How to prostate exam?

Contents

Prostate Tests

On this page:

  • What is the prostate?
  • What are some common prostate problems?
  • What are the symptoms of prostate problems?
  • How are prostate problems diagnosed?
  • How is a digital rectal exam (DRE) performed?
  • What is the first test for detecting prostate problems?
  • Why is a prostate-specific antigen (PSA) blood test performed?
  • What are additional tests for detecting prostate problems?
  • What happens after the prostate tests?
  • How soon will prostate test results be available?
  • Eating, Diet, and Nutrition
  • Clinical Trials

What is the prostate?

The prostate is a walnut-shaped gland that is part of the male reproductive system. It has two or more lobes, or sections, enclosed by an outer layer of tissue. The prostate is located in front of the rectum and just below the bladder, where urine is stored. It surrounds the urethra at the neck of the bladder and supplies fluid that goes into semen.

Side view of male urinary tract

What are some common prostate problems?

The most common prostate problem in men younger than age 50 is inflammation, called prostatitis. Prostate enlargement, or benign prostatic hyperplasia (BPH), is another common problem. Because the prostate continues to grow as a man ages, BPH is the most common prostate problem for men older than age 50. Older men are at risk for prostate cancer as well, but it is much less common than BPH.

What are the symptoms of prostate problems?

The symptoms of prostate problems may include

  • urinary retention—the inability to empty the bladder completely
  • urinary frequency—urination eight or more times a day
  • urinary urgency—the inability to delay urination
  • urinary incontinence—the accidental loss of urine
  • nocturia—frequent urination at night
  • trouble beginning a urine stream
  • weak or interrupted urine stream
  • blockage of urine
  • urine that has an unusual color or odor
  • pain after ejaculation or during urination

Different prostate problems may have similar symptoms. For example, one man with prostatitis and another with BPH may both experience urinary urgency. Sometimes symptoms for the same prostate problem differ among individuals. For example, one man with BPH may have trouble beginning a urine stream, while another may experience nocturia. A man in the early stages of prostate cancer may have no symptoms at all. Because of this confusing array of symptoms, a thorough medical exam and testing are vital.

How are prostate problems diagnosed?

To diagnose prostate problems, the health care provider will perform a digital rectal exam (DRE). The health care provider will also ask the patient

  • when the problem began and how often it occurs
  • what symptoms are present
  • whether he has a history of recurrent urinary tract infections
  • what medications he takes, both prescription and those bought over the counter
  • the amount of fluid he typically drinks each day
  • whether he consumes caffeine and alcohol
  • about his general medical history, including any major illnesses or surgeries

Answers to these questions will help the health care provider identify the problem or determine what medical tests are needed. Diagnosing BPH may require a series of medical exams and tests.

How is a digital rectal exam (DRE) performed?

A DRE is a physical exam of the prostate. The health care provider will ask the patient to bend over a table or lie on his side while holding his knees close to his chest. The health care provider slides a gloved, lubricated finger into the rectum and feels the part of the prostate that lies next to it. The DRE may be slightly uncomfortable, but it is brief. This exam reveals whether the prostate has any abnormalities that require more testing. If an infection is suspected, the health care provider might massage the prostate during the DRE to obtain fluid to examine with a microscope. This exam is usually done first. Many health care providers perform a DRE as part of a routine physical exam for men age 50 or older, some even at age 40, whether or not the man has urinary problems.

Digital rectal exam

What is the first test for detecting prostate problems?

The first test for detecting prostate problems is a blood test to measure prostate-specific antigen (PSA), a protein made only by the prostate gland. This test is often included in routine physical exams for men older than age 50. Because African American men have higher rates of getting, and dying from, prostate cancer than men of other racial or ethnic groups in the United States, medical organizations recommend a PSA blood test be given starting at age 40 for African American men. Medical organizations also recommend a PSA blood test be given starting at age 40 for men with a family history of prostate cancer. Some medical organizations even recommend a PSA blood test be given to all men starting at age 40.

If urination problems are present or if a PSA blood test indicates a problem, additional tests may be ordered. These tests may require a patient to change his diet or fluid intake or to stop taking medications. If the tests involve inserting instruments into the urethra or rectum, antibiotics may be given before and after the test to prevent infection.

Why is a prostate-specific antigen (PSA) blood test performed?

A PSA blood test is performed to detect or rule out prostate cancer. The amount of PSA in the blood is often higher in men who have prostate cancer. However, an elevated PSA level does not necessarily indicate prostate cancer. The U.S. Food and Drug Administration has approved the PSA blood test for use in conjunction with a DRE to help detect prostate cancer in men age 50 or older and for monitoring men with prostate cancer after treatment. However, much remains unknown about how to interpret a PSA blood test, its ability to discriminate between cancer and problems such as BPH and prostatitis, and the best course of action if the PSA level is high.

When done in addition to a DRE, a PSA blood test enhances detection of prostate cancer. However, the test is known to have relatively high false-positive rates. A PSA blood test also may identify a greater number of medically insignificant lumps or growths, called tumors, in the prostate. Health care providers and patients should weigh the benefits of PSA blood testing against the risks of follow-up diagnostic tests. The procedures used to diagnose prostate cancer may cause significant side effects, including bleeding and infection.

What are additional tests for detecting prostate problems?

If the DRE or the PSA blood test indicates a problem may exist, the health care provider may order additional tests, including urinalysis, urodynamic tests, cystoscopy, abdominal ultrasound, transrectal ultrasound with prostate biopsy, and imaging studies such as magnetic resonance imaging (MRI) or computerized tomography (CT) scan.

Urinalysis

Urinalysis is the testing of a urine sample for abnormal substances or signs of infection. The urine sample is collected in a special container in a health care provider’s office or commercial facility and can be tested in the same location or sent to a lab for analysis.

