Posted: February 16th, 2023

Steps to Examine an Older Adult’s Rectum:

You are about to perform a rectal examination of an older adult.

What are the steps to examine this patient?
Explain your rationale.
What are some findings you can have while assessing the rectal sphincter?
Describe the differences during the rectal examination of acute prostatitis and benign prostatic hypertrophy.
What findings would expect on physical examination of acute prostatitis and benign prostatic hypertrophy?

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Steps to Examine an Older Adult’s Rectum:

Prepare the patient: Explain the procedure, obtain informed consent, and ensure the patient’s privacy and comfort. Position the patient in the left lateral decubitus (side-lying) position with knees flexed towards the chest.
Inspect the perianal area: Visually examine the perianal region for any abnormalities, such as fissures, hemorrhoids, fistulas, or skin conditions.
Palpate the external anal sphincter: Gently palpate the external anal sphincter for any tenderness, induration, or muscle tone abnormalities.
Lubricate the gloved index finger: Apply a water-soluble lubricant to your gloved index finger to facilitate the examination.
Insert the finger: Slowly and gently insert your gloved, lubricated finger into the rectum, aiming towards the umbilicus. Gradually advance until the sphincter is relaxed, and then continue to advance about 2-4 cm further.
Assess the rectal walls: Rotate your finger gently to evaluate the rectal walls, noting any masses, nodules, or irregularities.
Palpate the prostate gland: With your finger in the rectum, palpate the prostate gland anteriorly. Assess its size, shape, consistency, and tenderness. Note any abnormalities, such as enlargement, nodules, or irregularities.
Evaluate the rectal ampulla: Advance your finger further to assess the rectal ampulla, noting any fecal masses, strictures, or abnormalities.
Withdraw the finger: Slowly and gently withdraw your finger while continuing to palpate the rectal walls, prostate, and sphincter for any additional findings.
Provide patient care and documentation: Offer any necessary post-examination care, including hand hygiene and patient education. Document your findings accurately and appropriately in the patient’s medical record.
Rationale:
Performing a rectal examination allows healthcare providers to assess the rectal and prostate regions for abnormalities, such as tumors, inflammation, or anatomical changes. It can provide valuable information about the patient’s overall health, including the presence of conditions like hemorrhoids, rectal prolapse, prostate disorders, or colorectal cancer. The examination should be conducted with sensitivity, ensuring patient comfort and privacy throughout the process.

Findings during Rectal Sphincter Assessment:
While examining the rectal sphincter, the healthcare provider may observe several findings, including:

Tone: Normal sphincter tone feels firm and elastic. Decreased tone may indicate neurological or muscle dysfunction, while increased tone may suggest local inflammation or irritation.
Sensation: The patient should experience a normal sensation of pressure during the examination. A decreased sensation may be indicative of nerve damage or other neurological issues.
Reflexes: The anal reflex, which causes contraction of the external anal sphincter when the inner rectal mucosa is stimulated, can be tested during the examination. Absence or exaggerated reflex responses may suggest nerve dysfunction.
Differences between Acute Prostatitis and Benign Prostatic Hypertrophy during Rectal Examination:

Rectal Examination in Acute Prostatitis:

Prostate Gland: The prostate gland may feel enlarged, tender, and indurated (firm) due to inflammation.
Rectal Wall: There may be areas of tenderness or induration along the rectal wall due to inflammation and infection.
Sphincter Tone: The sphincter tone is typically normal unless there are concurrent issues.
Rectal Examination in Benign Prostatic Hypertrophy (BPH):

Prostate Gland: The prostate gland may feel enlarged and smooth, without tenderness or induration. It often has a symmetrical shape.
Rectal Wall: The rectal wall may be compressed or displaced by the enlarged prostate, resulting in a palpable mass or nodules.
Sphincter Tone: The sphincter tone is usually normal unless there are additional complications.
Findings to Expect on Physical Examination:

Acute Prostatitis:

Fever and chills.
Prostate tenderness, warmth, and swelling.
Urinary symptoms, such as increased frequency, urgency, dysuria (painful urination), or obstructive symptoms.
Systemic signs of infection, such as malaise, body aches, or elevated white blood cell count.
Benign Prostatic Hypertrophy (BPH):

Urinary symptoms, such as hesitancy, weak urinary stream, increased frequency, nocturia (frequent nighttime urination), or incomplete bladder emptying.
Enlarged prostate on rectal examination.
Post-void residual urine volume may be increased.
Obstructive symptoms, such as straining to urinate or a sensation of incomplete emptying.

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