Originally published Feb. 4, 2024
The digital rectal exam (DRE) is something most men would prefer to avoid. They might be relieved over the growing professional opinion that the DRE is an ineffective way to screen for prostate cancer (PCa), as explained in our original blog below. However, many urologists continue to include it because feeling a lump in a patient whose PSA blood test was normal might be the only way to detect a PCa tumor early enough for successful treatment. Thus, a recent blog from a Texas urology practice says, “A prostate exam often includes both a digital rectal exam and a prostate-specific antigen (PSA) test. They are often administered together to get the most accurate results.” However, so much information is still missing. Even if PCa is present, the DRE exam offers little clue to the stage (extent/location) of the tumor. This is why a 2025 journal article notes that screening has evolved to include multiparametric MRI (mpMRI). Launer, et al. write, “Incorporating this advanced imaging tool has further limited the well-established problem of overdiagnosis, aiding in the identification of higher grade, clinically significant cancers. For this reason, mpMRI has become an important part of the diagnostic pathway and is recommended across guidelines in biopsy naïve patients or for patients with prior negative biopsy.”[i] Thus, mpMRI should be the next step to clarify an abnormal PSA, an abnormal DRE, or both.
Vienna is one of the most romantic cities in Europe. It is the home of the Waltz King, Johann Strauss Jr., whose music sends women in gowns and men in tuxes whirling around over 400 balls per year. This City of Beauty is where the snow globe was born, mesmerizing generations of children. Did you know that the oldest operating Ferris wheel in the world is a symbol of Austria’s capital? And chocolate lovers find Vienna’s Sacher Cake simply to die for. No wonder visitors rapidly fall in love with Vienna.
Recently, publication of new research out of Vienna’s University Hospital and its MedUni Department of Urology suggest that clinicians are rapidly falling out of love—not with Vienna, but with the Digital Rectal Exam (DRE). Patients already don’t love it. Being rectally probed by a lubricated, gloved finger has hardly been a favorite screening PCa test for men subjected to it. Untold numbers of men who might otherwise have participated in annual screenings simply stayed away out of embarrassment or discomfort. This has led to a sorry situation for many of them, because early PCa has no symptoms. Therefore, many of these men later ended up diagnosed with advanced disease.
Thankfully, the new Viennese paper offers good news for patients who avoid DRE as part of PCa screening. The study by Matsukawa, et al. (2024) finds that “the screening performance of digital rectal examination for detection of prostate cancer is not particularly impressive, suggesting that it might not be necessary to conduct this examination routinely.”[ii] The conclusion is based on an analysis of over 85,000 cases (data integrated from eight previously published studies), a very impressive number!
Historically, in the late 1980s the combination PSA-plus-DRE was accepted for widespread use as the conventional way to screen for PCa. Since then, the value of DRE has been called into question many times. As one example, I recently posted a blog citing a study that showed how the accuracy of multiparametric MRI simply erases the need for the DRE.
A news story explains the significance of the Viennese analysis. “The results suggest that DRE alone or in combination with PSA may not be more effective in the early detection of prostate cancer compared to PSA testing alone. In particular, DRE alone showed a lower cancer detection rate (CDR) compared to the PSA test.” In other words, the authors are suggesting that the use of the DRE for routine screening be discontinued. It is their hope that by doing so, more men will participate in annual PSA tests.
The world of PCa screening is at a crossroads: if not PSA screening, then what? The US Protective Services Task Force currently recommends that given each individual’s PCa risk factors, the blood test’s merits for him be discussed with his doctor. This advice is understandable because in the past, a single suspicious PSA result led many patients down a biopsy-to-treatment pathway that resulted in collateral harms. Not only do these harms impact quality of life, managing them for months and years after biopsy and/or treatment drives healthcare costs way up. We now see that the baby was thrown out with the bath, as trends now show that as more men skip screening, more patients are being diagnosed with later stage disease requiring more aggressive treatments with long term side effects.
Doctors and patients don’t have to go down that road. Instead, let’s turn the corner onto a new PCa detection highway with no DRE: PSA-plus-mpMRI. Not only can this route eliminate a needless biopsy, in the long run it avoids costs of expensive overtreatments, and of managing biopsy and overtreatment side effects! It overcomes the shortsighted objections of those who point to a cost of a single MRI scan after an abnormal PSA test.
In an interview, study co-author Shahrokh Shariat noted how important it is to identify the best early detection method: “The continuous improvement of prostate cancer screening methods remains of paramount importance to protect the health and well-being of men worldwide.”[iii] I believe following a suspicious PSA with an MRI before biopsy already achieves that goal. We should modify the timeless adage about an ounce of prevention. In the case of the Viennese study, it should now be, “An ounce of accurate early detection is worth a pound of overkill.”
NOTE: This content is solely for purposes of information and does not substitute for diagnostic or medical advice. Talk to your doctor if you are experiencing pelvic pain, or have any other health concerns or questions of a personal medical nature.
References
[i] Launer BM, Ellis TA, Scarpato KR. A contemporary review: mpMRI in prostate cancer screening and diagnosis. Urol Oncol. 2025 Jan;43(1):15-22. doi: 10.1016/j.urolonc.2024.05.012.
[ii] Matsukawa A, Yanagisawa T, Bekku K, Kardoust Parizi M et al. Comparing the Performance of Digital Rectal Examination and Prostate-specific Antigen as a Screening Test for Prostate Cancer: A Systematic Review and Meta-analysis. Eur Urol Oncol. 2024 Jan 4:S2588-9311(23)00292-4.
[iii] Medical University of Vienna. “Study: rectal examination has no advantage over PSA blood test for prostate cancer screening.” MedicalXpress, Jan. 19, 2024. https://medicalxpress.com/news/2024-01-rectal-advantage-psa-blood-prostate.html
About Dr. Dan Sperling
Dan Sperling, MD, DABR, is a board certified radiologist who is globally recognized as a leader in multiparametric MRI for the detection and diagnosis of a range of disease conditions. As Medical Director of the Sperling Prostate Center, Sperling Medical Group and Sperling Neurosurgery Associates, he and his team are on the leading edge of significant change in medical practice. He is the co-author of the new patient book Redefining Prostate Cancer, and is a contributing author on over 25 published studies. For more information, contact the Sperling Prostate Center.
