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PubMed2006

Detection of clinical unilateral T3a prostate cancer - by digital rectal examination or transrectal ultrasonography?

OBJECTIVE: To assess, in a retrospective study, the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of digital rectal examination (DRE), transrectal ultrasonography (TRUS) and the combination of both in unilateral clinical T3a (cT3a) prostate cancer. PATIENTS AND METHODS: The long-term outcome of surgical treatment for locally advanced prostate cancer is very good and surpasses that for radiotherapy outcomes, so it is anticipated that surgical management for cT3a disease will become more important, but staging methods for cT3a disease are not well studied. Between 1990 and 2004, 2240 patients had a radical prostatectomy at our institution; 267 were diagnosed as having clinical cT3a prostate cancer either by DRE or TRUS. The final histopathology was compared with the findings of DRE and TRUS. The sensitivity, specificity, PPV and NPV for DRE, TRUS and the combination of both were calculated. RESULTS: The sensitivity, specificity, PPV and NPV by DRE only was 90.9%, 15.8%, 47.2% and 67.7%, by TRUS only was 80.2%, 25.3%, 47.1% and 60.7%, and by both DRE and TRUS was 71.1%, 41.1%, 50.0% and 63.2%. Although the sensitivity was lower in the combined group, it had the highest specificity (41.1%) and PPV (50.0%). The combination of DRE and TRUS can detect T3a prostate cancer more accurately than either method alone. CONCLUSION: Until data on staging methods like magnetic resonance imaging become available, the combination of DRE and TRUS is advisable in selecting cT3a patients for primary radical prostatectomy.

Adult↗
PubMed2006

[Validity of digital rectal examination in the era of prostate specific antigen].

OBJECTIVE: To determine the presence of a possible correlation between prostate specific antigen (PSA) and the findings from digital rectal examination (DRE) in patients with prostate cancer or benign prostatic hyperplasia. DESIGN: Retrospective, longitudinal, and observational study of diagnostic tests. SETTING: Gregorio Marañón Hospital, Madrid, Spain. PARTICIPANTS: It included 706 patients with a PSA in the range 4.1-20 ng/mL, studied owing to suspected prostate cancer localised using DRE and transrectal ultrasound, in whom randomised prostate biopsies were performed. MAIN MEASUREMENTS: Total PSA and free/total PSA ratio and DRE normal or suspicious were studied as main variables. The outcome variable was the diagnosis of prostatic cancer by biopsy. RESULTS: With a detection of cancer of 28.2%, there were no statistically significant differences in the PSA or free/total PSA ratio mean values between patients with or without suspicious DRE. The analysis using ROC curves (with a 95% confidence interval) between both groups of patients found the same sensitivity of 95% with a similar specificity of 6% and 10%, respectively, for a PSA of 4.8 ng/mL. CONCLUSIONS: In the PSA range of 4.1-20 ng/mL, the findings of DRE appeared as a variable unrelated to the increase in PSA or the free/total PSA ratio and, therefore are not indicative of a lesser or greater volume of a tumour producing PSA. The performing of this examination could be considered as optional.

Adult↗
PubMed1991

Validation of the digital rectal examination as an estimate of anal sphincter squeeze pressure.

Although digital examination is commonly used to assess anal sphincter tone and maximal squeeze pressure, the accuracy of this test has never been adequately validated. A total of 27 patients with a spectrum of subjectively assessed anal sphincter tones were studied. Simultaneous subjective (digital) and objective (manometric) determinations of maximal anal squeeze pressures were made. Subjective digital assessment revealed the following: three patients, absent squeeze pressure (grade 0); two patients, markedly reduced (grade +1); six patients, reduced (grade +2); and the remaining 16 patients had normal maximal squeeze pressure (grade +3). Simultaneous objective anal sphincter pressure measurements, when compared with these subjective values, revealed a correlation coefficient of 0.97 (p less than 0.05). Therefore, the clinician can reliably use the digital rectal examination to judge anal sphincter strength.

Anal Canal↗
PubMed1993

Effect of patient age on early detection of prostate cancer with serum prostate-specific antigen and digital rectal examination.

