be from..

1. advance your fingers until they touch the cervix

2. run fingers around the circumference

3. palpate for:

   • contour

   • consistency

   • mobility

   • tenderness

how to palpate the cervix

1. should feel firm and soft (like the tip of your nose).

2. it is rounded and can be moved somewhat from side to side without eliciting tenderness.

normal findings for palpating the cervix

1. cancer

2. infection (chandelier sign)

(abnormal findings)for palpating the cervix)

1. hard, immobile cervix may indicate..

2. pain with movement of the cervix (cervical motion tenderness, CMT) may indicate..