If an infection is suspected, the health care provider may ask that the urine sample be collected in two or three containers during a single urination to help locate the infection site. After the first collection, the health care provider will have the patient stop the urine stream for a prostate massage before collecting more urine. If signs of infection appear in the first container but not in the others, the infection is likely to be in the urethra. If the urine contains significantly more bacteria after the prostate massage or bacteria are in the prostate fluid itself, the infection is likely to be in the prostate.

Urodynamic Tests

Urodynamic testing is any procedure that looks at how well the bladder, sphincters, and urethra are storing and releasing urine. Most urodynamic tests focus on the bladder’s ability to hold urine and empty steadily and completely. If the prostate problem appears to be related to urine blockage, the health care provider may recommend tests that measure bladder pressure and urine flow rate. One test involves urinating into a special device that measures how quickly the urine is flowing and records how many seconds it takes for the peak flow rate to be reached. Another test measures postvoid residual, the amount of urine left in the bladder when urination stops. A weak urine stream and urinary retention may be signs of urine blockage caused by an enlarged prostate that is squeezing the urethra. Some urodynamic tests are performed in a health care provider’s office without anesthesia. Other urodynamic tests are performed in a health care provider’s office, outpatient center, or hospital with local anesthesia.

Cystoscopy

Cystoscopy is a procedure that allows the health care provider to look for blockage in the lower urinary tract. A cystoscope is a tubelike instrument used to look inside the urethra and bladder. After a solution numbs the inside of the penis, the health care provider inserts the cystoscope through the opening at the tip of the penis and into the lower urinary tract. By looking through the cystoscope, the health care provider can determine the location and degree of the urine blockage. A cystoscopy is performed in a health care provider’s office, outpatient center, or hospital with local anesthesia. The procedure is usually performed by a urologist, a doctor who specializes in treating problems of the urinary tract and the male reproductive system.

Abdominal Ultrasound

Ultrasound uses a device, called a transducer, that bounces safe, painless sound waves off organs to create an image of their structure. The transducer can be moved to different angles to make it possible to examine different organs. In abdominal ultrasound, the health care provider applies a gel to the patient’s abdomen and moves a handheld transducer over the skin. The gel allows the transducer to glide easily, and it improves the transmission of the signals. The procedure is performed in a health care provider’s office, outpatient center, or hospital by a specially trained technician and interpreted by a doctor, usually a radiologist—a doctor who specializes in medical imaging. Anesthesia is not needed. An abdominal ultrasound can create images of the entire urinary tract. The images can show damage or abnormalities in the urinary tract resulting from urine blockage at the prostate.

Transrectal Ultrasound with Prostate Biopsy

Transrectal ultrasound is most often used to examine the prostate. In a transrectal ultrasound, the health care provider inserts a transducer slightly larger than a pen into the man’s rectum next to the prostate. The ultrasound image shows the size of the prostate and any abnormal-looking areas, such as tumors. Transrectal ultrasound cannot definitively identify prostate cancer.

To determine whether a tumor is cancerous, the health care provider uses the transducer and ultrasound images to guide a needle to the tumor. The needle is then used to remove a few pieces of prostate tissue for examination with a microscope. This process, called biopsy, can reveal whether prostate cancer is present. A transrectal ultrasound with prostate biopsy is usually performed by a doctor in a health care provider’s office, outpatient center, or hospital with light sedation and local anesthesia. The biopsied prostate tissue is examined in a laboratory by a pathologist—a doctor who specializes in diagnosing diseases.

Tansrectal ultrasound with prostate biopsy

MRI and CT Scan

An MRI is a test that takes pictures of the body’s internal organs and soft tissues without using x-rays. The MRI machines use radio waves and magnets to produce detailed pictures. An MRI may also involve the injection of dye. A CT scan uses a combination of x-rays and computer technology to create three-dimensional (3-D) images. A CT scan may also involve the injection of a dye. MRI and CT scan images can help identify abnormal structures in the urinary tract, but they cannot distinguish between cancerous tumors and noncancerous prostate enlargement. Once a biopsy has confirmed cancer, these imaging techniques will show how far the cancer has spread. MRIs and CT scans are usually performed at an outpatient center or hospital by a specially trained technician and interpreted by a radiologist; anesthesia is not needed. For an MRI, light sedation may be used for people with a fear of confined spaces.

What happens after the prostate tests?

Urodynamic tests and cystoscopy may cause mild discomfort for a few hours after the procedures. Drinking an 8-ounce glass of water every half-hour for 2 hours may help reduce discomfort. The health care provider may recommend taking a warm bath or holding a warm, damp washcloth over the urethral opening to relieve discomfort. A prostate biopsy may produce pain in the area of the rectum and the perineum, which is between the rectum and the scrotum. A prostate biopsy may also produce blood in urine and semen.

An antibiotic may be prescribed for 1 or 2 days to prevent infection.

How soon will prostate test results be available?

Results for simple medical tests such as some urodynamic tests, cystoscopy, and abdominal ultrasound are often available soon after the test. The results of other medical tests such as PSA blood test and prostate tissue biopsy may take several days to come back. A health care provider will talk with the patient about the results and possible treatments for the problem.

Eating, Diet, and Nutrition

Eating, diet, and nutrition have not been shown to play a role in causing or preventing prostate problems.

Clinical Trials

The National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) and other components of the National Institutes of Health (NIH) conduct and support research into many diseases and conditions.

What are clinical trials, and are they right for you?

Clinical trials are part of clinical research and at the heart of all medical advances. Clinical trials look at new ways to prevent, detect, or treat disease. Researchers also use clinical trials to look at other aspects of care, such as improving the quality of life for people with chronic illnesses. Find out if clinical trials are right for you.

