{"id":680,"date":"2021-09-29T10:14:29","date_gmt":"2021-09-29T14:14:29","guid":{"rendered":"https:\/\/pressbooks.library.ryerson.ca\/assessmentnursing\/?post_type=chapter&#038;p=680"},"modified":"2023-01-11T13:37:57","modified_gmt":"2023-01-11T18:37:57","slug":"perianal-region-inspection-and-palpation","status":"publish","type":"chapter","link":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/chapter\/perianal-region-inspection-and-palpation\/","title":{"raw":"Perianal Region - Inspection and Palpation","rendered":"Perianal Region &#8211; Inspection and Palpation"},"content":{"raw":"<p style=\"text-align: left\"><span style=\"color: #000000\">The perianal region extends around the anal opening by about five centimetres. Assessment of the perianal region can create feelings of discomfort and nervousness in clients, so you should always employ a <strong>trauma-informed approach<\/strong>. <\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Explain each step.<\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Ask permission to touch.<\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Use a drape, and only expose the client as long as needed. <\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Avoid words that may be triggering, such as \u201cbed\u201d and \u201cspread your legs.\u201d Instead, use \u201cexam table\u201d and make requests like \u201cmove this leg out.\u201d <\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Ask the client if they would like to have another person present such as a family member\/friend or another healthcare provider.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Positioning<\/strong> for this assessment depends on several factors including age, what is most comfortable for the client, and other parts of the assessment. It is best to use an <strong>inclusive approach<\/strong> to assessment: provide the client with options on how to proceed with positioning. Where appropriate, you can provide choices by saying, for example, \u201cI need to exam your anal region. I usually have clients in position XX or XX, do you have a preference or another option?\u201d Specific considerations for positioning include:<\/span><\/p>\r\n\r\n<ul style=\"text-align: left\">\r\n \t<li><span style=\"color: #000000\">To ensure <strong>infants<\/strong> and <strong>toddlers<\/strong> are comfortable and safe, involve their caregiver\/parent when possible. They are often best positioned in supine position on the exam table or the caregiver\u2019s lap and then the legs (hips and knees) are flexed towards the chest.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">With <strong>older children, adolescents<\/strong>, and <strong>adults<\/strong>, use a position that is comfortable and familiar for the client. For example, if you are only doing an examination of the perianal region and\/or the client is restricted to the bed, you can help the client into a left lateral position. If clients have difficulty maintaining this position, place a pillow between their legs with the right leg flexed.<\/span><\/li>\r\n \t<li><span style=\"color: #000000\">A rectal exam is often performed at the same time as genitourinary or prostate exam, so you should use the position required for that to minimize position changes. More importantly, it is important to use a position that is <strong>most comfortable<\/strong> for the client and usually <strong>gender-affirming<\/strong>. For example, for a [pb_glossary id=\"1482\"]cisgender[\/pb_glossary] woman, you may use a lithotomy position in which they are in supine position with their legs flexed and abducted, and their feet in stirrups. With a cisgender man, you may use a standing position in which they lean over on a table with toes pointing inward. With [pb_glossary id=\"1484\"]transgender[\/pb_glossary] and [pb_glossary id=\"1485\"]non-binary[\/pb_glossary] clients, use a position that is most comfortable for them at that moment: this is usually a position that is gender-affirming. For example, for a transman, you may use a standing position and for a transwoman, you may use a lithotomy position. Be aware that the preferred position may change over time for a non-binary or a trans client, so always ask.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Perianal assessment<\/strong> involves the following steps:<\/span><\/p>\r\n<span style=\"color: #000000\">1. Prepare <strong>supplies<\/strong> needed (e.g., cover sheet\/drape, gloves).<\/span>\r\n\r\n<span style=\"color: #000000\">2. Don <strong>gloves<\/strong>.<\/span>\r\n\r\n<span style=\"color: #000000\">3. Provide options for <strong>positioning<\/strong>.<\/span>\r\n\r\n<span style=\"color: #000000\">4. Assist the client into position and ensure they are comfortable.<\/span>\r\n\r\n<span style=\"color: #000000\">5. Expose the <strong>rectal<\/strong> <strong>area<\/strong>. If the client is in a left lateral position, place your dominant hand on the right buttock and gently pull it up. If the client is standing, you may need to gently spread the buttocks apart with both of your hands; you may also need to do this if the client is in supine or lithotomy position.