Chapter 15 (Anus, Rectum and Prostate)
A 36-year-old married bank teller comes to your office, complaining of pain with
defecation and occasional blood on the toilet paper. She states that last week she had
food poisoning with nausea, vomiting, and diarrhea. She had runny stools but no black
or bloody stools. Ever since her illness, she has continued to have severe pain with
bowel movements. She now tries to put off defecation as long as possible. Although she
is having constipation she denies any further diarrhea or leakage of stool. She has a
past medical history of hypothyroidism and two spontaneous vaginal deliveries. She has
had no other chronic illnesses or surgeries. She does not smoke and rarely drinks. She
has two children. There is no family history of breast or colon cancer. She has had no
weight gain, weight loss, fever, or night sweats. On examination she is afebrile, with a
blood pressure of 115/70 and a pulse of 80. On abdominal examination correct
answers Ans: C
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Feedback: Anal fissures often occur after severe diarrhea or constipation. They cause
bright blood on the toilet paper and are extremely painful during defecation. A small
ulceration or fissure is observed proximal to the anus.
A 42-year-old house painter comes to your clinic, complaining of pain with defecation
and profuse bleeding in the toilet after a bowel movement. He was in his usual state of
health until 2 weeks ago, when he was injured in a car accident. After the accident he
began taking prescription narcotics for the pain in his shoulder. Since then he has had
very few bowel movements. His stool is hard and pebble-like. He states he has always
been "regular" in the past, with easy bowel movements. His diet has not changed but he
states that he is exercising less since the accident. His past medical history includes
hypertension and he is on a low-dose diuretic. He has had no other chronic illnesses or
surgeries. He has a family history of hypertension, coronary heart disease, and diabetes
but no cancer. He is divorced and has three children. He smokes two packs of
cigarettes per day and quit drinking more than 10 years ago. He has correct answers
Ans: B
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Feedback: A swollen, bluish ovoid mass is most likely a thrombosed external
hemorrhoid. These can cause brisk bleeding with defecation. Hemorrhoids are often
caused by low-fiber diets, dehydration, lack of exercise, and anything that causes
constipation leading to increased straining with defecation. Narcotics can cause severe
constipation, leading to this disorder.
A 75-year-old retired construction worker comes to your clinic, complaining of bright red
blood in the toilet for the last several months. He has no pain with defecation but has
occasional constipation. He states he eats a healthy diet with fruits and vegetables and
, walks 2 miles a day. He has had a 10-pound weight loss over the last 3 months. He
denies fever or night sweats. His medical history includes high blood pressure, coronary
artery disease, and arthritis. He has also had an appendectomy. He smoked for 40
years, two packs a day, but quit 15 years ago. He used to drink alcohol but doesn't now.
His father died in his 60s of a heart attack and his mother had breast cancer in her 70s.
On examination he appears his stated age and sits comfortably on the examining table.
His blood pressure is 150/85 and his pulse is 88. He is afebrile. His cardiac, lung, and
abdominal examinations are normal. Visualization of the a correct answers Ans: D
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Feedback: This patient has the common symptom of bright red blood in the toilet over
time. He also has had weight loss and has an irregular hard mass in the rectum. It is not
uncommon for these masses to be friable (bleed easily), even with gentle manipulation.
A 60-year-old coach comes to your clinic, complaining of difficulty starting to urinate for
the last several months. He believes the problem is steadily getting worse. When asked
he says he has a very weak stream and it feels like it takes 10 minutes to empty his
bladder. He also has the urge to go to the bathroom more often than he used to. He
denies any blood or sediment in his urine and any pain with urination. He has had no
fever, weight gain, weight loss, or night sweats. His medical history includes type 2
diabetes and high blood pressure treated with medications. He does not smoke but
drinks a six pack of beer weekly. He has been married for 35 years. His mother died of
a myocardial infarction in her 70s and his father is currently in his 80s with high blood
pressure and arthritis. On examination you see a mildly obese male who is alert and
cooperative. His blood pressure is 130/70 with a heart rate of 80. He correct answers
Ans: A
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Feedback: BPH becomes more prevalent during the fifth decade and is often associated
with the urinary symptoms of hesitancy in starting a stream, decreased strength of
stream, nocturia, and leaking of urine. On examination an enlarged, symmetric, firm
prostate is palpated. The anterior lobe cannot be felt. These patients may also develop
UTIs secondary to the obstruction.
A 24-year-old graduate student comes to your clinic, complaining of burning during
urination and increased urinary frequency. He has had a low-grade fever (100.5
degrees) and does not feel very well. He is very worried about sexually transmitted
diseases because he had a drunken encounter 2 weeks ago and did not use a condom.
He has had no recent weight loss, weight gain, or night sweats. His past medical history
includes knee surgery in high school and genital warts in college. He does not smoke
but drinks six beers every Friday and Saturday night. He denies using any IV drugs but
has tried marijuana in the past. His father has high cholesterol but his mother is healthy.
On examination he appears tired. His temperature is 99.5 degrees and his blood
pressure is 110/70. His abdominal examination is normal. Visualization of the anus
shows no masses, inflammation, or fissures. Digital rectal examination reveals a warm,
correct answers Ans: B