What clinical trials are open?

Clinical trials that are currently open and are recruiting can be viewed at www.ClinicalTrials.gov.

Symptom check

Your GP will ask about your symptoms, how long you’ve had them, whether they are getting worse over time, and how they are affecting your life.

Before you visit your GP, you might want to think about how often you’ve had symptoms over the last month. This may help you explain your symptoms to your GP. You might also want to keep a diary of how much you drink and how often you urinate.

Your GP will check whether your symptoms might be caused by another health problem, such as diabetes, or by any medicines you are taking, such as blood pressure medicines, anti-depressants or herbal medicines.

They will also check whether your symptoms could be caused by your lifestyle – for example, if you often drink large amounts of fluid, alcohol, or drinks containing caffeine (such as tea, coffee or cola).

Bladder diary

Your GP may ask you to keep a diary for a few days to check how much you are drinking, what type of drinks you have, how much urine you pass, and how often and at what times you urinate. A diary can help your doctor to work out what may be causing your symptoms and how to treat them.

Urine test

Your GP may ask you for a urine sample to check for blood or any infection that could be causing your symptoms. You may need to give more than one sample. If you have an infection your GP will give you a course of antibiotics.

Blood tests

You may be offered a blood test to check your kidneys are working properly. You may also be offered a prostate specific antigen (PSA) blood test. PSA is a protein produced by cells in your prostate. If the PSA level is raised, there may be a problem with your prostate. An enlarged prostate can cause the amount of PSA in your blood to rise. Age, infection, inflammation and prostate cancer can also make your PSA level rise.

Physical examination

Your GP may examine your abdomen (stomach area) and penis. They may also feel your prostate through the wall of the back passage (rectum). This is called a digital rectal examination (DRE).

Insights

If you’re a man who hasn’t made his first urologist office visit, you may wonder what to expect.

First, it’s helpful to understand who urologists are. They are physicians who specialize in the genitourinary tract—the kidneys, urinary bladder, adrenal glands, urethra and male reproductive organs—and male fertility. Urologists are also trained in the surgical and medical treatment of diseases that affect these organs.

Here are the typical things you can expect during an appointment with a urologist:

  1. A urologist will request you to provide a urine specimen, so don’t go to the office with an empty bladder. Many urological conditions may prevent you from being able to hold urine in. So when you arrive, inform the office staff that you are ready to provide a specimen.
  2. Each urologist office visit starts with assorted paper work. This may include questionnaires to help assess how severe your ailment is. On the questionnaires, you to “rate” things like lower urinary tract symptoms, incontinence and/or sexual health. You may also complete a “voiding diary” to documents times and amounts of urination if (and when) you experience incontinence.
  3. You will enter an exam room and a staff member will record your detailed medical history. It will focus on your genitourinary system and what your underlying problem is and also involve a complete review of all body systems. Disease of other systems can help diagnose urologic problems. Be prepared to provide a complete list of all your medications, including over-the-counter drugs, vitamins and supplements that you take. If you think you may not recall the names of everything you take, bring all your medications with you.
  4. The urologist will perform a physical exam. The will concentrate on the genitourinary system and evaluate other systems as well. The physician will perform a genital exam plus a digital rectal exam to assess the prostate.
  5. After the examination, the urologist will discuss a treatment plan for you to determine what is happening. This will usually involve additional tests, either during this visit or, more commonly, at a later visit. The urologist may want to check blood counts, kidney function, or test PSA (prostate-specific antigen) or testosterone levels.
  6. Your urologist may order imaging studies. This can include sonography of the kidneys, the bladder, and/or the prostate; or an imaging scan to visualize specific organs.
  7. The urologist may recommend an ambulatory, office-based procedure. It may be cystoscopy, a minimally invasive procedure that examines the bladder and urethra; urodynamics, which assesses bladder functionality for patients who have incontinence; and/or a biopsy.

A focused, detailed urologist office visit will allow the doctor to determine learn the correct course of action to treat your symptoms.

Do all men who are treated for prostate cancer lose sexual and urinary function?

It’s definitely not true that all men are incontinent and impotent after treatment for prostate cancer. Urinary incontinence is usually temporary.

There can be a sexual impact for guys who have normal function. If the cancer is near their nerve bundle, they’re going to have a decrease in sexual function. If it’s not, and we can do bilateral nerve sparing surgery, studies show 70 (to 80) percent can get back their normal sexual function. It all depends on where the cancer is. But the truth is that we can’t predict very well who will be the 30 percent who will have—or still have—ED; some already do have ED because of age, diabetes, hypertension or renal failure.

Are you seeing prostate cancer becoming more prevalent in younger patients?

It’s pretty rare. It’s less common that men in their 40s have prostate cancer, but, we also are very rarely screening them. The young men who come in to be screened tend to have one of those high-risk features. They most likely had a father who had prostate cancer, so they’re nervous about it. Or they’re African-American, and they’ve been flagged by their health care providers.

If you’re young, your quality of life is even more important to you right now. We know that, if diagnosed with low-grade prostate cancer, a person will need treatment at some time in life. If we can delay treatment—which could negatively impact urinary or sexual function—by several years, then we should do that and obviously discuss that there is a low but possible chance of metastasis developing during that time.

What do you want men to know about prostate cancer?

The important thing to know is that, if you live long enough, you will probably get prostate cancer. If you live into your 80s, about 80 percent of men have some sort of prostate cancer. That doesn’t mean they’re going to die from prostate cancer because, as a percentage, very few men die from prostate cancer. It means it’s important to be aware of it and consider screening early, so if it’s a high-grade type, we can identify it and treat it.

So, how many of your patients comment on your last name sounding a lot like “sprinkle?”

