The Rectal

Spinal & extremities

examination

Liu YanFang
1st Teaching Hospital
Henan Medical University

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Rectal examination

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 POSITION

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Record: POSITION+CLOCK
POSITION+PATHOLOGICAL
CHANGE

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Anal inspection

Anal atresia 肛门闭锁 Stenosis 狭窄 Infection 感染

Fistula and fissure in ano, Proctoptosis

Hemorrhoids 痔 Internal,External,Mixed 混合
痔

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 fistula and fissure in ano

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Proctoptosis

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Hemorrhoid 痔
—— Internal & Mixed

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Archo-rectal palpation

• Archos 肛门
– Tenderness 触痛
• fissure in ano 肛裂
• anal fistula 肛瘘
• Perianal infection 肛周感染
– fluctuation 波动感 : Perianal
abscess
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Archo-rectal palpation
• Rectum
– Mass 肿块
Soft: Polyp 息肉 ,Internal hemorrhoids 内痔
质硬管腔狭窄 : rectal cancer 直肠癌
– Mucus with pus 粘液脓血 : Inflamation, tissue
damage
– Deep tenderness 深部触痛 : Inflamation

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Method of palpation

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Colonic polyp

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 A saying:
If a man’s urine is like the urine of an
ass, like beer yeast, like wine yeast or
varnish, that man is sick… and through
a bronze tue in the penis pour oil and
beer and licorice.
From the Sushruta Samhita
CA. 3000 BC

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 GU Organs
• Internal
Kidney
Ureter
Bladder
Prostate
Seminal vesicle
Vasal ampulla

• External
Penis
Testis
Epididymis
Vas deferens
Spermatic cord

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Seminal Vesicle 精囊
• Impalpable except in rare cases
• Lies postero-lateral to prostate
• Function
• Radiologic imaging
• Enlargement
– Tumor
– Ejaculatory duct obstruction
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Vasal Ampulla
• Impalpable except in rare cases

• Lies posterior to prostate either side of

midline

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Penis 阴茎
• Anatomy

• Abnormalities
– Meatus
– Prepuce
– Skin
– Erectile chambers

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Urethritis and carcinoma of penis

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Syphilis

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Testis
• Dimensions

• Consistency

• Enlargement
Testis versus entire hemiscrotum?
“Get above mass?”
Tenderness?
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Vas Deferens
• Difficult to palpate except through
practice

• Fibrous, mobile cord

• Presence vs absence

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Epididymis 附睾
• Posterolateral to testis

• Anatomic parts

• Enlargement
Inflammation/infection
Tumor
Obstruction
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Spermatic Cord 精索
• Varicose veins (Varicoceles)

• Lipoma

• Hernia

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Prostate
• Palpable by DRE
• “Chestnut-sized, squash ball consistency”
• Enlargement in 30’s
• Examination
- Position
- Landmarks
- Prostate features
• Radiologic imaging

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 The Spine
• Normal curves
• Deformities
– Kyphosis: abnormal outward hump
– Lordosis: exaggerated incurving
– Scoliosis: lateral curvature of the spine
– Poker back spine: loss of all curves

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Common Diseases

• Vertebral: bone destruction, fracture

• Intervertebral: protrusion of the disc, joint

dislocation

• Paravertebral: muscle and ligament injury

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 PATHOLOGICAL DEFORMITY
Kyphosis
•Aging and osteoporosis
•Poor posture
•Gibbous deformity: spinal
tuberculosis, fracture, or
metastatic disease to the
spine

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 •Scoliosis Kyphosis • Lordosis
–Postural • Aging and osteoporosis Whenever a patient must
scoliosis: • Poor posture
rock backwards to
protrusion of maintain a center of
• Gibbous deformity: spinal
intervertebral disc, tuberculosis, fracture, or
gravity:
short leg metastatic disease to the spine – Pregnancy, ascites,
large tumor
–Structural
– Flexion contractures or
scoliosis: rickets, tuberculosis at the hips
thorax deformity, – 30
Short Achilles tendons
pleural thickening
right: Liu YF, Ph D., 1 Teaching Hospital, Zhengzhou U.
st
 PATHOLOGICAL DEFORMITY
• Lordosis
Whenever a patient must
rock backwards to
maintain a center of
gravity:
– Pregnancy, ascites,
large tumor
– Flexion contractures or
tuberculosis at the hips
– Short Achilles tendons

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 PATHOLOGICAL DEFORMITY

•Scoliosis
–Postural scoliosis:
protrusion of
intervertebral disc,
short leg
–Structural scoliosis:
rickets, thorax
deformity, pleural
thickening

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Spinal mobility
 Normal
Cervico-lumbar vertebrae> Thoracic vertebrae
> Sacrococcygeal vertebrae

procurvation 前屈 retrocurvation 后伸
lateral curvature 侧弯 rotation 旋转

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Spinal mobility
 Limitation
Cervical vertebrae:
Muscle fibrofascitis 肌纤维织炎
Cervical syndrome 颈椎病
Tb, Tumor, Trauma, Fracture, Disarticulation
Lumbar vertebrae:
Muscle fibrofascitis,
Ligament stain 韧带劳损 ,
Spinal canal stenosis 椎管狭窄症
Intervertebral disk hernia 椎间盘突出 ,
Tb, Tumor, Trauma, Fracture, Disarticulation

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 NORMAL MOBILITY

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Tenderness &
Percussion pain
Tenderness 脊柱压痛
– Palpate the spinous processes for
tenderness
Percussion pain 脊柱叩击痛
Direct percussion
Indirect percussion

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Spine Examination:
Technique
• Motions of the spine:
– Forward bending
– Extension
– Lateral bending
– Rotation

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Clinical Features
• Abnormal sites: limited motion and
tenderness
• Spinous tenderness: location of spine
and intervertebral diseases
• Paravertebral tenderness: location of
muscle and ligament damage

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Clubbing (acropachy)

• Seen in carcinoma
of the lung or pleura,
bronchiectasis, lung
abscess, congenital
heart disease, etc.

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Koilonychia 匙状甲（反甲）
• Spoon-shaped nails

Seen in iron deficiency

anemia, mountain sickness,
rheumatic fever, etc

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Fusiform (Sausage)
Swelling of the Joints
• The swelling is not
bone but rather
synovium and soft
tissues filled with
edema fluid, seen
in rheumatoid
arthritis

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Paramorphia 形态异常 : Clawhand 爪
形手

Progressive muscular
atrophy
Progressive muscular
atrophy
Ulnar nerve injury

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Genu Varum and Genu Valgus

• Genu Varum 膝内翻 :

bowlegged knees 弓形腿
• Genu Valgus 膝外翻 :
knockkneed.
– Seen in rickets, Kaschin-
beck disease

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Varicose veins of lower extremity 下肢静脉曲张
& arthroedema of articular genu 膝关节腔积液

• Varicose veins: STANDING WORKERS

– Veins become 炎
Angiitis obliterans 栓塞性静脉

distended ,
beaded, and
tortuous
• Knee effusions:
– Joint swelling
– Patella tap sign Rheumarthritis 风湿性关节炎
Tuberculous arthritis 结核性关节炎
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 Bone Fracture and Joint
Dislocation
• Fracture:
– Decurtational deformity
– Localized swelling and
tenderness
– Bony fremitus and
crepitus

• Joint dislocation:
– Anatomical
derangement
– Limited joint motions
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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.
 QUESTIONS

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right: Liu YF, Ph D., 1st Teaching Hospital, Zhengzhou U.