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The prostate exam, or digital rectal exam (DRE), allows a healthcare provider to check on the health of the prostate gland. It can be a part of the prostate cancer screening process, though it’s less accurate than the PSA test.
The American College of Physicians (ACP) now recommends against its use in prostate cancer screening. This comes after a review (ACP, 2018) of several studies which revealed that the DRE might be ineffective for prostate cancer screening. However, many healthcare providers still use it for other purposes and in addition to the PSA test for prostate cancer screening.
The prostate gland sits just in front of the rectum. This means that it can be felt by gently inserting a finger in the rectum via the anus. The healthcare provider can feel the prostate to detect areas that are larger than usual, lumps, tenderness, or any other problems. While performing the DRE, the healthcare provider can also detect abnormalities in or around the rectum, like hemorrhoids, anal fissures, blood in the stool, etc.
- A digital rectal exam (DRE) is sometimes used along with prostate-specific androgen (PSA) testing as part of the prostate cancer screening process.
- Recent research suggests that the DRE may be ineffective in prostate cancer screening, however.
- DRE and PSA testing are not recommended for men younger than 40 or older than 70 years of age.
- Men aged between 55-69 years should discuss with their healthcare provider regarding their risks and benefits of prostate cancer screening.
Prostatitis: The Prostate Problem That Can Happen at Any Age
Men with an average risk of prostate cancer over the age of 50 (Detection, 2013) should discuss the need and timing of a prostate exam with their healthcare provider as part of a prostate cancer screening. (1) However, men with a higher risk of prostate cancer or patients having urinary or sexual symptoms should have that discussion sooner rather than later. These higher-risk patients include:
- African Americans
- Men with a family history of prostate cancer or who have tested positive for BRCA1, BRCA2, or HOXB13 gene mutations.
- Men who with symptoms like blood in the urine, painful or frequent urination, or sexual problems as they could be a sign of problems with the prostate, including prostate cancer.
What to expect in a prostate exam?
Before performing the exam, the healthcare provider will ask you to remove your clothes from the waist down and will provide you with a gown to wear. During the DRE, you will be asked to stand and bend at the waist or lie on your side with your knees bent. He or she will apply lubricant to a gloved finger and gently insert it into your rectum. The healthcare provider will sweep their finger along the wall of the rectum, feeling for any abnormalities in the prostate and may also press down on your lower abdomen during this process. It is normal to feel mild discomfort and the urge to urinate, but these sensations should last no longer than a few minutes.
Prostate-Specific Antigen (PSA) test
Prostate-specific antigen is a protein produced by the prostate. The PSA blood test has become the mainstay of the prostate cancer process as it’s far more sensitive than the DRE. However, it is sometimes still used along with the PSA as part of a prostate cancer screening.
While measuring PSA levels is important in prostate cancer screening, an abnormal PSA test does not necessarily mean that you have prostate cancer. A PSA outside of the normal range could be due to benign prostatic hyperplasia or enlarged prostate, prostatitis, a urinary tract infection, among other reasons. A healthcare provider will help you interpret PSA test results and recommend further testing if he or she thinks it necessary.
Various organizations have slightly different recommendations regarding screening.
The American Urological Association’s (AUA) recommendations.
The United States Preventive Services Task Force (USPSTF) has recommendations that are very similar to the AUA, though they do not comment on men under the age of 55 or on men 70+ in excellent health.
The American Academy of Family Practice (AAFP) recommends against routine screening for prostate cancer because they believe the risks outweigh the benefits. The AAFP is unclear about whether healthcare providers should start a conversation with men about screening or should only screen if someone asks for it specifically.
Results and follow-up
After a DRE, a healthcare provider will know right away if there are any abnormalities like any lumps or a prostate that is larger than usual (like in BPH). He or she will discuss these with you, and together you will make a plan for the next steps. The results from a PSA test typically take around two weeks to come back. The healthcare provider will review the results with you and help you decide on an individualized plan.
In most cases, if all results are normal and the decision is made to continue screening, it is usually done every two years. If the PSA test is abnormal, you may be referred to a urologist for a biopsy or undergo additional testing.
There are two main benefits of prostate cancer screening. One is potentially preventing death from prostate cancer. Since men can have prostate cancer without experiencing symptoms, screening can potentially identify prostate cancer early on when it can be treated more easily.
Another benefit of screening and early detection is earlier and more effective treatment. Earlier treatment can help prevent prostate cancer from spreading beyond the prostate (metastatic prostate cancer), which can cause a number of symptoms.
Unfortunately, there are drawbacks to prostate cancer screening. As we’ve talked about, the DRE is not very sensitive or specific (Naji, 2018). This means that people who have prostate cancer can still have a normal DRE while patients with an abnormal DRE may not have prostate cancer. It’s for this reason that healthcare providers are no longer performing DRE alone for routine prostate cancer screening and relying instead on the PSA test.
But that’s not to say that the PSA is not without its own limitations in screening for prostate cancer. First off, elevated PSA levels do not only occur in prostate cancer. As we discussed earlier, prostatitis (inflammation of the prostate) and enlarged prostate (benign prostatic hyperplasia or BPH) are also likely to result in a PSA that is outside of the normal range. Abnormal test results can ultimately lead to undue anxiety and further testing that may prove unnecessary.
Another problem with the PSA test is that of overdiagnosis and overtreatment. Screening uncovers patients with prostate cancer who would otherwise never had any issues resulting from the disease.
This overdetection means that PSA testing leads to more men getting prostate cancer diagnoses. And once someone is diagnosed, he may elect to undergo prostate cancer treatment, which is not without its own risks. Treatment risks include infections, bleeding, and urinary problems due to biopsies, as well as erectile dysfunction (ED), urinary incontinence, and fecal incontinence.
Routine prostate cancer screening, especially for men younger than 40, is not recommended. The DRE is no longer used routine prostate cancer screening, though it is often still used in conjunction with a PSA test. Screening tests have their own risks and benefits. The most significant risk is overtreatment, a direct result of overdiagnosis.
Current prostate exam screening recommendations vary based on your age, risk factors, and any symptoms you may or may not be experiencing. There is no “one-size-fits-all” when it comes to prostate exams and cancer screenings. It’s vital to discuss your risk of prostate cancer with your healthcare provider. Together, you can decide whether to screen for prostate cancer and the best screening plan for you.