Abnormal Findings (Chapter 25: Anus, Rectum, and Prostate)

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1

Anal Region Abnormalities

Pilonidal Cyst or Sinus

A hair-containing cyst or sinus location in the midlines over the coccyx or lower sacrum. Often opens as a dimple with visible tuft of hair and possibly an erythematous halo. Or may appear as a palpable cyst. When advanced, has a palpable since tract. Although a congenital disorder, it is first Dx between 15-30 y/o

2

Anal Region Abnormalities

Anorectal Fistula

A chronically inflamed GI tract (Crohn disease, local irradiation) create an abnormal passage from inner anus or rectum out to skin surrounding anus. May result from a local abscess.

The red, raised tract opening may drain serosanuineous or purulent matter when pressure is applied. Bidigital palpation may reveal an indurated cord. May heal with warm batch, high-fiber diet, and analgesics.

3

Anal Region Abnormalities

Fissure

An exquisitely painful longitudinal tear in the superficial mucosa at the anal margin. Most (90%) occurring the posterior midline area.

Pain is described as passing "shards of glass"; may have bright red blood in the stool.

A resulting spasm in the sphincters makes the area painful to examine. Inspection shows a recent issue has haring sharp edges.

A chronic fissure as indurated and accompanied by a papule of skin, sentinel tag, on the anal margin below or a polyp above.

Fissures may be caused by trauma (passing a large hard stool) or form irritant diarrheal stools.

Tx with stool softeners, fiber, warm soaking baths, topical analgesics.

Healing may be enhanced with topical nitroglycerin ointment or Botox injection

4

Anal Region Abnormalities

Hemorrhoids

These painless, flabby papule are caused by varicose veins.

External hemorrhoid starts below the anorectal junction and is covered by anal skin.

When thrombosed, it contains clotted blood and becomes painful, swollen, shiny blue mass that itches and bleeds with defecation. When it resolves, it leaves a painless, flabby skin sac around the anal orifice.

Internal hemorrhoid start above the anorectal junction and is covered by mucous membrane.

When the person forms a Valsalva maneuver, it may appear as a red mucosal mass.

All hemorrhoids result from increased portal venous pressure: as occurs with straining at stool, chronic constipation, pregnancy, obesity, chronic liver disease, or the low-fiber diet common in Western society.

5

Anal Region Abnormalities

Rectal Prolapse

The complete rectal mucous membrane protrudes through the anus, appearing as a moist red doughnut with radiating lines.

When prolapse is incomplete, only mucosa bulges.

When complete, it include the anal sphincters.

Occurs following a Valsalva maneuver such as straining at stool or with exercise.

Caused by weakened pelvic support muscles and requires surgery

6

Anal Region Abnormalities

Pruritus Ani

Intense perianal itching is caused by pinworm infection in children and institutionalized adults and by prolapsed hemorrhoids, anal fissure, dermatitis, chronic diarrhea, poor hygiene, perfume or dye irritants, systemic disease such s DM or IBD.

Inspection shows red, raised, thickened excoriated skin around the anus. The area is swollen and moist.

With fungal infection it appears dull grayish pink.

Treat the underlying cause; encourage good hygiene, use topical steroid cream

7

Rectum Abnormalities

Abscess

A localized cavity of pus from infection in the pararectal space. Infection usually extends from an anal crypt.

Characterized by persistent throbbing rectal pain. Termed by the space it occupies (e.g., perianal abscess is superficial around the anal skin) and appears red, hot, swollen, indurated, and tender.

An ischiorectal abscess is deep and tender bidigital palpation; occurs laterally between the anus and ischial tuberosity and is rare.

Must be rained before it worsens or develops sepsis.

8

Rectum Abnormalities

Rectal Polyp

A protruding growth from the rectal mucous membrane that is fairly common. the poly may be pedunculated (on the stalk) or sessile (a mound on the surface, close to the mucosal wall).

The soft nodule is difficult to palpate. Colonoscopy and biopsy are needed to screen for a malignant growth.

Removal of adenomatous polyps has been shown to prevent deaths from colorectal cancer.

9

Rectum Abnormalities

Fecal Impaction

A complete colon blockage by hard, desiccated immovable stool in the rectum, which presents as constipation or overflow incontinence.

Results from decreased bowel motility as in hospitalized older adults and people with spinal cord injuries; also with low-fiber diet, hypothyroidism, opiate use.

Abd palpation or DRE reveals mass.

Treat with laxatives, enemas, suppositories.

Community-dwelling older adults are at risk, especially those with dementia who cannot communicate. Use extreme caution in treating this group.

10

Rectum Abnormalities

Carcinoma

A malignant neoplasm in the rectum is asymptomatic, this the importance of routine DRE.

An early lesion may be a single firm nodule. You may palpate an ulcerated center with rolled edges. As the lesion grows it has an irregular cauliflower shape and is fixed and stone-hard.

Refer a person with any rectal lesion for cancer screening.

Suggest screening guidelines: careful family Hx, fecal occult blood tests annually, and colonoscopy every 10 years, staring at age 50 years for those at average risk

11

Prostate Gland Abnormalities

Benign Prostatic Hypertrophy (BPH)

S: Urinary frequency, urgency, hesitancy, straining to urinate, weak stream, intermittent stream, sensation of incomplete emptying, nocturia

O: A symmetric nontender enlargement; commonly occurs n makes beginning in the middle years. The prostate surface feels smooth, rubbery, or fit (like the consistency of a use), with the median sulcus obliterated.

12

Prostate Gland Abnormalities

Prostatitis

S: Fever, chills, malaise, urinary frequency and urgency, dysuria, urethral discharge; dull, aching pain in perineal and rectal area

O: An exquisitely tender enlargement is acute inflammation, yielding a swollen, slightly asymmetric gland

With chronic inflammation the signs can vary from tender enlargement with a boggy feel to isolated firm areas cured by fibrosis. Or the gland may feel normal.

13

Prostate Gland Abnormalities

Carcinoma

S: Frequency, nocturia, hematuria, weak stream, hesitancy, pain or burning on urination; continuous pain in lower back, pelvis, thighs

O: A malignant neoplasm often starts as a single hard nodule on the posterior surface, producing asymmetry and a change in consistency. As it invades normal tissue, multiple hard nodules appear, or the entire gland fields stone-hard and fixed. The median sulcus is obliterated.