ANATOMY & PHYSIOLOGY
The gastrointestinal tract terminates in a short segment, the anal canal. Its external margin is poorly demarcated, but generally the skin of the anal canal can be distinguished from the surrounding perianal skin by its moist, hairless appearance. The anal canal is normally held in a closed position by action of the voluntary external muscular sphincter and the involuntary internal sphincter, the latter an extension of the muscular coat of the rectal wall.
The direction of the anal canal on a line roughly between anus and umbilicus should be carefully noted. Unlike the rectum above it the canal is liberally supplied by somatic sensory nerves, so that a poorly directed finger or instrument will produce pain.
The anal canal is demarcated from the rectum superiorly by a serrated line marking the change from skin to mucous membrane. This anorectal junction (often called the pectinate or dentate line) also denotes the boundary between somatic and visceral nerve supplies. It is readily visible on proctoscopic examination but is not palpable.
Above the anorectal junction, the rectum balloons out and turns posteriorly into the hollow of the coccyx and sacrum, forming almost a right angle with the anal canal. In the male, the prostate gland is palpable anteriorly as a rounded heart-shaped structure about 2.5 cm in length. Its two lateral lobes are separated by a shallow median sulcus or groove. The seminal vesicles, shaped like rabbit ears above the prostate, are not normally palpable.
Through the anterior wall of the female rectum the uterine cervix can usually be felt.
The rectal wall contains three inward foldings called valves of Houston. The lowest of these can sometimes be felt, usually on the patient's left.
Although most of the rectum accessible to the examining finger does not have a peritoneal surface, the anterior rectum, which the tip of the examining finger reaches, usually does. This relationship makes it possible to identify the tenderness of peritoneal inflammation or the nodularity of peritoneal metastases by rectal examination.
TECHNIQUES OF EXAMINATION
MALE RECTAL EXAMINATION
Many examiners prefer to do a rectal examination on an ambulatory patient when he is standing, with hips flexed and upper body resting across the examining table. This position tends to flatten the buttocks and make the anal canal and rectum more accessible to the examining finger.
For the non-ambulatory patient, the lateral position is necessary and some examiners may prefer to use it routinely. In this situation, ask the patient to lie on his left side with his right hip and knee somewhat flexed, his buttocks close to the edge of the examining table near you.
Adjust the lighting for good visualization of the anus and surrounding area. Put a glove on your right hand and lubricate the index finger. With your left hand, spread the buttocks apart.
Inspect the sacrococcygeal and perianal areas for lumps, inflammation, rashes or excoriations. Palpate any abnormal areas, noting lumps or tenderness.
Ask the patient to strain down. Inspect the anus, noting any lesions.
As the patient strains, place the pad of your lubricated and gloved index finger over the anus. As the sphincter relaxes, gently insert your fingertip into the anal canal, in a direction pointing toward the umbilicus.
An example of an abnormality may be swollen, thickened, fissured skin with excoriations in pruritus ani. See more examples of abnormalities are included below under "Abnormalities of the Anus, Surrounding Skin and Rectum.
Instruct the patient to relax. Explain that this examination will make him feel as if he is moving his bowels.
- The sphincter tone of the anus.
- Irregularities or nodules.
Examples of abnormalities include sphincter tightness in anxiety, inflammation or scarring, laxity in some neurological disease and with habitual anal intercourse.
Insert your finger further into the rectum so that you can examine as much of the rectal wall as possible. Palpate in sequence the right lateral, posterior and left lateral surface, noting any nodules or irregularities. Then turn your hand so that your finger can examine the anterior surface. Identify the lateral lobes of the prostate and the median sulcus between them. Note the size, shape and consistency of the prostate and any nodularity or tenderness.
If possible, extend your finger above the prostate to the region of the seminal vesicles and peritoneal cavity. Note nodules or tenderness.
Rectal lesions just beyond your fingertip can sometimes be felt by asking the patient again to strain down. Use this maneuver if there is any suspicion of cancer.
Gently withdraw your finger and test any fecal material adherent to it for occult blood.
FEMALE RECTAL EXAMINATION
The rectum is usually examined after the female genitalia, while the patient is in the lithotomy position. This position is essential for bimanual palpation. If a rectal examination alone is indicated, the lateral position offers a satisfactory alternative and affords much better visualization of the perianal and sacrococcygeal areas.
The technique is basically similar. The cervix is usually readily felt through the anterior rectal wall. Sometimes a retroverted uterus is also palpable. Neither of these, nor a tampon, should be mistaken for a tumor.
BIMANUAL VAGINAL INSPECTION
Apply a small amount of lubricant to the index and middle fingers of the dominant hand.
Uncover the vulva and lower abdomen by moving the center of the drape away from the examiner.
The midwife or health examiner announces what she is going to do and then touch the patient on the thigh with the back of the hand before proceeding.