\u00a0<\/span>\r\n\r\n<span style=\"color: #000000\">6. Inspect the area for <strong>colour<\/strong>. The peri-anal area is slightly darker than the rest of the client\u2019s skin, but the colour in the region should be consistent with no discoloration (e.g., redness, dark brown\/purple) or rashes.<\/span>\r\n\r\n<span style=\"color: #000000\">7. Inspect the area for <strong>lesions<\/strong> or <strong>lumps <\/strong>(e.g., a wart).<\/span>\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, palpate them for consistency (soft or hard) and pain.<\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, identify the location, colour, size, shape, elevation, and whether the area is intact.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">8. Inspect the area for <strong>discharge<\/strong>. If any is noted, identify the quantity, colour, and consistency.<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">9. Inspect the area for <strong>malformations<\/strong>. (e.g., hemorrhoids). See <strong>Figure 5.8<\/strong>\u00a0for an image of a hemorrhoid. If any malformations are noted, describe the appearance, location, colour, and size.<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, palpate them for consistency (soft or hard) and pain.<\/span><\/li>\r\n<\/ul>\r\n<img src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-300x258.png\" alt=\"\" width=\"300\" height=\"258\" class=\"alignnone size-medium wp-image-2129\" \/>\r\n\r\n<strong>Figure 5.8<\/strong>: Hemorrhoids\r\n<p style=\"font-weight: 400\">Photo by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Pachacamac33&amp;action=edit&amp;redlink=1\" target=\"_blank\" rel=\"noopener\">Pachacamac33<\/a>, Public Domain, from <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?search=hemmorhoid&amp;title=Special:MediaSearch&amp;go=Go&amp;type=image\" target=\"_blank\" rel=\"noopener\">Wikimedia Commons<\/a><span style=\"color: #000000\">\u00a0(image was cropped and illustrated upon for the purposes of this chapter)<\/span><\/p>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">10. Assess for <strong>anal tone<\/strong> by asking the client to try to contract or \u201cdraw in\u201d their anus. This can also be achieved by gently touching a cotton ball just lateral from the anus. Observe the external anal sphincter. Normally, a client has \u201cgood\u201d anal tone as demonstrated by contraction or puckering of the anus.<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">This is important to assess particularly in older clients or clients who may have indicated problems with [pb_glossary id=\"1528\"]fecal incontinence[\/pb_glossary]. Anal tone can be affected by nerve or muscle damage. There are many causes of this damage, but it is sometimes related to individuals who strain when trying to have a bowel movement. Straining can be associated with constipation and can be treated by health promotion related to diet, sufficient water intake, and routine bowel training.<\/span><\/li>\r\n<\/ul>\r\n<p style=\"text-align: left\"><span style=\"color: #000000\">11. Note the <strong>findings<\/strong>.<\/span><\/p>\r\n\r\n<ul>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Normal findings might be documented as: \u201cPerianal area is consistent in colour with no discolouration, lesions, discharge, or malformations. Good anal tone.\u201d<\/span><\/li>\r\n \t<li style=\"text-align: left\"><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cPerianal area has swollen veins at the anal opening with slight bleeding.\u201d<strong style=\"font-size: 1em\">\u00a0<\/strong><\/span><\/li>\r\n<\/ul>\r\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Activity: Check Your Understanding<\/strong><\/span><\/h2>\r\n<span style=\"color: #000000\">[h5p id=\"47\"]<\/span>","rendered":"<p style=\"text-align: left\"><span style=\"color: #000000\">The perianal region extends around the anal opening by about five centimetres. Assessment of the perianal region can create feelings of discomfort and nervousness in clients, so you should always employ a <strong>trauma-informed approach<\/strong>. <\/span><\/p>\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Explain each step.<\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Ask permission to touch.<\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Use a drape, and only expose the client as long as needed. <\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Avoid words that may be triggering, such as \u201cbed\u201d and \u201cspread your legs.\u201d Instead, use \u201cexam table\u201d and make requests like \u201cmove this leg out.\u201d <\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Ask the client if they would like to have another person present such as a family member\/friend or another healthcare provider.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Positioning<\/strong> for this assessment depends on several factors including age, what is most comfortable for the client, and other parts of the assessment. It is best to use an <strong>inclusive approach<\/strong> to assessment: provide the client with options on how to proceed with positioning. Where appropriate, you can provide choices by saying, for example, \u201cI need to exam your anal region. I usually have clients in position XX or XX, do you have a preference or another option?