Cox & Roper: Clinical Skills

Chapter 07 - Rectal examination

Instructions: Each group of extended matching questions consists of lettered options followed by a list of numbered problems/questions. For each numbered problem/question select the one lettered option that most closely answers the question. You can use the lettered options once, more than once, or not at all.

Options:

1. Perianal warts
2. Anal fissure
3. Faecal loading
4. Benign prostatic hypertrophy
5. Prostatic carcinoma
6. Skin tags
7. Rectal carcinoma
8. Squamous cell carcinoma of the anus
9. Thrombosed haemorrhoid
10. Rectal prolapse

You are about to perform a series of rectal examinations. Which option best represents your clinical findings?

1

Scenario 1 a) You perform a rectal examination on an 85 year old woman who was admitted with constipation. Inspection of the anus was unremarkable. Following digital insertion a large mass is found protruding into the lumen. By pushing gently upwards the finger indents the mass. Following withdrawal of the finger, a small residue of brown faecal matter is observed on the glove. Choose... Perianal warts Anal fissure Faecal loading Benign prostatic hypertrophy Prostatic carcinoma Skin tags Rectal carcinoma Squamous cell carcinoma of the anus Thrombosed haemorrhoid Rectal prolapse Correct. This mass could easily be mistaken for a rectal tumour but this indentation helps to identify this as a faecal mass. See pages 189-190.Incorrect. See pages 189-190.Your answer has been saved.

2

Scenario 2 a) You perform a rectal examination on a forty two year old man with intermittent rectal bleeding. He describes bright red streaking of blood on his stool and he tends towards constipation. As you attempt digital insertion he shouts in pain and you have to abandon the examination. Choose... Perianal warts Anal fissure Faecal loading Benign prostatic hypertrophy Prostatic carcinoma Skin tags Rectal carcinoma Squamous cell carcinoma of the anus Thrombosed haemorrhoid Rectal prolapse Correct. The pain is highly suggestive of an anal fissure. It is likely that he has passed very hard stools with his constipation which has damaged the mucosa of the anal canal. This leads to intermittent bleeding and discomfort on defaecation. See page 188.Incorrect. See page 188.Your answer has been saved.

3

Scenario 3 a) You perform a rectal examination on a 70 year old man with mild lower abdominal pain. As you rotate your finger anteriorly you note that the prostate is larger than normal with a rubbery consistency. You are able to appreciate both lateral lobes and the median sulcus. Choose... Perianal warts Anal fissure Faecal loading Benign prostatic hypertrophy Prostatic carcinoma Skin tags Rectal carcinoma Squamous cell carcinoma of the anus Thrombosed haemorrhoid Rectal prolapse Correct. This is a good description of prostatic enlargement as palpated per rectum. This may be an incidental finding while investigating his abdominal pain or he may have cystitis or other bladder conditions that could be related to poor urine outflow. See page 190.Incorrect. See page 190.Your answer has been saved.

4

Scenario 4 a) You examine a 69 year old woman who presents with altered bowel habit and faecal incontinence. You perform a rectal examination and feel a hard craggy mass posteriorly that does not indent. When you withdraw your finger there is blood dark red blood on your finger. Choose... Perianal warts Anal fissure Faecal loading Benign prostatic hypertrophy Prostatic carcinoma Skin tags Rectal carcinoma Squamous cell carcinoma of the anus Thrombosed haemorrhoid Rectal prolapse Correct. This has all the hallmarks of a rectal tumour. She will need the rest of her bowel investigated to make sure that she has not got lesions elsewhere. See pages 189-190.Incorrect. See pages 189-190.Your answer has been saved.

5

Scenario 5 a) A 79 year old man is being assessed for obstructive urinary symptoms. He has hesitancy, a poor stream and terminal dribbling. A rectal examination demonstrates a hard swelling in the prostate gland. In addition the median sulcus cannot be indentified. Choose... Perianal warts Anal fissure Faecal loading Benign prostatic hypertrophy Prostatic carcinoma Skin tags Rectal carcinoma Squamous cell carcinoma of the anus Thrombosed haemorrhoid Rectal prolapse Correct. This patient has all the hallmarks of obstructive urinary symptoms that have been outlined above. However the finding of a hard swelling together with the loss of the median sulcus strongly suggests a prostatic cancer. See page 190.Incorrect. See page 190.Your answer has been saved.

(c) Oxford University Press, 2007