Perform a bimanual examination. From a standing position, introduce the index and middle finger of the gloved and lubricated hand into the vagina, again exerting pressure primarily posteriorly. Avoid the anterior structures. The thumb should be abducted, the ring and little fingers flexed into the palm. Note any nodularity or tenderness in the vaginal wall, including the region of the urethra and bladder anteriorly.
Identify the cervix, noting its position, shape, size, consistency, regularity, mobility and tenderness. Palpate the fornix around the cervix. Note that during pregnancy, the cervix will be softer in consistency (like palpating the lips) as compared to non-pregnancy (like the end of the nose). If the woman is in the latter stages of her pregnancy, the cervix may be very "squishy" feeling and pliable. Dilation and/or effacement (opening and thinning) of the cervix may have already began.
Place the abdominal hand about midway between the umbilicus and symphysis pubis and press downward toward the pelvic/vaginal hand. The pelvic/vaginal hand should be kept in a straight line with the forearm, and inward pressure exerted on the perineum by the flexed fingers. Support and stabilize the arm by resting the elbow either on the hip or on the knee which is elevated by placing the foot on a stool. Continue to lift the cervix with the vaginal hand. Identify the uterus between the hands and note its size, shape, consistency, mobility, tenderness and masses. This procedure may cause some discomfort for the client. Uterine enlargement suggests pregnancy, benign or malignant tumors.
Palpating Uterine Fundus
Palpating Behind Uterus
Place the abdominal hand on the right lower quadrant, the pelvic hand in the right lateral fornix. Maneuver the abdominal hand downward 3 or 4 cm medial to the iliac crest, and using the pelvic hand for palpation, identify the right ovary and nay masses in the adnexa. Gently "trap" the ovary between the fingers of both hands (if possible). Three to five years after menopause, the ovaries have usually atrophied and are no longer palpable. If you can feel an ovary in a post-menopausal woman, suspect an ovarian tumor.
View from the right side.
Note the size, shape, consistency, mobility and tenderness of any palpable organs or masses. The normal ovary is somewhat tender. Repeat the procedure on the left side.
MoonDragon's ObGyn Womens Health Information: Adrenal Masses
FEMALE VAGINAL-RECTAL EXAM
Withdraw your fingers, removing your gloves and throwing them away after the vaginal exam. Re-glove using fresh, clean gloves. Place lubricant (K-Y Jelly) on internal exam glove. Another method is to double glove and then remove the outer glove after the vaginal exam before proceeding with the rectal exam. This prevents cross contamination of any infectious organisms.
Then slowly reintroduce the index finger into the vagina, the middle finger into the rectum. Ask the client to strain down as the midwife/examiner does this so that her anal sphincter will relax. Tell her that this examination may make her feel as if she has to move her bowels - but, reassure her that she will not.
Repeat the maneuvers of the bimanual examination, giving special attention to the region behind the cervix which may be accessible only to the rectal finger. In addition, try to push the uterus backward with your abdominal hand so that your rectal finger can explore as much of the posterior uterine surface as possible. Check the rectum itself and other nearby structures for any abnormalities.
The risk of spreading infection between vagina and rectum should always be considered. Gonorrhea may infect the rectum as well as the female genitalia. This fact, together with the rising prevalence of gonorrhea, has led to the recommendation that gloves be changed between vaginal and rectal examination in order to avoid spreading of gonococcal infection. In order to avoid fecal soiling, gloves should always be changed if for some reason the practitioner examines the vagina after the rectum. Another helpful suggestion is to double glove (put one glove over another) so that after the exam, the used glove is easily removed and discarded while still having a clean glove underneath. It saves time for the examiner.
Replace the drape and assist the client to remove her feet from the stirrups and sit up.
Reassure the patient, if the exam is normal, say so.
Leave the room and allow the patient to dress before continuing with the consultation.
MoonDragon's ObGyn Womens Health Information: Pictorial Description of Female Pelvic Exam
MoonDragon's ObGyn Womens Health Information: Pelvic Examination and Pap Smear (Cervical Smear)
MoonDragon's ObGyn Womens Health Information: Pictorial Description of Pap Smear (Cervical Smear)
Sister Zeus: Learning How to Use a Speculum (Do-it-yourself Cervical Exam)
After the examination, wipe off the external genitalia and anus or offer the client some tissue with which to do it him or herself. Throw away any used disposable items and clean up supplies.
Tenderness with cervical motion is an important sign of pelvic disease. You should both observe the clients's face and ask her if the examination is painful in any way.
Your ability to palpate the uterus and ovaries will depend on the client's anatomy, the size of your hands, and your level of skill.
ABNORMALITIES OF THE ANUS, SURROUNDING SKIN & LESIONS, CYSTS, TUMORS
This webpage will discuss a few of the abnormalities that frequently effect the anus and surround areas. I will not discuss the treatment in detail. For more information about various types of abnormalities, consult with your health care provider or do an internet search for more information. It is very important that treatment should be decided in consultation with a health care practitioner. It depends on many factors and the final decision should be made after a discussion between health care provider and patient.