This study was designed to determine the effects of age by decade on the efficacy of digital rectal examination (DRE) and serum prostate-specific antigen (PSA) for early detection of prostate cancer in men aged fifty and over. A prospective multicenter clinical trial was conducted at six university centers. All 6,630 male volunteers underwent a serum PSA (Hybritech, Tandem) determination and DRE. Quadrant biopsies of the prostate were performed if PSA was > 4 ng/mL or DRE suspicious. A total of 1,167 biopsies were performed, and 264 cancers were detected. The cancer detection rate increased from 3 percent in men aged fifty to fifty-nine to 14 percent in men eighty years or older (p < 0.0001). PSA detected significantly more of the total cancers than DRE at all age ranges (p < 0.05). The positive predictive values (PPV) for PSA were 32 percent (50-59 years), 30 percent (60-69 years), 34 percent (70-79 years), and 38 percent (80+ years). The corresponding PPVs for DRE were 17 percent, 21 percent, 25 percent, and 38 percent. Eighteen percent of the cancers were detected solely by DRE, whereas 45 percent of cancers were detected solely by PSA. Thus, the use of both tests in combination provided the highest rate of detection in all age groups. One hundred-sixty patients underwent radical prostatectomy and pathologic staging. Cancer was organ-confined in 74 percent (25/34) of men aged fifty to fifty-nine, 76 percent (65/86) of men aged sixty to sixty-nine, and 60 percent (24/40) of men aged seventy or over (chi 2, < 70 vs. > or = 70, p < 0.05). Early detection programs yield a lower, yet still substantial, cancer detection rate in younger men, and there is a greater likelihood for detection of organ-confined disease in this age range. Younger men have the longest projected life expectancy and, therefore, the most to gain from early prostate cancer detection.

Age Factors↗
PubMedDate not supplied

Interobserver variation of prostatic volume estimation with digital rectal examination by urological staffs with different experiences.

PURPOSE: To compare the accuracy of estimating prostatic volume with digital rectal examination (DRE) by urological staffs with different experiences. Measurement of prostatic volume with transrectal ultrasonography (TRUS) serves as the reference standard. MATERIALS AND METHODS: Thirty-nine consecutive male patients admitted with acute urinary retention had their prostatic volume estimated with DRE by a urology junior trainee, a urology higher trainee and a trained urologist. All patients had TRUS to measure their prostatic volumes. Pearson correlation coefficients (r) were used to assess the relationships between the prostatic volume measured with TRUS and that estimated with DRE by the 3 urological staffs. Wilcoxon signed ranks tests were used to compare the discrepancies between the prostatic volume measured with TRUS and that estimated with DRE for the 3 Urological staffs, and to assess the inter-observer differences of these discrepancies. RESULTS: The correlation coefficients for the 3 urological staffs were r = 0.573 for the urology junior trainee, r = 0.541 for the urology higher trainee, and r = 0.640 for the trained urologist. The median discrepancies between the prostatic volume measured with TRUS and that estimated with DRE were -9.1 mL for the urology junior trainee, -1.3 mL for the urology higher trainee and 0.9 mL for the trained urologist. These discrepancies were statistically significant only in the case of urology junior trainee (p = 0.015, Wilcoxon signed ranks test). The difference in these discrepancies was statistically significant only between the urology junior trainee and the trained urologist (p = 0.003, Wilcoxon signed ranks test). CONCLUSIONS: The trained urologist was more accurate in estimating prostatic volume with DRE than the urology junior trainee.

Aged↗
PubMed2005

Comparison of endorectal magnetic resonance imaging, guided prostate biopsy and digital rectal examination in the preoperative anatomical localization of prostate cancer.

