the rectal refusal syndrome “but i don’t have any symptoms”

Br J Gen Pract. 2004 Aug;54(505):617-21.

Symptomatic diagnosis of prostate cancer in primary care: a structured review.

Hamilton W, Sharp D.

Division of Primary Health Care, University of Bristol, Cotham House, Cotham Hill, Bristol BS6 6JL.

BACKGROUND: Prostate cancer has the second highest cancer incidence and mortality in European men. Most prostate cancers are diagnosed after lower urinary tract symptoms (LUTS) are presented to primary care, but such symptoms more often have a benign cause. A general practitioner (GP) has to try and identify which of these patients have prostate cancer. AIMS: To review the presenting features of symptomatic prostate cancer. DESIGN OF STUDY: Structured review. METHOD: We searched Medline from 1980 to 2003 for symptoms, signs, and investigations reported in prostate cancer. This list was then expanded by secondary searches of reference lists. We excluded studies on post-diagnostic topics, such as staging, treatment, and prognosis; studies on non-Western patients; and studies on investigations that are not available in primary care. A second cycle of exclusions removed studies whose results would not guide a GP in deciding whether a patient has prostate cancer. RESULTS: No studies from primary care compared prostate cancer patients directly with controls. Two secondary care studies had enough information to allow a comparison of symptoms in cases compared with controls. In these studies, symptoms were generally more prevalent in cases, but the differences were small. Screening and secondary care studies suggest that early prostate cancer is symptomless, and that locally advanced cancer has LUTS that are similar to those for benign prostatic hypertrophy. CONCLUSION: There is a very weak evidence base for the primary care diagnosis of prostate cancer in men with lower urinary tract symptoms.

PMID: 15296564 [PubMed – indexed for MEDLINE]

my thoughts

Having no symptoms in terms of how a male voids is irrelevant in the early diagnosis of prostate cancer. It is the most common objection to the rectal exam by a male that I hear day in and day out. This article however makes a very good point. Males present to the family doctor with prostate voiding symptoms and often times in the evaluation are found to have prostate cancer. The two issues, however are unrelated, the symptoms of the enlarging prostate got the patient to the doctor and that in turn prompted an exam or PSA. Job number one in the early detection of prostate cancer is education of the male patient about getting exams and PSAs  even if they have no symptoms. The most common finding on rectal exam today in a man with prostate cancer is a normal prostate. Most cancers are diagnosed because of an elevated PSA.


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