Should a digital rectal examination (DRE) be performed for all patients with suspected prostate cancer, such as those with lower urinary tract symptoms (LUTS) or elevated serum prostate-specific antigen (PSA) levels?

Digital Rectal Examination in Suspected Prostate Cancer

Yes, a digital rectal examination (DRE) should be performed for all patients with suspected prostate cancer, including those with lower urinary tract symptoms (LUTS) or elevated serum PSA. 1, 2

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
• DRE is essential to exclude locally advanced prostate cancer, which can also produce LUTS 2
• The American Urological Association recommends that a physical examination, including both a DRE and a focused neurologic examination, should be performed in patients with suspected prostate cancer 2
• 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

Complementary Role with PSA Testing

• PSA (together with DRE) provides a relatively sensitive approach to exclude prostate cancer as a diagnosis 2
• The European Society for Medical Oncology recommends that patients with either abnormal DRE or elevated PSA should be considered for further evaluation including prostate biopsy 1
• While recent research suggests that DRE has lower cancer detection rates compared to PSA alone (1% vs 3%), it still provides valuable diagnostic information, especially for peripheral zone tumors 3, 4

Clinical Value Beyond Cancer Detection

• DRE helps assess prostate size: if the prostate feels large by DRE, it is usually also found to be enlarged by ultrasound or other measurement techniques 2
• 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), indicating more aggressive disease 3

Important Considerations and Limitations

• DRE tends to underestimate the true prostate size 2
• DRE has higher recall rates for peripheral zone tumors (65.5%) compared to central zone or transition zone tumors (34.55%) 3
• In resource-limited settings, DRE combined with PSA can guide treatment decisions, especially in cases with severe symptoms of advanced prostate cancer 5
• The diagnostic accuracy of DRE alone is approximately 63.45%, highlighting the importance of combining it with other diagnostic modalities 3

Algorithmic Approach to Suspected Prostate Cancer

1. For all patients with LUTS or elevated PSA:

   • Perform DRE to assess prostate size, texture, and nodularity 2, 1
   • Measure serum PSA 2, 1
   • Conduct urinalysis to rule out UTI or hematuria 2, 6

2. If DRE is abnormal OR PSA is elevated:

   • Proceed with prostate biopsy under transrectal ultrasound guidance 2, 1
   • Obtain a minimum of eight cores from different areas of the peripheral prostate 2, 7

3. For staging after cancer diagnosis:

   • Use DRE to evaluate clinical T stage 2, 1
   • Consider additional imaging based on risk stratification 2

By combining DRE with PSA testing, clinicians can maximize the detection of clinically significant prostate cancer while minimizing unnecessary biopsies.