\u201d Specific considerations for positioning include:<\/span><\/p>\n<ul style=\"text-align: left\">\n<li><span style=\"color: #000000\">To ensure <strong>infants<\/strong> and <strong>toddlers<\/strong> are comfortable and safe, involve their caregiver\/parent when possible. They are often best positioned in supine position on the exam table or the caregiver\u2019s lap and then the legs (hips and knees) are flexed towards the chest.<\/span><\/li>\n<li><span style=\"color: #000000\">With <strong>older children, adolescents<\/strong>, and <strong>adults<\/strong>, use a position that is comfortable and familiar for the client. For example, if you are only doing an examination of the perianal region and\/or the client is restricted to the bed, you can help the client into a left lateral position. If clients have difficulty maintaining this position, place a pillow between their legs with the right leg flexed.<\/span><\/li>\n<li><span style=\"color: #000000\">A rectal exam is often performed at the same time as genitourinary or prostate exam, so you should use the position required for that to minimize position changes. More importantly, it is important to use a position that is <strong>most comfortable<\/strong> for the client and usually <strong>gender-affirming<\/strong>. For example, for a <button class=\"glossary-term\" aria-describedby=\"680-1482\">cisgender<\/button> woman, you may use a lithotomy position in which they are in supine position with their legs flexed and abducted, and their feet in stirrups. With a cisgender man, you may use a standing position in which they lean over on a table with toes pointing inward. With <button class=\"glossary-term\" aria-describedby=\"680-1484\">transgender<\/button> and <button class=\"glossary-term\" aria-describedby=\"680-1485\">non-binary<\/button> clients, use a position that is most comfortable for them at that moment: this is usually a position that is gender-affirming. For example, for a transman, you may use a standing position and for a transwoman, you may use a lithotomy position. Be aware that the preferred position may change over time for a non-binary or a trans client, so always ask.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\"><strong>Perianal assessment<\/strong> involves the following steps:<\/span><\/p>\n<p><span style=\"color: #000000\">1. Prepare <strong>supplies<\/strong> needed (e.g., cover sheet\/drape, gloves).<\/span><\/p>\n<p><span style=\"color: #000000\">2. Don <strong>gloves<\/strong>.<\/span><\/p>\n<p><span style=\"color: #000000\">3. Provide options for <strong>positioning<\/strong>.<\/span><\/p>\n<p><span style=\"color: #000000\">4. Assist the client into position and ensure they are comfortable.<\/span><\/p>\n<p><span style=\"color: #000000\">5. Expose the <strong>rectal<\/strong> <strong>area<\/strong>. If the client is in a left lateral position, place your dominant hand on the right buttock and gently pull it up. If the client is standing, you may need to gently spread the buttocks apart with both of your hands; you may also need to do this if the client is in supine or lithotomy position.\u00a0<\/span><\/p>\n<p><span style=\"color: #000000\">6. Inspect the area for <strong>colour<\/strong>. The peri-anal area is slightly darker than the rest of the client\u2019s skin, but the colour in the region should be consistent with no discoloration (e.g., redness, dark brown\/purple) or rashes.<\/span><\/p>\n<p><span style=\"color: #000000\">7. Inspect the area for <strong>lesions<\/strong> or <strong>lumps <\/strong>(e.g., a wart).<\/span><\/p>\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, palpate them for consistency (soft or hard) and pain.<\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, identify the location, colour, size, shape, elevation, and whether the area is intact.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">8. Inspect the area for <strong>discharge<\/strong>. If any is noted, identify the quantity, colour, and consistency.<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">9. Inspect the area for <strong>malformations<\/strong>. (e.g., hemorrhoids). See <strong>Figure 5.8<\/strong>\u00a0for an image of a hemorrhoid. If any malformations are noted, describe the appearance, location, colour, and size.<\/span><\/p>\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">If any are noted, palpate them for consistency (soft or hard) and pain.