Digital Rectal Examination in Suspected Prostate Cancer
Digital rectal examination (DRE) should be performed in all patients with suspected prostate cancer as it is an essential component of both diagnosis and staging. 1
Diagnostic Role of DRE
- DRE should be carried out in all patients presenting with urinary symptoms alongside serum PSA measurement as part of the initial diagnostic workup 1
- Prostate biopsy should be offered to men suspected of having clinically significant prostate cancer, particularly those with an abnormal DRE and elevated serum PSA 1
- DRE is a straightforward, cost-effective, and practical examination method that provides valuable information that cannot be obtained through PSA testing alone 2
- In patients with suspected prostate cancer, DRE has a diagnostic accuracy of approximately 63.45%, making it an important complementary test to PSA 2
Staging Role of DRE
- Clinical T stage should be evaluated by DRE as part of the risk assessment process for all patients with suspected prostate cancer 1
- DRE findings are crucial for categorizing patients into risk groups (low, intermediate, or high risk), which guides treatment decisions 1
- DRE-positive results are significantly correlated with higher Gleason scores (≥7), helping to identify more aggressive cancers 2
Value of DRE in Different Clinical Scenarios
- DRE is particularly valuable for detecting peripheral zone tumors, which have a higher recall rate (65.50%) compared to central zone or transition zone tumors (34.55%) 2
- In patients with normal PSA but abnormal DRE, approximately 3% may still have significant cancer, justifying the continued use of DRE even when PSA is normal 3
- DRE can detect approximately 17.3% of cancers that would remain undetected by PSA-based screening alone 4
Limitations and Considerations
- The positive predictive value of DRE varies significantly based on PSA levels, ranging from 4-11% in men with PSA levels of 0-2.9 ng/mL to 33-83% in men with PSA levels of 3.0-9.9 ng/mL 4
- DRE has poor performance in low PSA ranges, but remains valuable when used in conjunction with PSA testing 4, 5
- The concordance between primary and secondary care DRE findings may be limited (approximately 46%), highlighting the importance of specialist evaluation 3
Current Recommendations in the COVID-19 Era
- While virtual consultations have become more common during the COVID-19 pandemic, making DRE more difficult to perform, it remains an important part of the diagnostic pathway 6
- In settings where MRI is readily available, some clinicians now rely more on PSA measurements and MRI without requiring a DRE, but this approach is not universally recommended 6, 5
Practical Approach
- All patients with urinary symptoms should undergo both PSA testing and DRE as initial diagnostic steps 1, 7
- Patients with either abnormal DRE or elevated PSA should be considered for further evaluation including prostate biopsy 1
- DRE should be performed by trained clinicians who can accurately assess prostate size, consistency, shape, and abnormalities 7
- DRE findings should be integrated with other clinical information, including PSA levels, to determine the need for additional imaging or biopsy 1, 2