How to perform an accurate
digital exam of the prostate
Jack H. Mydlo, MD, FACS
Professor and Chair
Dept. of Urology, Temple
University School of Medicine
Overview
•
•
•
•
Indications for prostate exam
Anatomy
Setting positioning
Setting,
Findings and implications for prostate CA
and other than prostate
• Frequency of exam
• When
Wh nott to
t do
d exam
• Factors affecting exam
Indications for prostate exam
• Prostate cancer screening , J Urology 182:
2232, 2009
• AUA PSA best practice statement: start at
age 40 provided
id d 10 year lif
life expectancy
t
• Men in 40’s and 50’s with PSA> mean (0.6
to 0.7 ng/ml)
g ) are at higher
g
risk for p
prostate
cancer (Loeb et al Urology67:316, 2006)
Prostate cancer screening (cont)
• Younger men less likely to have BPH as
confounding factor in prostate cancer
detection
• Can perform infrequent testing in the 40”s
with annual testing in 50’s
Overview: male GU tract
The Prostate: Anterior view
Prostate Anatomy: posterior
Prostate gland: base,
base apex
apex, mid
Radical Prostatectomy
Specimen
Palpation of prostate
• Most prostate cancers will be in peripheral
zone which is palpable by DRE
zone,
• Fewer cancers are in central zone, picked
up on transurethral resection of prostate
Technique of DRE of prostate
• Position
• Lean over exam table with elbows on table (“kneeelbow”)
• Left lateral decubitus position
• Frank et al BJU International 87: 331, 2001
• Compared the two positions in same men
sequentially
• Knee elbow permitted greater proportion of prostate
to be examined in 35%, no difference in 65%
• Knee elbow was 1.9 times more comfortable
Technique of DRE
• Done at end of physical exam
• Well lubricated finger introduced into
rectum checking for anal lesions
rectum,
• Palpate base of prostate (farthest from
examiner)
i ) iin a sweeping
i motion
ti ffrom lleft
ft
to right, repeating sweeps several times
• Move toward apex
y for rectal masses
• Check anteriorly
Findings on DRE
• Normal size of prostate: walnut at age 25
(20 gm)
• Large glands can be 100
100-200
200 gm
• Normal Consistency
• Same
S
as thenar
th
eminence
i
• Symmetric lobes
• ? Discomfort: usually not unless having
prostatitis ((“boggy
ggy p
prostate”))
acute p
Abnormal findings on DRE
• Consistency
• Nodules- discrete areas
• Diffuse consistency
• Asymmetry
• Increase in consistency
• Size: can use system of 1+
1+, 2+
2+, 3+ etc for
normal, twice normal, three times, etc
• Seminal vesicles- should not be palpable
Abnormal Findings on DRE
• Palpable
p
seminal vesicle: CA until p
proven
otherwise
•
• Prostate asymmetry in absence of increase in
consistency? – follow it
• Prostate nodule: differential diagnosis
•
•
•
•
BPH
Decrease in prostate blood flow
Prostatitis/Inflammation
Prostate Cancer
Non prostate findings on DRE
• Rectal tone: decreased with sacral
neurologic lesion
• Rectal mass
• Anal lesions and masses
Prostate exam diagram for chart
2+-3+,
3 , non
o te
tender,
de , nodule
odu e o
on right
g t
Differences in exam between more
and
d lless experienced
i
d persons
• Balkissoon et al Am J Surg 197: 525
525, 2009
• Used simulator to compare attendings,
residents and med students for DRE
• Recorded where areas palpated, finger
position
iti
• Experienced clinicians more likely to
• Palpate more laterally
p
• Use more pressure
Areas palpated: students vs. clinicans
Balkissoon et al Am J Surg 197: 525, 2009
DRE palpation techniques
Balkissoon et al Am J Surg 197: 525, 2009
Common textbook pictures: only
anterior and posterior
Balkissoon et al Am J Surg 197: 525, 2009
Bates textbook of
Physical exam
Factors that affect DRE
• Inflammation/infection
• Medication:
M di ti
Fi
Finasteride
t id
• Reproducibility
• Inter
Inter-observer
observer variation
• Changes in given individual from visit to visit
Prostate inflammation
• May give abnormal consistency after acute
infection- acute prostatitis
• Reassess in 3 months after acute process resolves
• Same for PSA elevation
• Chronic prostatitis/Chronic pelvic pain
syndrome:
• do not see tenderness
• Do not see nodules
• Same for PSA elevation
Finasteride and DRE
• Thompson et al J Urology 177: 1749
1749, 2007
• Prostate Cancer Prevention Trial
• Finasteride:
Fi
t id iinhibits
hibit 5
5-a reductase,
d t
shrinks
hi k
prostate by 24%, more sensitivie DRE ?
• Sensitivity of DRE in PCA patients
• Placebo: 16.7%
• Finasteride: 21.3% (p= 0.015)
p
y
• No difference in specificity
Smaller prostate: better biopsy
sampling?
DRE in detecting high grade cacner
• Thompson et al J Urol 177: 1749
1749, 2007
• Sensitivity of DRE for prostate cancer
• O
Overall:
ll 17
17-21%
21%
• Gleason 7 or higher: 22-26%
• Gleason
G
8 or higher: 36-38%
%
• Specificty: 90-93% for all categories
• Concl: DRE picks up more high grade
cancers
When not to perform DRE
• Acute prostatitis
• Rectum surgically absent
• US Preventative Services Task Force:
recommend against screening men over
age 75 (Ann Int Med 149:185, 2008)
• Uses average age for 10 year life expectancy
• Must be individualized
US Task Force: Mammography
• Mammography should be done > 50 yrs.
• 25% of all breast cancers in US < 50 yrs.
• Should be guide
guide, not absolute mandate
Thank You
Questions
Question # 1
• DRE should not be performed on
•
•
•
•
•
Patients
P
ti t with
ith acute
t prostatitis
t titi
Patients without a rectum
Patients above 75 and in poor health
All of the above
None of the above
Question # 1
• DRE should not be performed on
• All of the above
Question # 2
• A nodule on DRE indicates:
•
•
•
•
•
Prostate
P
t t cancer
Normal variant
The need for a biopsy to r/o cancer
All of the above
None of the above
Question # 2
• A nodule on DRE indicates:
• The need for a biopsy to r/o cancer
Question # 3
• In comparing the two techniques to do
DRE (with elbows on table (“knee-elbow”)
or left lateral decubitus position:
• Knee elbow p
permitted greater
g
proportion
p p
of prostate to be examined in 35%
• No difference was noted in 65%
• Knee elbow was 1.9 x more comfortable
• All of the above
• None of the above
Question # 3
• In comparing the two techniques to do
DRE (with elbows on table (“knee-elbow”)
or left lateral decubitus position:
• All of the above
Thank you