What is the next step after a digital rectal examination (DRE) shows a slightly enlarged, firm, and nontender prostate gland with no palpable nodules?

Next Step After Digital Rectal Examination Findings

Measure serum PSA immediately and refer urgently to urology for consideration of prostate biopsy, as a firm prostate on DRE—even without nodules—is suspicious for prostate cancer and constitutes an absolute indication for further evaluation. 1

Immediate Diagnostic Actions

The clinical presentation described—a slightly enlarged, firm, nontender prostate without palpable nodules—raises significant concern for malignancy despite the absence of discrete nodules. The firmness itself is the critical finding that mandates further workup. 1

Required Next Steps:

• Obtain serum PSA testing immediately in any patient with at least a 10-year life expectancy, as PSA combined with DRE provides relatively sensitive detection of prostate cancer 1
• Refer urgently to urology for consideration of prostate biopsy, as DRE findings suspicious for prostate cancer constitute an absolute indication for specialist evaluation before any treatment decisions 1
• Do not delay referral based on patient age alone—any man with a suspicious DRE and reasonable life expectancy deserves cancer evaluation 1

Why This Finding Is Concerning

A firm prostate argues strongly against benign prostatic hyperplasia (BPH), which characteristically presents with smooth, symmetric enlargement rather than firmness. 1 The key distinguishing features include:

• Prostate cancer typically presents with firm, irregular, or nodular texture on DRE, contrasting sharply with the smooth, symmetrically enlarged prostate of BPH 1
• The small size of the prostate argues against BPH, which characteristically causes prostatic enlargement 1
• Any irregularity, nodularity, or induration (firmness) detected on DRE should raise immediate suspicion for locally advanced prostate cancer, as these findings indicate potential extracapsular extension or aggressive disease 1

Definitive Diagnostic Procedure

The standard diagnostic procedure to obtain histological confirmation when DRE or PSA suggests malignancy is transrectal ultrasound (TRUS)-guided biopsy. 1 Current guidelines specify:

• TRUS-guided prostate biopsy is rated as "usually appropriate" (rating 9/9) for clinically suspected prostate cancer in biopsy-naïve patients 2
• A minimum of 10-12 cores should be obtained under antibiotic cover and local anesthesia 2
• Systematic biopsies (at least six cores) are standard, with histopathologic assessment including number of positive biopsies, extent of cancer in biopsy cores, and stage 2

Role of MRI in This Clinical Scenario

Multiparametric MRI (mpMRI) may be performed before TRUS-guided biopsy so that targeted samples can be obtained using MRI or TRUS fusion technology in patients with appropriate targets 2. The 2024 European Urology guidelines note:

• MRI has pooled sensitivity of 0.91 for ISUP grade 2 cancers and 0.95 for ISUP grade 3 cancers 2
• In biopsy-naïve men, an MRI-based indication for biopsy leads to lower rates of biopsy, fewer men diagnosed with insignificant PCa, and more men diagnosed with clinically significant PCa compared with systematic biopsy alone 2
• MRI pelvis without and with IV contrast is rated as "usually appropriate" (rating 7/9) for clinically suspected prostate cancer with no prior biopsy 2

Common Pitfalls to Avoid

Do not assume a small prostate excludes significant pathology—while BPH causes enlargement, prostate cancer does not require prostatic enlargement and can occur in small glands 1. Additional pitfalls include:

• Do not mistake prostatic calcifications for malignancy—these may create palpable irregularity but are typically detected incidentally on imaging and do not produce the diffuse firmness characteristic of malignancy 1
• Do not perform imaging as the primary diagnostic work-up—there is no indication for imaging in the primary diagnostic work-up; the standard is PSA testing followed by biopsy 2
• Do not delay biopsy if PSA is elevated or DRE is suspicious—any anomaly detected during digital rectal examination suggestive of prostate cancer in the absence of infection should be investigated further with transrectal ultrasound-guided biopsy even if the PSA concentration is normal 2

Clinical Context and Prognosis

Research demonstrates that palpable nodules have high cancer detection rates: 70% for clinical stage B1, 76% for B2, and 88% for B3 nodules 3. Even abnormally firm, non-nodular prostates show cancer in 36% of cases 3. DRE-positive results are significantly correlated with Gleason score ≥7 prostate cancer (P<0.001), and the average Gleason score of DRE-positive PCa patients is significantly higher than DRE-negative patients (7.92 vs 7.11) 4.