Assessment of Anus, Rectum, and Prostate

Assessment of the anus, rectum, and prostate should be completed during a comprehensive assessment or as part of a focused assessment if your patient is experiencing issues with their anus, rectum, or prostate. Inspection and palpation are used to assess the anus; and the rectum and prostate are palpated through a digital rectal exam, or DRE, performed by the health care provider. As the nurse, you will act as a chaperone or assist with this part of the assessment.

Begin your assessment by inspecting the pilonidal area, which is the area at the base of the tailbone at the cleft of the buttocks, just where the buttocks begin to divide. The skin should appear smooth without lumps, hair, warts, rashes, excoriation, or dimpling. If a pilonidal cyst, or sinus is present, this could be due to a congenital anomaly or related to excessive or repeated pressure on the sacrococcygeal area.

Next, to inspect the perianal area and anus, spread apart the buttocks, and use a penlight for adequate visualization. The skin directly surrounding the anus is normally more coarse and darker in pigmentation than the rest of the surrounding skin. Unexpected findings include anal warts, which are related to infection with human papilloma virus, or HPV; and irritation, which may occur with fungal infections or pinworm. Other unexpected findings include lesions, polyps, fissures, and skin tags. You'll also inspect for signs of constipation, such as a protrusion of a dry, hard stool, and the presence of external hemorrhoids, or swollen, inflamed veins.

Now, palpation is typically performed by the health care provider with assistance from the nurse. Starting with the perianal area, this location should be free from tenderness or lumps. If your patient reports pain or tenderness upon palpation, this may indicate a perianal abscess, or an infection of the anal tissue; an anal fistula, where an inflammatory tract forms at the anus and runs through the perianal skin; or pruritus ani, which is itching that could be caused by a fungal infection.

Next, the health care provider will perform a DRE. During a DRE, your patient should be able to tighten their external anal sphincter around the health care provider's finger with ease and without pain. A weak sphincter can be related to neurological conditions, the effects of childbirth, or trauma to the anus; whereas extreme tightness of the sphincter can be associated with fissures, scarring, or inflammation.

Next, the health care provider will palpate inside the anus, around the anal ring. They'll feel the anterior, lateral, and posterior rectal walls to assess for masses, tenderness, or any other irregularities. Rectal pain is typically associated with a local problem, such as an anal fissure, internal hemorrhoids, or fistula. Following the DRE, the health care provider will inspect their gloved finger for the presence of stool, which is normally brown and soft. It is considered abnormal for the stool to contain blood or pus. If indicated, you can send a sample of the feces for an occult blood test to assess for blood that's not readily visible.

Next, assist the health care provider with palpation of the prostate gland, which is typically palpable on its posterior surface through the anterior wall of the anal canal. You should reassure your patient that it's normal to feel pressure or the urge to urinate during this exam. The health care provider will note the size, shape, and mobility of the prostate gland. Normal findings include a prostate that is around 4 centimeters or 1.6 inches wide; non-tender; firm; smooth; and movable.

Protrusion of the prostate into the rectum more than 1 centimeter indicates there's prostate enlargement, which can be secondary to infection, benign prostatic hyperplasia, or BPH, or cancer. A very soft and boggy prostate may also occur with BPH, whereas hard nodules can indicate cancer, calculi, or prostate fibrosis. A tender prostate that has fluctuating softness upon palpation is typically associated with an abscess. Also, any secretions that come through the urethral orifice during palpation of the prostate is an unexpected finding, and the fluid should be cultured.

Alright, as a quick recap… Assessment of the anus, rectum, and prostate should be completed during a comprehensive assessment or as part of a focused assessment if your patient is experiencing issues with their anus, rectum, or prostate. Inspection and palpation are used to assess the anus; and the rectum and prostate are palpated through DRE, performed by the health care provider.