PURPOSE: We compared the accuracy of endorectal magnetic resonance imaging (erMRI), transrectal ultrasound (TRUS) guided biopsy and digital rectal examination (DRE) for detecting the location of cancer in the prostate gland and seminal vesicles. MATERIALS AND METHODS: This is a retrospective study of 106 consecutive patients with prostate cancer who were referred for erMRI before radical prostatectomy. Step-section pathological data and erMRI were available in 90 patients, DRE data were available on 86 and individually labeled sextant core biopsies were available in 45. T1 and T2-weighted erMRI was interpreted by a single reader, who scored the likelihood of tumor on a 5-point scale in each seminal vesicle and in 12 locations in the prostate gland. MR spectroscopy data were not used for erMRI interpretation. One pathologist reviewed whole mount serial sections of radical prostatectomy specimens. The area under ROC curves was used to evaluate accuracy. RESULTS: The area under ROC curves for tumor localization was higher for erMRI than for DRE at the prostatic apex (0.72 vs 0.66), mid gland (0.80 vs 0.69) and base (0.83 vs 0.69). It was likewise higher for erMRI than for TRUS biopsy in the mid gland (0.75 vs 0.68) and base (0.81 vs 0.61) but not in the apex (0.67 vs 0.70). On mixed model analysis erMRI significantly increased the accuracy of prostate cancer localization by DRE or TRUS biopsy (each p <0.0001). CONCLUSIONS: For prostate cancer localization erMRI contributes significant incremental value to DRE or TRUS biopsy findings (each p <0.0001).

Biopsy↗
PubMed1995

Digital rectal examinations and prostate cancer screening: attitudes of African American men.

PURPOSE/OBJECTIVES: To explore the relationship between attitudes toward digital rectal examination (DRE) and participation in prostate cancer screening among African American men. DESIGN: Survey. SETTING: Prostate cancer screenings with a prostate-specific antigen (PSA) blood test held at churches with African American members in Detroit, MI. SAMPLE: 613 African American men between the ages of 40 and 70. METHODS: Self-administered, structured questionnaires examining attitudes toward DRE, past experiences with DRE, and fear of cancer. MAIN OUTCOME MEASURES: Willingness to undergo DRE. FINDINGS: The majority of men who were screened had positive attitudes about DRE. Fear of cancer was associated with negative attitudes toward DRE. DREs were not a deterrent among men who attended the screenings. CONCLUSION: Negative attitudes toward DRE do not necessarily deter African American men from participating in prostate cancer screenings. IMPLICATIONS FOR NURSING PRACTICE: Prostate cancer screening programs should attempt to use both DRE and PSA. More reliable prostate cancer indicators are obtained by incorporating DRE with PSA tests.

Adult↗
PubMed2006

Role of transperineal six-core prostate biopsy in patients with prostate-specific antigen level greater than 10 ng/mL and abnormal digital rectal examination findings.

OBJECTIVES: To define whether six-core biopsies still have a role in patients presenting with prostate-specific antigen (PSA) levels greater than 10 ng/mL and abnormal digital rectal examination (DRE) findings. Recent studies have suggested that the six-core biopsy is inadequate for the diagnosis of prostate cancer; however, it remains controversial whether an increased number of cores is justified in all patients. METHODS: From June 2002 to February 2005, 122 (18.8%) of 650 patients underwent prostate biopsy because of a PSA level greater than 10 ng/mL and abnormal DRE findings. All patients underwent transperineal ultrasound-guided prostate biopsy in a standardized fashion: a six-core biopsy was performed first, followed by six additional cores during the same session, four in the peripheral and two in the transition zone. RESULTS: The detection rate in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings was 72.1% (88 of 122) and 75.4% (92 of 122) using the 6-core and 12-core biopsy, respectively. One case of tumor was missed by the six-core biopsy among patients with a PSA level greater than 15 ng/mL and abnormal DRE findings. No cases of tumor were missed by six-core biopsy in the group with a PSA level greater than 20 ng/mL and abnormal DRE findings. CONCLUSIONS: Six-core biopsy provided a similar cancer detection rate compared with 12-core biopsy in patients with PSA levels greater than 10 ng/mL and abnormal DRE findings. An initial approach with 6-core biopsy is reasonable in patients with a PSA level greater than 10 ng/mL and abnormal DRE findings and is advocated in those with PSA greater than 20 ng/mL and abnormal DRE findings.

