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Digital Rectal Exam for Prostate Cancer

Who should have this exam?

Let's start by saying that the digital rectal exam (DRE) appears to be on the way out as a way to screen for prostate cancer.

For years, it was a standard tool, often referred to as "the urologist's handshake." The doctor would manually check your prostate -- a walnut-sized gland that surrounds the duct connecting the bladder with the penis -- to look for signs of prostate cancer.

Sure, it was uncomfortable, maybe even a little embarrassing. But it appeared to be worth it. But now, urology is taking another look at the exam-- and many are finding it wanting.

After the advent of the PSA test for prostate cancer, wrote Justin Dubin, MD, and Sanoj Punnen, MD, MAS, in Renal and Urology News, "does the DRE provide helpful information for decision-making or is it an obsolete practice perpetuated by historical dogmatism? We believe it is the latter and it is time to say goodbye to the DRE for PCa screening."

As Dubin and Punnen point out, the test is less than 29% accurate for prostate tumors. In addition, the stigma, pain and discomfort associated with the procedure has, the authors believe, led many men to avoid getting tested for prostate cancer altogether -- something backed up by surveys. They do concede that there are some uses for the DRE exam, such as assessing those who may require a post radiation prostatectomy.

But, they say, "As the technology in our field continues to evolve, the DRE will continue to become more outdated. More and more literature supports the use of the prostate MRI for screening, and it has become the “go-to test” prior to a biopsy. If performing a DRE presents a barrier to care, causes pain in two-thirds of the patients who do get screened, and ultimately cannot even provide us with any sound guidance in future decision-making, then we really need to ask ourselves exactly why it is still accepted as a standard of care."

What does the American Cancer Society say?

The American Cancer Society no longer recommends that doctors offer this procedure, along with information on its potential risks and benefits, every year to all men aged 50 and up with at least a 10-year life expectancy; it is used as a screening for both colon cancer and prostate cancer, or to men 40 to 45 and at very high to high risk of prostate cancer. It does say that the test "might be included" along with a PSA test.

The doctor will also check to see if your prostate is enlarged, a common problem in men who are middle-aged or older. If you've noticed problems with urination -- an urgent need to relieve yourself, a weak stream or leaking, or unusually frequent urination, especially at night -- you may have an enlarged prostate that's blocking the urine flow from your bladder. If you think this could be the case, call your doctor and ask about having the exam.

What should I expect?

Usually painless, the digital rectal exam, or DRE, takes a minute or less (though it may seem longer). The doctor will ask you to bend over or lie on your side; then he or she will insert a gloved, lubricated finger into your anus and check the rear surface of the prostate for abnormalities. Hardness or a lump, for example, might be a sign of prostate cancer.

Are there other tests for prostate cancer?

As noted, there's a blood screening known as the PSA test. The PSA test is more effective than the digital rectal exam in detecting cancer, but the DRE sometimes picks up cancers the blood test misses. The manual exam isn't an ideal screening tool either, though. Your doctor can't feel tumors that are on the front of the prostate or buried in the middle. The prostate MRI seems to be gaining widespread acceptance as a screening tool.

What if the doctor finds a lump?

Don't panic; it doesn't necessarily mean you're in trouble. About half of the time, a suspicious bump in the prostate turns out not to be cancer. If both your exam and your PSA test suggest that cancer may be present, your doctor will likely order a biopsy so that a sample of tissue can be examined under a microscope.

References

Time to Say Goodbye to the DRE for Prostate Cancer Screening. Renal and Urology News. Jan. 12, 2021.

American Cancer Society. Prostate Cancer Screening.

Prostate-Specific Antigen (PSA) Test. National Cancer Institute. U.S. National Institutes of Health.

National Library of Medicine. Digital rectal exam.

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