Saturday, March 17, 2018

Rectal Exam-Is it Needed?


Medical practice is constantly changing and this is a good thing.  As evidence comes forth, we change how we care for patients to ensure "evidence-based" quality. We no longer bleed patients or deliver caustic enemas.  We understand that ulcers are the result of H pylori bacteria and that autism is not caused by bad mothering.  It took 20 years for hand washing to be accepted for infection control after Ignaz Semmelweis made the connection of why 1/3 of hospitalized women died after childbirth in 1850.

Our newest evidence is that digital rectal exams (DRE) looking for prostate cancer in men is probably not effective for diagnosis.  In fact is might even be harmful if it leads to biopsies and further studies.

As an Internist, I was trained that a digital rectal exam (DRE) was needed and essential for every male physical exam after the age of 40.  And my male patients have come to expect it.  The March-April issue of Annals of Family Medicine reports that in 7 studies with 9241 male patients, the DRE is not sensitive or specific for evaluating prostate cancer.  This means there are more false-positives and more men sent for biopsy and further studies that prove to be not needed.  It is not an effective test for screening or diagnosing prostate cancer.

Digital Rectal Exam for screening of prostate cancer is no longer recommended.  In fact, in 2016 a large study in a little read journal, Current Medical Research and Opinion, also spoke against DRE as a recommended test.  I don't know if Medical Schools are still recommending DRE in physical exam.  Since 81% of doctors perform this test and patients expect it to be helpful, I suspect it will take time before this medical practice changes.  

2 comments:

Anonymous said...

Thank you for this informative article.

What do you suggest for prostrate screening, since the DRE is not recommended?

I don't trust the PSA, as I have had readings all over the scale, e.g., 8 followed a month later by 3 and staying at 3. My doctor advised me to go for a biopsy right after the 8. I declined and instead chose active surveillance.

Do you think that PSA tests lead to unnecessary biopsies as well?

FYI, I'm 67.

Thanks.

Mark Wright said...

The effectiveness depends upon the experience of the examiner. He can detect subtle abnormalities. I think DRE has been used for many years, whether it actually decreases the number of deaths from prostate cancer has not been determined.

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