Anus, Rectum, and Prostate

Outlet of the gastrointestinal tract.
Surrounded by two concentric layers of muscle:
- Internal sphincter: Under involuntary control.
- External sphincter: Under voluntary control.
Each anal column contains an artery and a vein.
Increased pressure on the vein can lead to hemorrhoids.

Lies in front of the anterior wall of the rectum.
Surrounds the bladder neck and urethra.
Two seminal vesicles secrete a fluid rich in fructose (nourishes sperm) and prostaglandins.
Two bulbourethral glands on either side of the urethra secrete a clear, viscid mucus.

Most frequently diagnosed cancer in men.
Known risk factors:
- Increasing age.
- African ancestry.
- Family history.
- Inherited mutation of BRCA1 and BRCA2 genes.
Ethnic/geographic variation:
- Higher incidence in black men, often diagnosed at an advanced stage.
- Diets heavy in red meat or high-fat dairy products may be a contributing factor.
Screening recommendations:
- Age 45 to 49: Get baseline screening.

Higher incidence in Alaska Natives and African Americans.
Men more than women.
Age paradox: Increased incidence in the younger population and increased death rate in the older population.
Screening recommendations relative to age and risk:
- Age 50.
Hereditary factors that lead to increased CRC risk:
- Family history.
- Inherited genetic syndromes.
- Personal history of inflammatory bowel disease.
- Type 2 diabetes.

Usual bowel routine:
- Frequency and characteristics of stool; straining or pain with movement.
- Changes in bowel habits: constipation versus diarrhea, onset, and duration.
- Associated clinical symptoms: pain, nausea, vomiting.
- Relationship to foods ingested and/or occurrence in other family/group members.
Rectal bleeding:
- Presence of blood in stool: quantity, color, odor, onset, duration, and frequency.
- Spotting or outright passing of blood with stool.
- Characteristics: clay-colored, pus or mucus, frothy.
- Accompanied by flatus.
Medications:
- Prescription or over-the-counter laxatives or stool softeners; iron pills.
- Use of enemas to move bowels.
Rectal conditions:
- Rectal area problems: itching, pain, or burning.
- Hemorrhoids: presence and treatment.
- Fistula: presence and treatment.
Family history:
- Polyps or cancer in the colon or rectum.
- Inflammatory bowel disease or prostate cancer.
Patient-centered care:
- Usual amount of high-fiber foods in the diet.
- Number of glasses of water taken daily.
- Last diagnostic testing, as well as PSA for males.

Perform rectal examination on all adults, particularly in middle and late years.
Place patient in the best position relative to gender:
- Males: Left lateral decubitus, standing, or lithotomy positions.
- Females: Lithotomy (for examining genitalia) or left lateral decubitus (for exam of rectum alone).
Equipment:
- Penlight.
- Lubricating jelly.
- Glove.
- Guaiac test container.

Anus normally looks moist and hairless with coarse folded skin more pigmented than perianal skin.
Anal opening tightly closed; no lesions present.
Inspect sacrococcygeal area; normally appears smooth and even.
Instruct the person to hold their breath and bear down by performing a Valsalva maneuver:
- No break in skin integrity or protrusion through the anal opening should be present.

Instruct the person that palpation is not painful but may feel like needing to move bowels.
Drop lubricating jelly onto a gloved index finger; place the pad of the index finger gently against the anal verge.
You will feel the anal verge tighten then relax.
As it relaxes, insert the finger toward the umbilicus.
Rotate examination finger to palpate the entire muscular ring.
Promptly report any mass you discover for further examination.

On the anterior wall in male, palpate the entire prostate in a systematic manner.
Note the elastic, bulging prostate gland.
Note the following characteristics:
- Size (< 1cm into rectum)
- Shape (heart)
- Surface (smooth)
- Consistency (elastic)
- Mobility (slightly moveable)
- Sensitivity (nontender)

Inspect any feces remaining on the glove:
- Normally, the color is brown and the consistency is soft.
Test any stool on the glove for occult blood:
- If the stool Hematest is positive, it indicates occult blood.
- A false-positive finding may occur if the person has ingested red meat within 3 days of the test.
Teach self-care by providing an at-home collection kit.
Colonoscopy at age 50.

Use caution in performing the Valsalva maneuver:
- Can decrease HR significantly (vasovagal).
May note relaxation of perianal musculature and decreased sphincter control.

Subjective:
- Has one BM daily, soft, brown, no pain, no change in bowel routine.
- On no medications.
- Has no history of pruritus, hemorrhoids, fissure, or fistula.
- Diet includes one to two servings daily each of fresh fruits and vegetables but no whole-grain cereals or breads.
Objective:
- No fissure, hemorrhoids, fistula, or skin lesions in the perianal area.
- Sphincter tone good, no prolapse.
- Rectal walls smooth, no masses or tenderness.
- Prostate not enlarged, no masses or tenderness.
- Stool brown, hematest negative.