is there a difference in who does your rectal exam for the detection of prostate cancer? a prostate cartoon

One of my attendings when I was a resident in urology in Augusta, Georgia told me once,”Johnny, we urologists make the rectal an art form.”Well I don’t know about that, but we do perform a lot of rectal exams in the course of our career.I have said many times to patients that specialists are no smarter than their non-specialist colleagues, but by virtue of seeing so much of the same thing and performing the rectal exam so often in both normal and abnormal cases, it allows for recognizing when an exam or symptoms fall outside the norm. I know normal. I know what ain’t normal. I know which symptoms count and have weight and which don’t and as a result I don’t chase that particular symptom (it falls outside the diameter of the tree of complaints I deem irrelevant). An example:”Doc my kidneys hurt.” And then the patient places both of his hands on the small of their back to indicate where the pain is. Well…that ain’t kidneys. That’s back, low back pain. The kidneys are up higher and more lateral and rarely hurt at the same time. They have a mind of their own so they don’t hurt if you push on them , they are unaffected by position, lying, standing or reproduced by some action. As I have said to many a low back pain sufferer:

“The kidneys are a lot like a hook in golf. They won’t listen to a damn thing you say.” You may know if you are a golfer that you can talk to a slice.

So here is a comment that makes a point and then asks a question:

Hi again,
This is quite difficult to write, but I think it raises an important point that for many reasons is often overlooked or simply ignored. I am a surgeon myself, and like Dr. McHugh I’ve also had my cancerous prostate removed robotically. However, although I had performed dozens of rectal exams throughout my career, I never realized that I didn’t know how to properly do the procedure until undergoing it myself in my urologist’s office. When my own PSA came back elevated, my internist, a man who had been doing rectal exams on me for years and who had always told me mine was negative, sent me for a urological consultation for further work-up and corroboration. That’s when I finally learned what a REAL rectal exam was; meaning just how deeply the doctor’s finger must probe the rectum to truly palpate the prostate gland. Perhaps the way I had learned to do this exam in medical school was too gentle to begin with, or maybe thru the years I had intentionally held back really pushing my finger as far as it would go because I didn’t want this part of the exam to be as unpleasant as most patient’s anticipated. Whatever the reason, it was exactly what my own doctors were doing to me; half-heartedly going through the motions of doing a digital rectal exam but never really going far enough to actually palpate my prostate gland. This is an error I still believe many — not all, of course — internists and family practitioners are guilty of perpetuating, all of them more or less subconsciously relying on the PSA results to correct any possible error in their physical diagnosis. What is your take on this Dr. McHugh?
Jack Brown

This is a fair question and here are some thoughts in bullet form:

• I admire the work and the work ethic and the job that the vast majority of family practitioners and internal medicine doctors do in the early detection of prostate cancer. The do a yeomen’s job in this regard in addition to all the other stuff they have to do.
• The most common finding on the rectal exam today at the time of the diagnosis of prostate cancer is a normal exam.
• The most common reason to refer to a urologist is an abnormal PSA.
• What is happening more often today by virtue of the ease of drawing a PSA and the patients reluctance to have a rectal exam (see cartoon by my wife-that’s right I twisted her arm to help me with this one-could you tell that yesterday’s was my handiwork) the rectal is skipped.
• I am told daily that a particular patient has not had a rectal exam for years and the referral was for the change in the PSA.
• In the above bullet the vast majority of patients have a normal rectal exam although some don’t and at times it has been a very bad and very abnormal exam.
• The majority of the time the family doctor has noted something on exam that when I check it am unimpressed with it being abnormal.
• It is less frequent that he FMD felt it was normal and on my exam it wasn’t, but I have had that happen.
• Here is the biggest advantage the urologist has over the family guys and that is that we get to examine a prostate, note the PSA, do the biopsy of the prostate and then get to see which ones really were cancer, i.e. which abnormalities were real issues and which were not. If the urologist does this drill two hundred times a year as I do then most certainly it stands to reason that the urologist knows the nuances of the prostate cancer and the rectal exam to a degree that could not be expected of the family MD.
• Some family doctors have a better feel (no pun intended) of the rectal exam of others.
• I have hundreds of patients that come to me once a year expressly for the purpose of having a urologist examine their prostate gland.
• I think this is a good idea, however not a mandatory idea. For one thing going to a urologist once a year assures it gets done.
• The rectal exam:An exam the patient does not want the physician easily persuaded not to perform.

So having said all that it is better to have your prostate “managed” by a urologist, but it is not mandatory. The PSA has helped in this regard. The rectal exam can be abnormal with a normal PSA (usually the most aggressive types do this) but this is not the most common presenting scenario.

In general if the PSA is well within normal limits and there is not a velocity change in the value of the PSA upwards and the family doctor says the exam is normal, things are going to be good.

If one feels that the family person has not examined the prostate or the patient feels that this is being put on the back burner or there is lack of confidence in this regard then a urologic referral is probably indicated.

One more way of viewing this: with all the talk about too many PSA’s being done, and too many screenings, and too many biopsies for the too many PSA’s, a family doctor that drags his feet a bit may be doing everyone a favor and actually doing exactly what will be the plan in our forthcoming national healthcare program. (Don’t think I am being critical, this is how it is now purposefully done in England-three weeks to get the result of you PSA if your family doctor has permission to order it in the first place.)

Dr. Brown, your doctor may have very well been well ahead of his time.

All pontificating aside…thanks for your comments and I hope you are doing well.