PILONIDAL CYST & SINUS
A pilonidal cyst is a fairly frequent, probably congenital abnormality located in the midline superficially identified by the opening of a sinus tract. This opening may exhibit a small tuft of hair and be surrounded by a halo of erythema. Although generally asymptomatic except perhaps for slight drainage, abscess formation and secondary sinus tracts may complicate the picture.
An anorectal fistula is an inflammatory tract or tube, one end of which opens into the anus or rectum, while the other end opens onto the skin surface, as shown here, or into another viscus. An abscess usually antedates such a fistula. Look for the fistulous opening or openings anywhere in the skin around the anus.
An anal fissure is a very painful oval ulceration of the anal canal, most commonly found midline posteriorly, less commonly in the midline anteriorly. Its long axis lies longitudinally. Inspection may reveal a "sentinel" skin tag just below it, and gentle separation of the anal margins may reveal the lower edge of the fissure. The sphincter is spastic; the examination painful. Local anesthesia may be required.
A rectocele is formed by the anterior and downward bulging of the posterior vaginal wall together with the rectum behind it. To identify it, spread the patient's/client's labia and ask her to strain down.
MoonDragon's ObGyn Womens Health Information: Uterine Prolapse (Including Cystocele, Rectocele)
Hemorrhoids are varicose veins. External hemorrhoids originate below the anorectal line and are covered by anal skin. When uncomplicated they may not be visible at rest, but a thrombosed hemorrhoid presents as a painful, bluish, shiny, ovoid mass at the anal margin. Flabby or fibrotic skin tags may mark the location of previously thrombosed or inflamed hemorrhoids.
Internal hemorrhoids originate above the anorectal junction and are covered by mucous membrane, not skin. They are not visible unless they prolapse through the anus, nor are the soft swellings normally identifiable by palpation. Proctoscopic examination is usually required for diagnosis.
MoonDragon's ObGyn Womens Health Information: Hemorrhoids
MoonDragon's Health & Wellness: Varicose Veins
PROLAPSE OF THE RECTUM
On straining for a bowel movement, the rectal mucosa, with or without its muscular wall, may prolapse through the anus, presenting as a doughnut or rosette of red mucosa. A prolapse involving only mucosa is shown here. When the entire bowel wall is involved, the prolapse is larger; and circular rather than radiating folds are seen.
POLYPS OF THE RECTUM
Polyps of the rectum are fairly common. Varying considerably in size and number, they can develop on a stalk (pedunculated) or may lie close to the mucosal surface (sessile). They are soft and may be difficult or impossible to feel even when in reach of the examining finger. Proctoscopy is usually required for diagnosis, as is biopsy for the differentiation of benign from malignant lesions.
CARCINOMA OF THE RECTUM
Asymptomatic carcinoma of the rectum makes routine rectal examination mandatory for virtually all adults. As noted above, polypoid masses may be malignant. Another common form of presentation is the firm nodular rolled edge of an ulcerated malignancy.
Widespread peritoneal metastasis from any source may develop in the area of the peritoneal reflection anterior to the rectum. A firm to hard nodular rectal "shelf" may be just palpable with the tip of the examining finger.
ABNORMALITIES OF THE PROSTATE
As palpated through the anterior rectal wall, the normal prostate is a rounded heart-shaped structure about 2.5 centimeters in length, projecting less than 1.0 centimeter into the rectal lumen. The median sulcus can be felt between the two lateral lobes. Only the posterior surface of the prostate is palpable. Anterior lesions, including those that may obstruct the urethra, may not be detectable by physical examination.
BENIGN PROSTATIC HYPERTROPHY
A very common condition in men over 50 years of age, benign prostatic hypertrophy presents as a firm smooth symmetrical and slightly elastic enlargement of the gland. It may bulge more than a centimeter into the rectal lumen. The hypertrophied tissue tends to obliterate the median sulcus.
CARCINOMA OF THE PROSTATE
A hard irregular nodule, producing asymmetry of the gland and a variation of its consistency, is especially suggestive of carcinoma. Prostatic stones and chronic inflammation can produce similar findings, and differential diagnosis often depends upon biopsy. Later in its course, the carcinoma grows in size, obliterates the median sulcus and may extend beyond the confines of the gland producing a fixed, hard, irregular mass.
The acutely inflamed prostate gland is swollen, tender and often somewhat asymmetrical.
The gland of chronic prostatitis is variable: it may (1) feel normal, (2) be somewhat enlarged, tender and body, or (3) contain scattered firm areas of fibrosis.
MoonDragon's Health & Wellness: Prostatitis
MoonDragon's Health & Wellness: Prostate Cancer
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