<\/span><\/li>\n<\/ul>\n<p><img loading=\"lazy\" decoding=\"async\" src=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-300x258.png\" alt=\"\" width=\"300\" height=\"258\" class=\"alignnone size-medium wp-image-2129\" srcset=\"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-300x258.png 300w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-1024x882.png 1024w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-768x661.png 768w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-65x56.png 65w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-225x194.png 225w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM-350x301.png 350w, https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-content\/uploads\/sites\/192\/2022\/08\/Screenshot-2022-08-25-at-11.39.46-PM.png 1370w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/p>\n<p><strong>Figure 5.8<\/strong>: Hemorrhoids<\/p>\n<p style=\"font-weight: 400\">Photo by <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?title=User:Pachacamac33&amp;action=edit&amp;redlink=1\" target=\"_blank\" rel=\"noopener\">Pachacamac33<\/a>, Public Domain, from <a href=\"https:\/\/commons.wikimedia.org\/w\/index.php?search=hemmorhoid&amp;title=Special:MediaSearch&amp;go=Go&amp;type=image\" target=\"_blank\" rel=\"noopener\">Wikimedia Commons<\/a><span style=\"color: #000000\">\u00a0(image was cropped and illustrated upon for the purposes of this chapter)<\/span><\/p>\n<p style=\"text-align: left\"><span style=\"color: #000000\">10. Assess for <strong>anal tone<\/strong> by asking the client to try to contract or \u201cdraw in\u201d their anus. This can also be achieved by gently touching a cotton ball just lateral from the anus. Observe the external anal sphincter. Normally, a client has \u201cgood\u201d anal tone as demonstrated by contraction or puckering of the anus.<\/span><\/p>\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">This is important to assess particularly in older clients or clients who may have indicated problems with <button class=\"glossary-term\" aria-describedby=\"680-1528\">fecal incontinence<\/button>. Anal tone can be affected by nerve or muscle damage. There are many causes of this damage, but it is sometimes related to individuals who strain when trying to have a bowel movement. Straining can be associated with constipation and can be treated by health promotion related to diet, sufficient water intake, and routine bowel training.<\/span><\/li>\n<\/ul>\n<p style=\"text-align: left\"><span style=\"color: #000000\">11. Note the <strong>findings<\/strong>.<\/span><\/p>\n<ul>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Normal findings might be documented as: \u201cPerianal area is consistent in colour with no discolouration, lesions, discharge, or malformations. Good anal tone.\u201d<\/span><\/li>\n<li style=\"text-align: left\"><span style=\"color: #000000\">Abnormal findings might be documented as: \u201cPerianal area has swollen veins at the anal opening with slight bleeding.\u201d<strong style=\"font-size: 1em\">\u00a0<\/strong><\/span><\/li>\n<\/ul>\n<h2 style=\"text-align: left\"><span style=\"color: #000000\"><strong>Activity: Check Your Understanding<\/strong><\/span><\/h2>\n<p><span style=\"color: #000000\"><\/p>\n<div id=\"h5p-47\">\n<div class=\"h5p-iframe-wrapper\"><iframe id=\"h5p-iframe-47\" class=\"h5p-iframe\" data-content-id=\"47\" style=\"height:1px\" src=\"about:blank\" frameBorder=\"0\" scrolling=\"no\" title=\"Ch.5 Perianal region\"><\/iframe><\/div>\n<\/div>\n<p><\/span><\/p>\n<div class=\"glossary\"><div class=\"glossary__tooltip\" id=\"680-1482\" hidden><p>refers to person whose gender identity aligns with their sex at birth<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"680-1484\" hidden><p>refers to a person whose gender identity incongruent with their sex at birth.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"680-1485\" hidden><p>refers to people who feel their gender cannot be defined based on the gender binary.<\/p>\n<\/div><div class=\"glossary__tooltip\" id=\"680-1528\" hidden><p>is the involuntary release of stool.<\/p>\n<\/div><\/div>","protected":false},"author":34,"menu_order":11,"template":"","meta":{"pb_show_title":"on","pb_short_title":"","pb_subtitle":"","pb_authors":[],"pb_section_license":""},"chapter-type":[],"contributor":[],"license":[],"class_list":["post-680","chapter","type-chapter","status-publish","hentry"],"part":48,"_links":{"self":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/680","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters"}],"about":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/types\/chapter"}],"author":[{"embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/users\/34"}],"version-history":[{"count":28,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/680\/revisions"}],"predecessor-version":[{"id":2155,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/680\/revisions\/2155"}],"part":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/parts\/48"}],"metadata":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapters\/680\/metadata\/"}],"wp:attachment":[{"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/media?parent=680"}],"wp:term":[{"taxonomy":"chapter-type","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/pressbooks\/v2\/chapter-type?post=680"},{"taxonomy":"contributor","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/contributor?post=680"},{"taxonomy":"license","embeddable":true,"href":"https:\/\/pressbooks.library.torontomu.ca\/assessmentnursing\/wp-json\/wp\/v2\/license?post=680"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}