A lot.

What do you say to them?

Yes, you’re right! I was not preselected for this career, though. My dad’s a doctor too—but he’s an allergist. There are a lot of funny urology names for sure.

For more information about prostate cancer screening, contact Yale Medicine Urology.

Overview


Prostate cancer

How is prostate cancer treated?

For many men with prostate cancer, treatment is not immediately necessary.

If the cancer is at an early stage and not causing symptoms, your doctor may suggest either “watchful waiting” or “active surveillance”.

The best option depends on your age and overall health. Both options involve carefully monitoring your condition.

Some cases of prostate cancer can be cured if treated in the early stages.

Treatments include:

  • surgically removing the prostate
  • radiotherapy – either on its own or alongside hormone therapy

Some cases are only diagnosed at a later stage, when the cancer has spread.

If the cancer spreads to other parts of the body and cannot be cured, treatment is focused on prolonging life and relieving symptoms.

All treatment options carry the risk of significant side effects, including erectile dysfunction and urinary symptoms, such as needing to use the toilet more urgently or more often.

For this reason, some men choose to delay treatment until there’s a risk the cancer might spread.

Newer treatments, such as high-intensity focused ultrasound (HIFU) and cryotherapy, aim to reduce these side effects.

Some hospitals may offer them as an alternative to surgery, radiotherapy or hormone therapy.

But the long-term effectiveness of these treatments is not known yet.

For years, doctors have used a PSA blood test to screen men for prostate cancer. The test measures a protein made by the prostate gland, called a prostate-specific antigen (PSA).

But the PSA test can do more harm than good. Here’s why:

The test is often not needed.

Most men with high PSAs don’t have prostate cancer. Their high PSAs might be due to:

  • An enlarged prostate gland.
  • A prostate infection.
  • Recent sexual activity.
  • A recent, long bike ride.

Up to 25% of men with high PSAs may have prostate cancer, depending on age and PSA level. But most of these cancers do not cause problems. It is common for older men to have some cancer cells in their prostate glands. These cancers are usually slow to grow. They are not likely to spread beyond the prostate. They usually don’t cause symptoms, or death.

Studies show that routine PSA tests of 1,000 men ages 55 to 69 prevent one prostate cancer death. But the PSA also has risks.

There are risks to getting prostate cancer tests and treatments.

If your PSA is not normal, you will probably have a biopsy. The doctor puts a needle through the wall of the rectum and into the prostate to take a few samples. Biopsies can be painful and cause bleeding. Men can get serious infections from biopsies, and they may need hospital care.

Surgery or radiation are the usual treatments for prostate cancer. They can do more harm than good. Treatment can cause serious complications, such as heart attacks, blood clots in the legs or lungs, or even death. In addition, 40 men out of 1,000 will become impotent or incontinent from treatment.

Screenings can lead to high costs.

The cost for a PSA test is fairly low—about $40.

If your result is abnormal, the costs start adding up. Your doctor will usually refer you to a urologist for a biopsy. Costs may include:

  • A consultation fee (up to $350).
  • An ultrasound fee (about $150).
  • Additional professional fees (up to $200).
  • Biopsy fees (about $500).

If the biopsy causes problems, there are more costs. You might also have hospital costs.

When is a PSA test needed?

If you are age 50 to 74, you should discuss the PSA test with your doctor. Ask about the possible risks and benefits.

Men under 50 or over 75 rarely need a PSA test, unless they have a high risk for prostate cancer.

  • You are more likely to get prostate cancer if you have a family history of prostate cancer, especially in a close relative such as a parent or sibling.
  • Your risks are higher if your relative got prostate cancer before age 60 or died from it before age 75. These early cancers are more likely to grow faster.
  • If you have these risks, you may want to ask your doctor about getting the PSA test before age 50.

This report is for you to use when talking with your healthcare provider. It is not a substitute for medical advice and treatment. Use of this report is at your own risk.

© 2014 Consumer Reports. Developed in cooperation with the American Academy of Family Physicians.

What Is Screening for Prostate Cancer?

Some men get a PSA test to screen for prostate cancer. Talk to your doctor, learn what is involved, and decide if a PSA test is right for you.

Cancer screeningexternal icon means looking for cancer before it causes symptoms. The goal of screening for prostate cancer is to find cancers that may be at high risk for spreading if not treated, and to find them early before they spread.

If you are thinking about being screened, learn about the possible benefits and harms of screening, diagnosis, and treatment, and talk to your doctor about your personal risk factors.

There is no standard test to screen for prostate cancer. Two tests that are commonly used to screen for prostate cancer are described below.

Prostate Specific Antigen (PSA) Test

A blood test called a prostate specific antigen (PSA) test measures the level of PSA in the blood. PSA is a substance made by the prostate. The levels of PSA in the blood can be higher in men who have prostate cancer. The PSA level may also be elevated in other conditions that affect the prostate.

As a rule, the higher the PSA level in the blood, the more likely a prostate problem is present. But many factors, such as age and race, can affect PSA levels. Some prostate glands make more PSA than others.

PSA levels also can be affected by—

  • Certain medical procedures.
  • Certain medications.
  • An enlarged prostate.
  • A prostate infection.

Because many factors can affect PSA levels, your doctor is the best person to interpret your PSA test results. If the PSA test is abnormal, your doctor may recommend a biopsy to find out if you have prostate cancer.

Digital Rectal Examination (DRE)

Digital rectal examination (DRE) is when a health care provider inserts a gloved, lubricated finger into a man’s rectum to feel the prostate for anything abnormal, such as cancer. In 2018, the U.S. Preventive Services Task Forceexternal icon stated that it does not recommend DRE as a screening test because of lack evidence on the benefits.

