Question: What’s every man’s favorite medical exam?
Answer: Pretty much anything as long as it’s not the Digital Rectal Exam!

I know a lot of men who stoically accept the fact that during their annual physical, their primary care doctor or urologist will perform a routine digital rectal exam (DRE). It’s sometimes jokingly called “the urologist’s handshake.” The DRE itself doesn’t take long, but for many men it is embarrassing, physically uncomfortable, or even painful in a minority of cases.

The DRE is performed by gently inserting a lubricated gloved finger into the patient’s rectum. The purpose is to check prostate size, and feel for abnormalities or lumps that might suggest prostate cancer (PCa). Before the PSA era, it was the only way to screen for PCa in hopes of detecting it early. Then, when the PSA blood test was developed, the DRE continued to be a companion exam. However, from the medical perspective, it has a significant limitation: it misses the majority of prostate tumors because it cannot explore the entire gland, only a single surface next to the rectal wall.

Furthermore, a team of German researchers believe that in men age 45 or younger, DRE fails at PCa screening because at that age, “…the changes in the tissue in the prostate may be too slight to detect with a finger. In addition, some cancers occur in a part of the prostate that cannot be easily reached by a finger.”^[i]

From the patient perspective, anticipation of unpleasantness becomes a rationalization for avoidance. A 2005 study of over 13,000 men found that “only 78% of men would participate in screening that included both DRE and PSA.”^[ii] According to a 2008 study about patient attitudes, “Patient expectations about DRE were negative before examination…” though most patients in the study said it was “acceptable” after the exam.^[iii] Let’s face it, if given a choice, all men would prefer to skip it. Their wish may soon come true. A growing wave of new research and opinions suggest dumping the DRE as a screening method for PCa.

Years ago, the leading edge of the wave was the question, does DRE had any value to detect recurrence after prostatectomy or radiation? Early studies attested to the fact that the PSA blood test alone was sufficient to monitor for recurrence—especially after prostatectomy when the gland had been completely removed. Eventually, DRE after radical treatment was dropped as a standard of care.

Today, skepticism about the merits of DRE for PCa screening is mounting. It may have value in other settings, so wholesale rejection of it is premature. However, compared to early detection advances in biomarkers, MRI-based detection and genomic testing, the DRE is nearly worthless. I like the way Drs. Dubin and Punnen expressed their opinion in “Time to Say Goodbye to the DRE for Prostate Cancer Screening”:

”…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.”^[iv]

I hate the thought of men avoiding a general physical because of “the urologist’s handshake.” It’s so simple to do an annual PSA blood test, and it’s completely noninvasive (and not embarrassing) to have a multiparametric MRI if the results are suspicious. For that reason alone, I’m in favor of dropping the DRE as a routine annual exam. The wave is catching up, and hopefully the day is coming soon.

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] Press release from European Association of Urology. “Digital rectal examination is not useful to early detect prostate cancers.” Mar. 9, 2023.
[ii] Nagler HM, Gerber EW, Homel P, et al. Digital rectal examination is barrier to population-based prostate cancer screening. Urology. 2005;65(6):1137-1140.
[iii] Furlan AB, Kato R, Vicentini F, Cury J, Antunes AA, Srougi M. Patient’s reactions to digital rectal examination of the prostate. Int Braz J Urol. 2008 Sep-Oct;34(5):572-5; discussion 576.
[iv] Dubin J & Punnen S. “Time to Say Goodbye to the DRE for Prostate Cancer Screening.” Renal & Urology News/Prostate Cancer Advisor. Jan. 12, 2021.