40 years ago the urologists only had DRE, There was no ultrasound or PSA.

Today, the DRE is more a tradition than a accurate medical exam.

If we use the DRE all of the prostate cancers diagnostics will be T2 or greater because cancer is palpable.

We have an instrument to detect the prostate cancer when is not palpalbe.. THE PSA.

The DRE kept the patients away from urologists offices.

The DRE is part of all of the guides but the importance in prostate cancer diagnostic is lower than the use of PSA

Do you perform a DRE to a patient with PSA 1 or less?

one of the best uses of DRE today is to evaluate if the prostate is fixed prior to a radical prostatectomy..

The probability of detection of PCa through a DRE in a man with PSA

DRE adds another dimension that is easily done at his first consultation and provides information which imaging may not. Whilst it is recognised that it is a not a very sensitive test, it is a good test to diagnose acute prostatitis, suspicious nodules in the prostate, rectal ca. etc. If you feel a nodule in the prostate in the presence of a normal PSA, would you not still biopsy it?

with high resulotion TRUS u will see all u can feel with DRE. also elatography is a new technique - more sensitive than DRE. furthermore hard nodules can be i.e. prostate stones - differentiation with DRE is difficult - with TRUS easy.

the time for DRE has gone - my opinion

what about testicles - u believe on palpation to exclude cancer - or use US?

But not everyone has high resolution TRUS or access to elastography which is still experimental (but has been around for 5-10 yrs now). Sure, you will "see" more with the TRUS than DRE, but so will most imaging modalities. However, if it is barndoor obvious, you will be kicking yourself for missing it or "put your leg in" according to the old PR adage. If you dont use it, you will lose it and DRE is a skill that you probably dont want to lose.

In our series near of 2% of patients were diagnosed of having prostate cancer due to the DRE with PSA below 2.5 ng/ml

PSA and TRUS are certainly better than DRE to detect prostate cancer. Still you must remember a large proportion of the world population has no access to these tests for screening purposes. Although theoretically these high tech is preferred (while condemning the clinical skills) but when you look at the problem in a global perspective it is a good thing for primary care doctors to assess a patient with a DRE.

And prostate volume ?

Yes, DRE doesn't appear as a "professional" or a "high-tech" exam...

But if elastography is not available in our office , a finger will certainly be more useful and painless in comparison with a TRUS probe.

The goals of a DRE in a screening intention are : Volume, T stage.

Indeed some PCa are diagnosed by DRE alone (i.e PSA level < 4 ng/mL).

But don't forget that PSA density is included in most of the available nomograms predicting PCa probability prior to biopsies.

TRUS volume measures are better than DRE, for sure.

But each urologist is able , after some years of experience, to determine wether the prostate is small, medium or large.

When counseling a patient, DRE still plays a role, but not alone.

ok

you can use DRE

but please keep in mind that in austria we use lower PSa cut off

therefore cancers found by DRE are more or less 0

concerning pain

in our study pain by DRE was higher compared with TRUS

the new probes are small and for elasto - no pressure

shear wave technology

best regards

ferdinand

ın general ı dont make DRE PSA is sufficient .

most patient don't llke DRE - or

mir can be useful

but who pays for it

and when to use

TRUS is used everywhere

Only if combined with psa and if tr us not available

i don't really see the benefit of DRE to TRUS

with high resolution TRUS you scan the whole gland

scan the anterior part too

DRE is no more longer state of the art

Prostate evasive anterior tumors represent 10% of all prostate cancers in a recent series by Mygatt et al. in Prostate Cnacer and prostatic diseases (2014 march).

Is it really a challenge to detect them while screening a population ? I don't think so. These patients would certainly have rapid PSA rising and the need for a second biopsy schedule with anterior biopsies would be my choice.

As an example :

65 yo male. Prostate = 20 grams on DRE. PSA = 7 ng/mL . No family history. No LUTS.

Prostatic biopsies, per sextant : 12 cores , posterolateral. Negative.

6 months later, PSA = 9 ng/mL, DRE remains the same : normal, small. I do perform anterior biopsies.

It may be of high interest to redefine the ways of a "reasonable" screening program. A comparison between "old school" screening (DRE, PSA, Family history...) , and "high-tech" screening would be the next "ERSPC" and/or "PLCO" great study...?

Being of the old school, I would. Perhaps Hamilton Bailey's grim aphorism still rings in my mind: " If you don't put your finger in it you put your foot in it".

If you don't have PSA available it will be ok.

The EDR keep patients away of urologists

If you use EDR to detect prostate cancer it will be allways a T2 (low chances of curation)

In 18 years in urology I only found 1 rectal cancer on EDR.

40 years ago there were no ultrasound or PSA. RIght now I use the EDR only in high PSA patients or pre Radical Prostatectomy.

When I introduced this topic almost one year ago, I was in the middle of a literature review about the pros and cons of prostate cancer screening (you can see the whole review downloading the book ‘Prostate cancer screening in Brazil’), and an important part of it was the recent reassessment supporting that DRE should not be used as first-line method during prostate cancer screening.

This statement was supported by the AUA, and it was based on the results of the two largest randomized trials investigating the impact of screening on prostate cancer mortality. The Prostate, Lung, Colorectal, and Ovarian (PLCO) Cancer Screening Trial, which offered both PSA and DRE to participants undergoing screening, demonstrated no benefit with screening; while the European Randomized Study of Screening for Prostate Cancer (ERSPC), which recommended PSA without DRE, showed a reduction in prostate cancer mortality with screening.

Despite of this, evidence is still insufficient to advise professionals routinely using DRE to stop doing so. Several international agencies and medical organizations continue to recommend that both DRE and PSA are carried out during prostate cancer screening, because up to 25% of men with cancer may have PSA levels less than 4.0 ng/mL; clinical observations have shown that high-grade prostate cancer can be detected by DRE in patients with PSA values below any cutoff for prostate biopsy indication; and also because DRE can improve the positive predictive value and the selective detection of potentially aggressive tumors by increased PSA levels.

Furthermore, in both PLCO and ERSPC trials, DRE was routinely performed by doctors, nurses, and other health care professionals, sometimes with only a few weeks of training. As it is known that an effective DRE requires experience and a relatively long learning curve, and that the accuracy of the test is greater in experienced hands, recommendations supporting that DRE should not be used as first-line method in prostate cancer screening should be extrapolated with caution in settings where DRE is performed by specialists with significant clinical experience (i.e., urologists and oncologists).

In conclusion, we suggest that, in patients who accept prostate cancer screening, the benefits and risks of DRE should be discussed as part of the informed decision-making process, and patients should decide with their physicians whether they think DRE is appropriate for them during screening.

With PSA measurements subject to variation I feel very strongly that a DRE alongwith a TRUS  should be standard practice in screening of Prostate CA

DRE exam is unreliable

no documentation

you can't exam the whole gland

no real value

best regards

ferdinand

In my opinion , in patients where multi-parametric MRI of the prostate will be performed as a screening test for prostate cancer, DRE should be omitted .