Prostate Cancer Screening

The prostate is the gland below a man’s bladder that produces fluid for semen. Cancer screening is looking for cancer before you have any symptoms. Cancer found early may be easier to treat.

There is no standard screening test for prostate cancer. Researchers are studying different tests to find those with the fewest risks and most benefits. One test is the digital rectal exam (DRE). The doctor or nurse inserts a lubricated, gloved finger into your rectum to feel the prostate for lumps or anything unusual. Another test is the prostate-specific antigen (PSA) blood test. Your PSA level may be high if you have prostate cancer. It can also be high if you have an enlarged prostate (BPH) or other prostate problems. If your screening results are abnormal, your doctor may do more tests, such as an ultrasound, MRI, or a biopsy.

Prostate cancer screening has risks:

  • Finding prostate cancer may not improve your health or help you live longer
  • The results can sometimes be wrong
  • Follow-up tests, such as a biopsy, may have complications

You and your doctor should discuss your risk for prostate cancer, the pros and cons of the screening tests, and whether you should get them.

Prostate Exam Every 4 Years

The current guidelines of the American Cancer Society recommend that men over age 50 should be “offered” a prostate exam every year

The Story: A new European study has shown that a thorough screening for prostate cancer every 4 years is adequate. The screening comprises a PSA blood test, a digital rectal exam, and a transrectal ultrasound. “Very few, if any, aggressive prostate cancers escape (this) screening….”

Comment: It looks as if the American Cancer Society guidelines for prostate cancer screening may be changing. Transurethral ultrasound is a procedure used to examine the prostate. An instrument (the ultrasound probe) is inserted into the rectum, and sound waves bounce off the prostate. These sound waves create echoes, which a computer uses to create a picture called a sonogram of the prostate.

Barbara K. Hecht, Ph.D.
Frederick Hecht, M.D.
Medical Editors, MedicineNet.com

Prostate Cancer Screening Interval of 4 Years Misses Few Cancers, Study Shows

Linda Wang, Assistant News Editor, Katherine Arnold, News Editor, Journal of the National Cancer Institute

A 4-year screening interval was adequate to detect most cancers in a large European randomized trial of prostate cancer screening, according to a study in the October 1 issue of the Journal of the National Cancer Institute.

The European Randomized Study of Screening for Prostate Cancer (ERSPC) is an ongoing randomized trial to determine the effect of screening on deaths from prostate cancer. Study participants randomly assigned to the intervention arm are screened every 4 years with a prostate-specific antigen (PSA) test, a digital rectal exam, and a transrectal ultrasound exam. Little is known about the sensitivity, or the percentage of people who test positive for a disease among people who have the disease, of these screening tests and the appropriateness of the 4-year screening interval.

To address these issues, Ingrid W. van der Cruijsen-Koeter, M.D., T. H. van der Kwast, M.D., Ph.D., and Fritz H. Schroder, M.D., Ph.D., of the Erasmus MC, University Medical Center in Rotterdam, Netherlands, looked at the rate of interval cancers (i.e., cancers detected between screening visits) among 17,226 men ages 55 to 74 who were enrolled in the Rotterdam section of the ERSPC. The occurrence of interval cancers can be used to determine whether screening tests are sensitive enough, and whether the screening interval is appropriate.

In the study, men were divided into two groups: an intervention group that received two scheduled screens 4 years apart, and a control group that did not receive scheduled screening. The researchers checked the Dutch national cancer registry annually for cases of prostate cancer among the study participants.

During the 4-year screening period, 18 “true” interval cancers were diagnosed in men in the intervention group and 135 cancers were diagnosed in men in the control group, suggesting a low rate of interval cancers among men in the intervention group. The authors determined that the screening procedure has a high sensitivity of 85.5%.

The authors conclude that the low rate of interval cancers found within the ERSPC-Rotterdam confirms a high sensitivity of the screening procedure. They add that the interval cancers were at a locally confined stage, suggesting that “very few, if any, aggressive prostate cancers escape screening with the procedures used within the ERSPC.”

What to Expect During Your Prostate Exam

Here is what else may happen:

  • Free PSA blood test. “Your urologist may order this blood test to get more information about your PSA. PSA can travel through your blood, attached to other proteins or by itself. If less than 25 percent of your PSA is ‘free,’ your risk of prostate cancer is higher,” says Dr. Feloney.
  • Trans rectal ultrasound (TRUS). If your urologist suspects prostate cancer after your history, DRE, and blood tests, he may order this test. TRUS is a 15-minute procedure that uses sound waves to create an image of your prostate gland. This image can help tell the difference between non-cancerous and cancerous changes in your prostate. You may need to have an enema the night before. You will lie on your side as a probe is passed into your rectum to do the test. There should be no pain.
  • Prostate biopsy. Getting tissue samples of your prostate gland to look at under a microscope is the only sure way to diagnose prostate cancer. Prostate biopsy is often combined with TRUS to guide your urologist to the site of the suspected cancer. A biopsy is an outpatient procedure. Most of the time, your prostate will be made numb with an injection and you will not be put to sleep. “The biopsy is done through the rectum, and 12 cores of prostate tissue are usually removed,” says Feloney. “You may need to take some antibiotics and have an enema before the procedure. Tell your urologist if you take any blood thinners. After the biopsy, you may expect some blood in your urine for a few days.”

“I felt a few zingers during the biopsy, but it went quickly,” Zenka recalls. “I went home on antibiotics and Advil. The day after the biopsy, I went back to all my normal activities.”

What You Will Learn From Prostate Cancer Tests

Results of your biopsy should be ready in about a week. They will show not only whether you have prostate cancer but, if you do, they’ll also give a pretty good idea of how aggressive the cancer is.

