The lateral, posterior, and anterior walls of the rectum are palpated. To palpate the lateral walls, rotate your digit along the sides of the patient's rectum, as shown in Figure 17-36. The ischial spines, coccyx, and lower sacrum can be felt easily. Palpate the walls for polyps, which may be sessile (attached by a base) or pedunculated (attached by a stalk). Any irregularities or undue tenderness should be noted. The only way to examine the entire circumference of the rectal wall fully is to turn your back to the patient, which will allow you to hyperpronate your hand. Unless you do so, you will be unable to examine the portion of the rectal wall between the 12 o'clock and 3 o'clock positions. A small lesion in this quadrant may go undetected.
Intraperitoneal metastases may be palpated anterior to the rectum. These tumors are hard, and a shelflike structure projects into the rectum as a result of infiltration of Douglas' pouch with neoplastic cells. This is Blumer's shelf.
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