Aged↗
PubMed2005

Prostate cancer detection with digital rectal examination, prostate-specific antigen, transrectal ultrasonography and biopsy in clinical urological practice.

OBJECTIVE: To evaluate the utility of digital rectal examination (DRE), prostate specific antigen (PSA) and transrectal ultrasonography and biopsy (TRUSB) in detecting prostate cancer in one teaching-hospital urological practice. PATIENTS AND METHODS: In all, 2800 consecutive patients had TRUSB as outpatients by one urologist, the indications for which were a raised or rising PSA level or an abnormal DRE. In addition, the indications for repeat TRUSB included previous abnormal histology, e.g. suspicious areas or atypia or high-grade prostatic intraepithelial neoplasia. All data were collected prospectively. RESULTS: Of 2800 TRUSB, 223 were known cases of prostate cancer (previously diagnosed from transurethral prostatectomy chips or after radical prostatectomy) and were excluded from the analysis. There were 2194 initial and 383 repeat TRUSB; of the former patients, 1129 were found to have prostate cancer, giving a cancer-detection rate of 52%. The positive predictive values (PPVs) for patients with a normal DRE and PSA of < 4, 4-10 and > 10 ng/mL were 9%, 31% and 48%, respectively; the corresponding PPVs for patients with an abnormal DRE and the same PSA levels were 27%, 67% and 85%, respectively. Of the 383 repeat TRUSB, the cancer-detection rate was 31% for the first repeat and 28% for the second. CONCLUSIONS: The present values are higher than those reported previously, because these patients were within a clinical urological practice, and the indications for and methods of TRUSB have changed in recent years, such that more lateral areas were biopsied. These values are useful in helping clinicians to counsel patients about the probability of detecting cancer.

Aged↗
PubMed2005

Is a digital rectal examination necessary in the diagnosis and clinical staging of early prostate cancer?

OBJECTIVE: To assess the role of a digital rectal examination (DRE) in the clinical diagnosis of prostate cancer and in predicting the pathological stage, as the diagnosis of early prostate cancer usually comprises prostate-specific antigen (PSA) testing, a DRE and transrectal ultrasonography (TRUS)-guided biopsies. PATIENTS AND METHODS: Over the 4 years between 2000 and 2004, 408 consecutive patients (mean age 63.8 years) referred with age-specific PSA levels of 2.5-10.0 ng/mL and who had a TRUS-guided 12-core prostate biopsy were included in the study. They had a DRE by either of two experienced consultant urologists. The results of the DRE and core biopsy histology were compared with the histology and the radical prostatectomy specimen in a subset (82 men) of the study population. RESULTS: Cancer was detected on biopsy in 152 patients; of the 196 with an abnormal DRE, 47% had cancer on biopsy. In the patients with a normal DRE, 59 cancers were detected. Men with cancer were older and had a higher median PSA level. There was no correlation between the DRE and biopsy findings, and none between an abnormal DRE and histological diagnosis of cancer. Of the patients who had a radical prostatectomy, 38% had a normal DRE. CONCLUSION: There was no correlation between the DRE, biopsy findings and pathological staging. The DRE did not contribute to managing patients with prostate cancer, but this does not mean that there is no longer a place for the DRE in assessing the urological patient. If patients are appropriately counselled before PSA testing, a DRE may not be essential for patients with a PSA level of 2.5-10 ng/mL.

Adult↗
PubMed1992

Digital rectal examination, imaging, and systematic-sextant biopsy in identifying operable lymph node-negative prostatic carcinoma.