Possible results include benign enlargement, inflammation, PIN, or cancer. PIN stands for prostatic intraepithelial neoplasia, which is a type of cell change that may become cancer. “The pathologist who looks at the biopsy will also grade the cells from 2 to 10,” explains Feloney. “This is called the Gleason score. A Gleason score over 8 indicates a more aggressive type of cancer.”

If you do get a prostate cancer diagnosis, there are many options for treatment. The good news is that prostate cancer is not a deadly disease for most men. In fact, studies show that the five-year survival after diagnosis is nearly 100 percent, and long-term survival at 15 years is over 90 percent – and these stats are getting even better over time as treatments improve. Prostate cancer is definitely a survivable disease, so don’t be afraid to go ahead and have that prostate exam.

The prostate exam | Take it like a man

When I meet a man to check his prostate, the first thing I do is shake his hand. That’s the point when many of them realise I have big hands – and big fingers. It can add trepidation to a situation already fraught with insecurity and embarrassment. But I’m quick to reassure them that this gives us an advantage: I can examine more of their prostate and it won’t be any less comfortable. Here are a few truths about the exam.

It’ll just take a minute

There’s no shying away from the fact that this exam involves inserting a gloved and lubricated digit into the rectum. While that may not sound pleasant, it’s over very quickly. The whole appointment might take just few minutes and the part you’re dreading – probably less than 20 seconds.

You’ll be granted some privacy to take off your lower clothing before being asked to lie on your side and draw your knees up to your chest. While it’s natural to tense up in these situations, you be surprised at how easily a lubricated finger slips in. Once it’s in there it usually takes just a few seconds for the anal sphincter to relax around it.

You’ll be aware of some pressing – this shouldn’t be painful but it may make you feel a brief urge to urinate. If you do experience any pain you should tell the examiner straight away. If the exam is physically intolerable for you but deemed necessary it can be performed under general anaesthetic. Once the surface of the prostate has been inspected, the digit is removed and the area around the anus cleaned of any residual lubricant.

What are we looking for?

Many men experience issues with their prostate gland as they age. The symptoms for benign prostate enlargement and prostate cancer are very similar – most men present first with urinary issues. When your prostate has simply enlarged the surface is usually smooth. We begin to suspect prostate cancer when the surface is hard and lumpy. It’s a key difference and the best way to find out is via a rectal exam.

What will I know afterwards?

A rectal exam can’t definitively diagnose prostate cancer. Only a biopsy can do that and you wont be offered one if you don’t need it. Rectal exams are part of a suite of diagnostic tests, including PSA blood tests and MRI scans, that help to either build or break the case for further investigation.

Can’t I just get a blood test?

If you have concerns about prostate cancer you certainly should have a Prostate Specific Antigen (PSA) blood test. Knowing your PSA level can help to establish what’s normal for you so that a spike (which could indicate the presence of cancer) is more easily identified. But a blood test alone is not enough. The test has been known to deliver ‘false-positive’ results in some cases – leading men into have invasive biopsies for no reason. Up to 20% of men with prostate cancer show no increase in PSA levels*. So it’s best used to check against the result of a rectal exam but can’t be relied upon in isolation.

What if we find something?

A rectal exam can give us an indication that cancer may be present but discovering a lump is not a cancer diagnosis. If the examiner finds the surface of your prostate to be hard and lumpy or your PSA levels are higher than expected you may be referred for additional tests. If you haven’t already seen a Consultant Urologist they may conduct another rectal exam to check the GP’s initial assessment.

The next step is usually to have an MRI scan so an image of your prostate can be examined. If necessary, you may then be referred for a biopsy to take a sample from your prostate. Even then, finding cancer cells in your prostate doesn’t necessarily mean you’ll need cancer treatment. Find out more on the truth about prostate cancer diagnosis here.

*Reference: NHS England

Last updated Wednesday 27 November 2019

What Happens When You Get a Prostate Exam?

If you or your doctor suspect that you may have prostate cancer, or think you should be screened for prostate cancer, the first step in the diagnostic process is investigating your personal history and performing a physical exam. Even if your doctor does not mention prostate cancer or prostate cancer screening during an appointment, you can initiate the conversation yourself. Regardless of whether or not you’re examined at a regular well visit or if you make a separate appointment to address your concerns, the history and physical exam portion of the process will be the same. Your doctor will talk with you about any symptoms you might be experiencing, risk factors you may possess, and perform a digital rectal exam (DRE).

Symptoms

Early prostate cancer is often asymptomatic, meaning that it has no symptoms. This can make it challenging to make a very early diagnosis, and why many individuals will undergo regular screening if they are at high risk. The earliest signs of prostate cancer are typically related to a prostate cancer tumor pressing on the urethra (the tube that carries urine form the bladder through the penis and out of the body), and are therefore, usually related to urination. These include:

  • Painful urination or a burning feeling while urinating or ejaculating
  • Blood in the urine or semen
  • An increased need to urinate (often during the night)
  • Weak urine stream or interrupted urine stream
  • Difficulty in starting or stopping urinating
  • Leaking of urine or loss of bladder control

Many of these symptoms can be caused by a variety of different issues, including benign prostatic hyperplasia (BPH), which is the non-cancerous growth of the prostate gland as a man ages. These symptoms can also be caused by urinary tract infections, prostate gland infections, or trauma to the urinary or reproductive tract, all of which are treatable.1,2 If you do have any of these symptoms, and if your doctor suspects that prostate cancer may be the cause, they will ask further information to determine your specific risk and decide if it’s appropriate to continue on with the examination.

