Left Side

If you feel the sphincter tighten, pause and reassure the patient. When in a moment the sphincter relaxes, proceed. Occasionally, severe tenderness prevents you from examining the anus. Do not try to force it. Instead, place your fingers on both sides of the anus, gently spread the orifice, and ask the patient to strain down. Look for a lesion, such as an anal fissure, that might explain the tenderness.

'you can proceed without undue discomfort, note:

■ The sphincter tone of the anus. Normally, the muscles of the anal sphincter close snugly around your finger.

Sphincter tightness in anxiety, inflammation, or scarring; laxity in some neurologic diseases

■ Induration

Induration may be due to inflammation, scarring, or malignancy.

■ Irregularities or nodules

Insert your finger into the rectum as far as possible. Rotate your hand clockwise to palpate as much of the rectal surface as possible on the patient's right side, then counterclockwise to palpate the surface posteriorly and on the patient's left side.

Note any nodules, irregularities, or induration. To bring a possible lesion into reach, take your finger off the rectal surface, ask the patient to strain down, and palpate again.

The irregular border of a rectal cancer is shown below.

Then rotate your hand further counterclockwise so that your finger can examine the posterior surface of the prostate gland. By turning your body somewhat away from the patient, you can feel this area more easily. Tell the patient that you are going to feel his prostate gland, and that it may make him want to urinate but he will not do so.

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