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Now we come to the part of the exam that is the butt of too many jokes.  I had considered leaving this subject behind, but realized I would be poo-pooed by many of my readers  (I just hate making a ass fool out of myself by wasting people’s time).  So let me wipe away your fear, get to the bottom of things, and put an end to the stink i know people would raise.  I hope you are all relieved and won’t dump on me anymore.

OK, now that I got the barrage of buns puns out of the way, we will move on the the rectal exam (AKA the “Finger Wave”).

Since I don’t to GYN, I won’t go into the part of the normal GYN visit that involves examination of the rectum, but there still are times when females do get rectal exam.  But the vast majority of rectal exams I perform are on men.  Many women see the regular prostate exam on men as some sort of divine payback on men for not having to do GYN exams.  Although this payback is not an equal trade, the remainder is made up by the fact that men die younger.

For the male, the normal rectal exam is notated as follows:

Rectal – Normal ST, prostate normal size/consistency, no masses.  Hemoccult negative.

For women, the exam is the same, minus the prostate.

The Exit

The first part of the rectal exam, is the external exam.  You look at it.

Yes, it takes some getting used to.  The main things seen on the external exam (besides Klingons) are hemorrhoids and fissures.  Both of these happen fairly commonly, both are caused (at least in part) by constipation, and both can cause bleeding.

Fissures are what they sound like: they are crevices in the normally smooth anal tissue.  They can be quite painful – generally regarded as more painful than hemorrhoids – but don’t usually cause much bleeding.  Kids get fissures but don’t usually get hemorrhoids.  Fissures normally heal on their own, but some people require a “sphincterectomy” to stop having them.  This procedure involves making deeper cuts into the muscles, thereby decreasing sphincter tone.

Which leads me to my first diversion: sphincter tone.

Pardon my French, but Cameron is so tight that if you stuck a lump of coal up his a**, in two weeks you’d have a diamond. – Ferris Bueller

The idea of a “tight sphincter tone” alludes to the idea of someone being anal-retentive.  Wikipedia defines anal-retentive as: “The term anal-retentive (or anally retentive, anal retentive), commonly abbreviated to “anal”, is used conversationally to describe a person with such attention to detail that the obsession becomes an annoyance to others, and can be carried out to the detriment of the anal-retentive person. The term derives from Freudian psychoanalysis.”

I have to confess, there have been patients I was really worried about doing a rectal exam on (mostly other doctors).  It seemed to me that my finger was in danger of coming out a few ring-sizes smaller.  Much to my relief, however, I found that the idea of a “tight sphincter” is only metaphorical.  Perhaps the Mythbusters should take that one up.

The Itching, the Burning

So what of hemorrhoids?  We have all seen the commercials that, next to feminine hygiene products, embarrass the highest number of people without them really understanding what they are about.  I wondered as a kid, with the hand motion the person on the commercial made when he said the words “shrinks hemorrhoidal tissue,” if hemorrhoids were really about six-inches wide.

What is a hemorrhoid?  Hemorrhoids are blood vessels that have gotten blown up like balloons.  This happens when the veins of the anal area are unable to empty – caused either by stool in the rectal vault or a baby wanting to come out of its mommy.  Yes, some of the scariest-looking hemorrhoids I have seen are the ones on a woman in labor.  I have yet to hear, however, someone shout, “run for cover everyone!  She’s gonna blow!”  Blood vessels are stretchy and while they may leak, they won’t explode.

That being said, the amount of bleeding from hemorrhoids can be impressive, causing many patients to come in worrying about worse problems.  But the large amount of bleeding is actually reassuring, as it more likely to be hemorrhoidal.

The worst complication of hemorrhoids is when they get a clot in them (or “thrombose”).  This causes a very large painful mass that makes sitting difficult and bike-riding impossible.  The only fix for thrombosed hemorrhoids is to cut them open.  While this sounds terrible, the pain relief is immediate and the patient is incredibly grateful.  It does feel kind of odd being thanked enthusiastically for doing that to someone, but life is strange sometimes.

Most hemorrhoids get better on their own (with OTC medications and stool-softeners).  Occasionally people have to get them surgically fixed or “rubber banded.”  This is one surgical procedure that you don’t share with your friends to get their sympathy.  Just the thought of surgery down there gives most people the heebie-jeebies.

The Glove

It is common for people’s blood pressure to go to dangerous levels when the doctor puts on only one glove.  It is about as intrusive you can be into another person’s existence without anesthesia (yes, ladies, don’t get all riled-up.  That is why I used the word “about”).  People commonly check the size of the doctor’s hands and whether or not they cut their nails.  Reality is, however, the average finger entering the rectum is smaller than most of the things that exit this locale.

I do keep my nails nicely trimmed.

Just what are doctors checking for?  In both men and women, we are looking for anything that shouldn’t be there.  I have diagnosed two people with rectal cancer after realizing that the story they told me obligated me to do a rectal exam.  This reminds me that no matter how much I don’t want to do a part of the exam, there are times where I do what I must.  A rectal exam can also find a case of PID (Poo in dere).

The vast majority of rectal exams I do, however, are to examine the prostate.  The prostate is the cause of many problems in men – particularly in older men.  It can become infected (prostatitis), enlarged (Benign Prostatic Hypertrophy), or cancerous.

Men with prostatitis are very uncomfortable, but they often are not sure where.  The pain is often a vague “inside pain” and is associated with difficulty urinating.  Proving prostatitis to be there is done via rectal exam.  The examiner pushes on the prostate (which is in front of the rectum) and a “soft boggy prostate” indicates prostatitis.  Oh yes, and the screams of the man when you push on the “soft boggy prostate” confirm the diagnosis.  Prior to the use of antibiotics for this condition, doctors used to treat it by “milking the prostate.”

I just can’t imagine, and I don’t really want to.

BPH is what keeps many men over 50 in shape.  It causes them to run frequently to the bathroom, which is the most exercise many of them get.  When there, the men have to wait for a while for things to get going (hesitency) and once they do, the amount is not proportionate to the urgency.  This is because it causes the bladder to empty incompletely.  BPH is treated with several medications, but occasionally needs to be fixed surgically (by a procedure called TURP – which bears the nickname of “roto-rooter”).

Prostate cancer is the main reason routine prostate exams have been done.  The irregular shape and texture of a cancerous prostate would be the first sign of the disease in some men.  With the advent of PSA testing – a blood test that screens for a protein found in high amounts in most prostate cancer – the necessity of routine prostate exams has been called into question.  Truthfully, the efficacy of PSA testing in reducing the rate of prostate cancer hasn’t been proven, but nether has routine digital exams.  So I have cut back on my use of routine rectal exams (although this may be a subconscious reaction to the fact that I am approaching 50).

The End

So ends the fun that is the rectal exam.  I hope you have enjoyed your journey, and I hope you took something away….uh, let me rephrase that…I hope you retained….uh….end up….

Forget it.

I can’t do this anymore.  I’m pooped.