The value of digital rectal examination, computerized tomography, magnetic resonance imaging, prostate-specific antigen, transrectal ultrasonography, and systematic-sextant biopsy in the identification of lymph node-positive patients before radical prostatectomy was analyzed in 103 men who had pelvic lymph node dissection, CT had a sensitivity of only 7% and a specificity of 96% in detecting lymph nodes, whereas magnetic resonance imaging had a sensitivity of 50% and a specificity of 100%. To evaluate the use of tumor volume in predicting lymph node metastasis, we counted the number of positive core biopsies and compared the results with the incidence of positive lymph nodes. If fewer than 5 positive core biopsies were considered negative for predicting lymph node metastasis, the sensitivity would be 67% (12 of 18), and the specificity 94% (50 of 53). To investigate tumor volume more precisely, we measured the extent of tumor volume in every biopsy as a percentage of the total biopsy core and added the percentage for the 6 biopsies. The lowest score was 10% (10% prostatic cancer in 1 of 6 cores), the highest score 580% (4 cores with 100% each and 2 with 90% each). The score was analyzed for sensitivity and specificity in predicting lymph node metastasis. If a score of 280% was used as a cutoff point, the sensitivity was 71% (10 of 14) and the specificity 91% (52 of 57). When we include the grading system by multiplying the percentage of tumor volume with tumor grade, the difference between the lymph node-positive state and lymph node-negative state becomes even more readily apparent.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2005

Digital rectal examination is no longer necessary in the routine follow-up of men with undetectable prostate specific antigen after radical prostatectomy: the implications for follow-up.

OBJECTIVES: We determined the role of Digital Rectal Examination (DRE) in the follow-up of those patients treated with radical prostatectomy for clinically localised prostate cancer having an undetectable PSA. We discuss the implications of our findings. MATERIALS AND METHODS: An analysis was performed of a prospectively organised data base of 1118 patients treated at our institution by radical prostatectomy after the introduction of PSA in 1987. A strict definition of PSA progression was used, that is any elevation above undetectable PSA or lowest recorded post-operative PSA (nadir), in order not to miss a single patient who may have recurrent local disease or distant metastases without PSA progression. We counted local recurrent disease as those patients having histologically proven adenocarcinoma on TRUS directed biopsies, and distant disease as those patients having detectable metastatic disease on radionuclide bone scan. RESULTS: The median follow-up was 4.0 years (3 months to 15 years). 524 men (46.9%) had a follow-up of more than 5 years and 88 men (7.9%) of more than 10 years. A total of 397 men (35.5%) had biochemical progression according to our strict definition. 53 patients (4.7%) developed a histological local recurrence and 57 men (5.1%) developed bony metastases; none of these men had an undetectable PSA or a stable PSA at nadir level at the time of detection. They all demonstrated a rising PSA. CONCLUSIONS: DRE is no longer necessary in the routine follow-up of patients with an undetectable PSA after radical prostatectomy. Following a period of approximately 2 years of out-patient clinic follow-up post-operatively in which issues such as incontinence and erectile dysfunction are addressed and treated, it is possible to restrict follow-up to PSA determinations alone and as long as the PSA remains undetectable counselling can be carried out by a nurse practitioner.

Adult↗
PubMed1988

Digital rectal examination to screen for prostatic cancer.

In a prospectively designed study 480 men, aged 45-67 years of age having routine medical examinations as part of the Occupational Health Service Program, underwent digital rectal examination to screen for early prostatic cancer. 26 men were referred to the Urology Service of the Aust-Agder Central Hospital for repeat examinations and further diagnostic procedures. Biopsies were performed on 16 patients, and transrectal ultrasound examination on 9. One patient was found to have prostate cancer. The value of an organized screening program for the detection of early prostatic cancer still seems to be under discussion.

Aged↗
PubMed1995

The diagnostic accuracy of digital rectal examination, transrectal ultrasonography, prostate-specific antigen (PSA) and PSA density in prostate carcinoma.

OBJECTIVE: To evaluate the efficacy of digital rectal examination (DRE), transrectal ultrasonography (TRUS), prostate-specific antigen (PSA) and PSA density (PSAD) in the diagnosis of prostate cancer (CaP). PATIENTS AND METHODS: Retrospective data were analysed from a selected population of 159 patients (mean age 66.7 years, range 50-83), 56 with histologically diagnosed CaP and 103 with benign prostatic hyperplasia (BPH). RESULTS: Among the four methods, DRE was found to have accuracy, sensitivity and specificity rates of 79.9, 91 and 73.8% respectively. The most common clinical practice, the combination of PSA (> 4 ng/mL), DRE and TRUS, showed a higher accuracy, a similar specificity rate, but a lower sensitivity (84.2, 91.2 and 71.4%, respectively). Rates from the combination of PSAD (> 0.15 ng/mL/cm3) with DRE and TRUS were not significantly different from those obtained using the combination of PSA, DRE and TRUS. CONCLUSION: PSAD alone or in combination did not improve the diagnostic value of PSA. We cannot claim DRE was the best method for the diagnosis of CaP, because this study group did not represent a true screening population. However, this study revealed that DRE should not be omitted from the physical examination of patients and, despite technological developments, it remains a major tool in the diagnosis of CaP.

