Source urology text book
Paul Goldfinger, MD, FACC.
When I would go for my semi-annual urology checkup, my urologist would say. “Could I interest you in a digital rectal exam?” Not too many doctors can succeed in finding humor in such a situation. The (DRE) examination has been routine for years as a way to screen for prostate cancer.
In medical school at the George Washington University, Dean John Parks was a surgeon who demanded perfection from the students. When he was a patient at GW University Hospital, one of my fellow students, Bill Adams, was assigned to conduct a physical exam on him. He nervously examined the Dean and concluded that the exam was normal. But as he turned to leave, the Dean called him back and said, “You forgot to check my prostate.” So Bill did it, and the story made its way quickly to our entire class.
We were taught that a digital rectal exam was important in men, but they even required it in women. In Gyn they told us, “A pelvic exam without a rectal is a half-assed examination.”
But it has been especially important in men because that’s how we detect early prostate cancer.
I was always skeptical of the value of that test because, if you study the anatomic drawing above, you can see that the doctor’s finger can only readily feel the superficial part of the prostate where it is adjacent to the rectum. During that exam which only lasts for about 30 seconds, the doctor feels for lumps in the gland.
It was also thought that the rectal exam was a good way to screen for colon (large intestine) cancer, but again the digital exam only allows access to a very small part of the colon.
People would kid me that I should be a rectal surgeon or a gynecologist with my name Goldfinger.
During my residency in internal medicine at Mt. Sinai we were always advised to conduct routine digital rectal exams.
Back then I had a moonlighting job with a company that did physical exams on teachers. They all were encouraged to undergo a sigmoidoscopy exam with a rigid scope with a light to check the lower colon.
They gave me the job of doing those exams, one after the other. It wasn’t pleasant for the patients, but we were looking for cancer of the colon. I got really good at it, but rarely found anything suspicious. Once again I was skeptical because that scope only was about 10 inches long. So you can only examine a small part of the colon. But 10 inches is better than 10 cm, the length of most index fingers.
Eventually that was replaced by examining the entire colon with a flexible scope. (colonoscopy–a very good test to pick up potentially risky polyps or actual early colon cancer.)
When I was practicing cardiology, I would ask all the men if they had a prostate exam. And if they said “no” I wouldn’t let them leave without it. Physicians never stop being physicians.
Recently a huge study of nearly 50.000 men in Germany revealed that the digital rectal exam is essentially useless to screen for prostate cancer. Now the best approach is the PSA blood test, checking yearly after the age of 45. And if imaging is needed an MRI is a very good test.
So now it looks like the DRE will eventually be eliminated as a screening test for prostate cancer, although many doctors will continue to do it routinely.
So the bottom line for men is DO NOT NEGLECT TO HAVE A PSA TEST AT LEAST ONCE PER YEAR. And if your doctor wants you to drop your pants and bend over, don’t be so smart—-let him do it and then thank him. Do it all because metastatic prostate cancer is horrible and usually fatal, and, as it says in our book, “Prevention Does Work.”
Thank you David. I’m not sure how your fascinating piece will help our readers consider the use of PSA screening. If you mean that they should be skeptical of such tests, then of course. That’s why there are medical doctors.
Berson and Yallow’s Nobel winning development of an insulin assay came in handy when I was working on a case report at Mt. Sinai—-a difficult diagnostic problem. Dr. Berson offered to run his insulin test. Of course I said yes, but I didn’t expect much. The assay was normal; it was a true negative, But testing patients with such labs almost always has a risk of inaccuracy. The physician must add such results to the diagnostic mix.
Tests for diagnosis/screening often improve over time as will the PSA. We’ve come a long way since doctors tasted a patient’s urine to diagnose diabetes.
.Paul GoldfingerMD
There are two kinds of lab tests, screening and diagnostic. The PSA test is a screening test. Tests of this sort are usually simple, inexpensive, and non-invasive. However, they have limited accuracy in detecting disease and should be followed up by a diagnostic test if positive or other signs are present.
The director of the lab where I essentially worked my whole life at the Albert Einstein College of Medicine, the late Harold M. Nitowsky, MD, found a link between low AFP in pregnant women and whether they were carrying a Down Syndrome fetus. Prior to this discover, the only other test was the diagnostic amniocentesis and chromosome studies. This involved growing cells taken from amniotic fluid collected by a syringe. Miscarriage could sometimes result from this procedure and it was reserved for older women. The simple blood test for screening had no adverse reactions and could be offered to women of all ages, even those thought previously to be too young.
People should be aware that not all lab tests are created equal.
Andy. Thank you for sharing. Our article was about the use of rectal exams to screen for prostate cancer.
The thrust is that we can’t depend on DRE to detect all or even most cases. You happened to be an example where your lesion was detectable that way, but most cases are not. It is surprising that your digital abnormality, being cancerous, was not detected by PSA.
If I were practicing now I would still do DRE’s, but I wanted to emphasize that all men need PSA’s regularly, and there are reasons for the DRE besides cancer detection including feeling the gland and appreciating its size and consistency.
And the other lesson which is dramatically illustrated by your case is that early detection allows for cures most of the time.
Men need to be assessed for early prostate cancer, and a careful and thorough primary doctor can do that. But if that screening is worrisome, get thee to a urologist. Paul @Blogfinger.
Thirteen years ago when I was 48 years old my doctor performed both a PSA and a digital rectal exam. The PSA found nothing. But when he conducted the DRE he said “something feels off here,” I’m going to suggest some additional testing. That found prostrate cancer and probably saved my life. I know lots of men are squeamish about this exam. It might save your life!!!