Risk factors

The next step in your examination will be to gain a better picture of your medical history, and assess for any prostate cancer-related risk factors that you may possess. Risk factors can be classified as modifiable or non-modifiable, and contribute to an increased risk in developing a condition. Modifiable risk factors are things we can potentially control or change, such as diet, obesity, or smoking. Non-modifiable risk factors are things we cannot change or were born with like race, family history, or age. While risk factors increase a person’s risk of developing a condition, they are not the cause of the condition’s presence. For example, being exposed certain chemicals, including Agent Orange, could lead to genetic mutations which can then go on to contribute to prostate cancer.

Examples of common risk factors your doctor may take into consideration or ask you about further include the following:

  • Race
  • Ethnicity
  • Family history
  • Geography or places of residence
  • Exposure to chemicals including Agent Orange (a chemical used in the Vietnam War)
  • Smoking history
  • Diet
  • Obesity or history of obesity
  • If you have any other medical conditions
  • Medications or supplements you are taking3-5

After your doctor collects this additional information, they can help paint a better picture of your prostate cancer risk, and if the symptoms you’re experiencing may be related to the condition. If you are asymptomatic, they will use this information to determine if it’s appropriate to still continue with screening.

Digital Rectal Exam

The next step in the exam may be for you to have a digital rectal exam, also known as a DRE. A DRE involves your doctor sticking a gloved, lubricated finger into your rectum. During this exam, they will be checking for changes in size, texture, or shape of the prostate to determine if there are any potential cancerous masses. The DRE may also be used to screen for BPH (benign prostatic hyperplasia).6

Life expectancy

Before moving forward with additional screening or diagnostic tests, your doctor may talk with you about your life expectancy. Although this may be a scary discussion to have at any stage in life, it’s an especially important one when it comes to prostate cancer. Prostate cancer is often diagnosed when it is still confined to the prostate, and is so slow growing that it may never cause any serious symptoms or be life-threatening. This is especially true for elderly men or men at any age who have other potentially life-threatening conditions.

Before further determining if you have prostate cancer and planning treatment, your doctor may look at your estimated life expectancy to see if it’s worth risking the chance of experiencing debilitating side-effects of treatment, such as erectile dysfunction and urinary or bowel incontinence. In some cases, treatment can lead to serious quality of life impairments for individuals that may impact their life more than the cancer would.

Your life expectancy is estimated using general population data to determine the average lifespan of an individual based on his age alone. For example, if the average age of an American male was 80 years old, and a man is currently 75, preliminary estimates would suggest his life expectancy is 5 more years. Of course, this is just an average, and many men will live much longer than this. This is why your doctor will also take into account your overall health to tailor the estimate specifically to you and your situation. For example, healthy behaviors such as a well-balanced diet or regular exercise may help increase a man’s projected life expectancy, while negative health behaviors such as smoking or excessive drinking may decrease the estimate. Further, certain medical conditions will be taken into account if they could potentially decrease a man’s life expectancy.7

It’s important to keep in mind that your life expectancy is just an estimate used to predict if further screening or diagnostic procedures for prostate cancer, and potential treatment of the cancer, outweighs the physical, mental, and emotional impacts of receiving a diagnosis. If further diagnostic tests or screening measures are recommended, your doctor will provide you with information on what the next steps are, and what to expect.

Screening Tests for Prostate Cancer

Screening is testing to find cancer in people before they have symptoms. It’s not clear, however, if the benefits of prostate cancer screening outweigh the risks for most men. Still, after discussing the pros and cons of screening with their doctors, some men might reasonably choose to be screened.

The screening tests discussed here are used to look for possible signs of prostate cancer. But these tests can’t tell for sure if you have cancer. If the result of one of these tests is abnormal, you will probably need a prostate biopsy (discussed below) to know for sure if you have cancer.

Prostate-specific antigen (PSA) blood test

Prostate-specific antigen (PSA) is a protein made by cells in the prostate gland (both normal cells and cancer cells). PSA is mostly found in semen, but a small amount is also found in blood.

The PSA level in blood is measured in units called nanograms per milliliter (ng/mL). The chance of having prostate cancer goes up as the PSA level goes up, but there is no set cutoff point that can tell for sure if a man does or doesn’t have prostate cancer. Many doctors use a PSA cutoff point of 4 ng/mL or higher when deciding if a man might need further testing, while others might recommend it starting at a lower level, such as 2.5 or 3.

  • Most men without prostate cancer have PSA levels under 4 ng/mL of blood. When prostate cancer develops, the PSA level often goes above 4. Still, a level below 4 is not a guarantee that a man doesn’t have cancer. About 15% of men with a PSA below 4 will have prostate cancer if a biopsy is done.
  • Men with a PSA level between 4 and 10 (often called the “borderline range”) have about a 1 in 4 chance of having prostate cancer.
  • If the PSA is more than 10, the chance of having prostate cancer is over 50%.

If your PSA level is high, you might need further tests to look for prostate cancer (see ‘If screening tests results aren’t normal’, below).

Factors that might affect PSA levels

One reason it’s hard to use a set cutoff point with the PSA test when looking for prostate cancer is that a number of factors other than cancer can also affect PSA levels.

Factors that might raise PSA levels include:

  • An enlarged prostate: Conditions such as benign prostatic hyperplasia (BPH), a non-cancerous enlargement of the prostate that affects many men as they grow older, can raise PSA levels.
  • Older age: PSA levels normally go up slowly as you get older, even if you have no prostate abnormality.
  • Prostatitis: This is an infection or inflammation of the prostate gland, which can raise PSA levels.
  • Ejaculation: This can make the PSA go up for a short time. This is why some doctors suggest that men abstain from ejaculation for a day or two before testing.
  • Riding a bicycle: Some studies have suggested that cycling may raise PSA levels for a short time (possibly because the seat puts pressure on the prostate), although not all studies have found this.
  • Certain urologic procedures: Some procedures done in a doctor’s office that affect the prostate, such as a prostate biopsy or cystoscopy, can raise PSA levels for a short time. Some studies have suggested that a digital rectal exam (DRE) might raise PSA levels slightly, although other studies have not found this. Still, if both a PSA test and a DRE are being done during a doctor visit, some doctors advise having the blood drawn for the PSA before having the DRE, just in case.
  • Certain medicines: Taking male hormones like testosterone (or other medicines that raise testosterone levels) may cause a rise in PSA.