Aged↗
PubMed1989

Comparison of the efficacy of digital rectal examination and transrectal ultrasonography in the diagnosis of prostatic cancer.

167 patients with a mean age of 64 years underwent digital rectal examination (DRE), transrectal ultrasonography with a 7-MHz transverse and/or longitudinal transducer, followed by prostatic biopsy under ultrasound guidance. 231 biopsies were performed. 74 peripheral hypoechogenic zones were demonstrated. The sensitivity of DRE was 82% and the specificity 91%. The sensitivity and the specificity of ultrasound were respectively 69 and 83%. On 123 patients with normal DRE, 19 hypoechoic zones were detected and 2 patients had a positive biopsy (11%). On 104 patients without hypoechoic zone, 5 biopsies were positive (5%). The use of transrectal ultrasound scanning is able to multiply the number of impalpable cancer by 2, but in only 3 lobes, a hypoechogenic zone associated with a normal rectal examination was confirmed to be a cancer on biopsy. These cases represent 5.5 of the 56 positive biopsies, 4% of the hypoechogenic zones and 1.6% of the investigated patients with normal rectal examination. No impalpable cancer of 5 mm or less was detected by high resolution ultrasonography. DRE is still the most reliable examination for the diagnosis of prostatic cancer. Ultrasonography is a useful complement, particularly by allowing collection of tissue interpretable by the histologist in 100% of cases.

Biopsy↗
PubMed1988

Prostate cancer: comparison of transrectal US and digital rectal examination for screening.

The authors examined 784 self-referred men over age 60 years to compare clinical usefulness of transrectal ultrasound (US) and digital rectal examination in a screening program for prostate cancer. Biopsy was performed in 77 cases, 83% (64 of 77) for abnormalities detected with transrectal US and 38% (29 of 77) because of findings at digital examination. Twenty-two cancers were detected, 20 with transrectal US and ten at digital examination. Overall detection rate for prostate cancer with transrectal US was two times higher than that with digital examination (2.6% vs 1.3%). Sensitivity, specificity, and negative predictive value for transrectal US and digital examination were calculated for a range of prevalences (0.028-0.1543). Sensitivity was two times higher for transrectal US than for digital examination. Transrectal US demonstrated 100% (17 of 17) of tumors with the most favorable prognosis (less than or equal to 1.5 cm in diameter) compared with 41% (seven of 17) for digital examination. The authors conclude that transrectal US is more sensitive than digital examination in the detection of prostate cancer, and they advocate broader implementation and evaluation of transrectal US as a tool for early detection.

Aged↗
PubMed2000

Male discomfort during the digital rectal examination: does examiner gender make a difference?

To determine if examiner gender affects men's perceived pain and embarrassment during an emergency department (ED) digital rectal examination, we prospectively studied male ED patients undergoing rectal examination. Each subject's perceived pain and embarrassment was gauged using 100 mm visual analog scales. Age, complaint, and examiner gender and training level were recorded. Two-tailed Mann-Whitney or Kruskal-Wallis tests examined significant differences among group mean pain and embarrassment scores. Of 126 subjects, 60 had female and 66 had male examiners. Mean pain scores were similar for patients of female (36.5 mm) and male (37.4 mm) examiners (95% CI -9.8 to 11.5, P = .73). Mean embarrassment scores were similar for female (36.6 mm) and for male (32.9 mm) examiners (95% CI -7.9 to 15.3, P = .67). Younger male patients experienced more pain and embarrassment (P < .027). Examiner training level and prostatic examination did not affect the score.

Adult↗