Some things might lower PSA levels (even if a man has prostate cancer):

  • 5-alpha reductase inhibitors: Certain drugs used to treat BPH or urinary symptoms, such as finasteride (Proscar or Propecia) or dutasteride (Avodart), can lower PSA levels. These drugs can also affect prostate cancer risk (discussed in Can Prostate Cancer Be Prevented?). Tell your doctor if you are taking one of these medicines. Because they can lower PSA levels, the doctor might need to adjust for this.
  • Herbal mixtures: Some mixtures that are sold as dietary supplements might mask a high PSA level. This is why it’s important to let your doctor know if you are taking any type of supplement, even ones that are not necessarily meant for prostate health. Saw palmetto (an herb used by some men to treat BPH) does not seem to affect PSA.
  • Certain other medicines: Some research has suggested that long-term use of certain medicines, such as aspirin, statins (cholesterol-lowering drugs), and thiazide diuretics (such as hydrochlorothiazide) might lower PSA levels. More research is needed to confirm these findings. If you take any of the medicines regularly, talk to your doctor before you stop taking it for any reason.

For men who might be screened for prostate cancer, it’s not always clear if lowering the PSA is helpful. In some cases the factor that lowers the PSA may also lower a man’s risk of prostate cancer. But in other cases, it might lower the PSA level without affecting a man’s risk of cancer. This could actually be harmful, if it were to lower the PSA from an abnormal level to a normal one, as it might result in not detecting a cancer. This is why it’s important to talk to your doctor about anything that might affect your PSA level.

Special types of PSA tests

If you decide to get a PSA screening test and the result isn’t normal, some doctors might consider using different types of PSA tests to help decide if you need a prostate biopsy, although not all doctors agree on how to use these tests. If your PSA test result isn’t normal, ask your doctor to discuss your cancer risk and your need for further tests.

Percent-free PSA: PSA occurs in 2 major forms in the blood. One form is attached to blood proteins, while the other circulates free (unattached). The percent-free PSA (%fPSA) is the ratio of how much PSA circulates free compared to the total PSA level. The percentage of free PSA is lower in men who have prostate cancer than in men who do not.

If your PSA test result is in the borderline range (between 4 and 10), the percent-free PSA might be used to help decide if you should have a prostate biopsy. A lower percent-free PSA means that your chance of having prostate cancer is higher and you should probably have a biopsy.

Many doctors recommend a prostate biopsy for men whose percent-free PSA is 10% or less, and advise that men consider a biopsy if it is between 10% and 25%. Using these cutoffs detects most cancers and helps some men avoid unnecessary biopsies. This test is widely used, but not all doctors agree that 25% is the best cutoff point to decide on a biopsy, and the cutoff may change depending on the overall PSA level.

Complexed PSA: This test directly measures the amount of PSA that is attached to other proteins (the portion of PSA that is not “free”). This test could be done instead of checking the total and free PSA, and it could give the same amount of information, but it is not widely used.

Tests that combine different types of PSA: Some newer tests combine the results of different types of PSA to get an overall score that reflects the chance a man has prostate cancer (particularly cancer that might need treatment).These tests include:

  • The Prostate Health Index (PHI), which combines the results of total PSA, free PSA, and proPSA
  • The 4Kscore test, which combines the results of total PSA, free PSA, intact PSA, and human kallikrein 2 (hK2), along with some other factors

These tests might be useful in men with a slightly elevated PSA, to help determine if they should have a prostate biopsy. These tests might also be used to help determine if a man who has already had a prostate biopsy that didn’t find cancer should have another biopsy.

PSA velocity: The PSA velocity is not a separate test. It is a measure of how fast the PSA rises over time. Normally, PSA levels go up slowly with age. Some research has found that these levels go up faster if a man has cancer, but studies have not shown that the PSA velocity is more helpful than the PSA level itself in finding prostate cancer. For this reason, the ACS guidelines do not recommend using the PSA velocity as part of screening for prostate cancer.

PSA density: PSA levels are higher in men with larger prostate glands. The PSA density (PSAD) is sometimes used for men with large prostate glands to try to adjust for this. The doctor measures the volume (size) of the prostate gland with transrectal ultrasound (discussed in Tests to Diagnose and Stage Prostate Cancer) and divides the PSA number by the prostate volume. A higher PSA density indicates a greater likelihood of cancer. PSA density has not been shown to be as useful as the percent-free PSA test.

Age-specific PSA ranges: PSA levels are normally higher in older men than in younger men, even when there is no cancer. A PSA result within the borderline range might be worrisome in a 50-year-old man but cause less concern in an 80-year-old man. For this reason, some doctors have suggested comparing PSA results with results from other men of the same age.

But the usefulness of age-specific PSA ranges is not well proven, so most doctors and professional organizations (as well as the makers of the PSA tests) do not recommend their use at this time.

Digital rectal exam (DRE)

For a digital rectal exam (DRE), the doctor inserts a gloved, lubricated finger into the rectum to feel for any bumps or hard areas on the prostate that might be cancer. As shown in the picture below, the prostate is just in front of the rectum. Prostate cancers often begin in the back part of the gland, and can sometimes be felt during a rectal exam. This exam can be uncomfortable (especially for men who have hemorrhoids), but it usually isn’t painful and only takes a short time.

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