Prostate Cancer With a Normal PSA: A Digital Rectal Exam Can Be Life-Saving

Andrew Siegel MD  2/22/2020

“Digital” of digital rectal examination (DRE) refers to the examining finger (digit) used to perform the prostate exam, typically the index finger of the physician.  It is not to be confused with “digital” meaning a series of data represented by zeroes and ones. 

Although most prostate cancers are detected because of an elevated or accelerated PSA (prostate specific antigen), some are found in the face of a low or normal PSA level, discovered only on the basis of the DRE, a vital part of the male physical exam. 


The slender examining digit of yours truly, estimated to have performed more than 100,000 prostate exams over the years!

Patient Beware:  Always take a peek at the index finger digit of your urologist before allowing him or her to lay a finger on or in you…if it is sausage-like or has long nails… 

Please note:  Although the anus is the “portal” to the prostate, urologists are NOT colon and rectal doctors, nor do we do colonoscopies.  The colon and rectum are the domain of the gastroenterologist or colon-rectal surgeon. Same foyer, different rooms! 

Please also note: Just because you have had a colonoscopy does not imply that you have had a proper DRE of the prostate. 

True story: When I was on the receiving end of my first DRE, I passed out and needed to be revived with spirits of ammonia!  It has never happened again, but I do literally “see stars” during my annual exam, which is humbling, demeaning and unpleasant, but necessary.  ‘Tis always better to give than receive! 

Finally, please do not ask me to buy you flowers or take you out to dinner as quid pro quo for doing the exam…those jokes are clichéd! However, I did recently chuckle when I handed a patient a box of tissues to clean up after the exam and he replied: “Are these to wipe up my tears?”

DRE is a vital part of the male physical exam in which a gloved, lubricated finger is placed gently within the rectum in order to examine the accessible surface of the prostate and gain valuable information about its health.  There are many positions in which to perform the test; the most common is with the patient standing, leaning forward with elbows on the exam table. Another perfectly acceptable position is with the patient lying on his side, knees bent upwards towards his chest.

After age 40, an annual DRE is highly recommended. Although it is not a pleasant examination, it is brief and not painful. Urologists do not relish performing this exam any more than patients desire receiving it, but it provides essential information that cannot be derived by any other means. If the prostate has an abnormal consistency, a hardness, lump, bump, or simply feels uneven and asymmetrical, it may be a sign of prostate cancer.  Prostate cancer most commonly originates in the peripheral zone, that region of the prostate that is accessed via DRE.

Digital Rectal Exam

From: PROSTATE CANCER 20/20: A Practical Guide to Understanding Treatment Options for Patients and Their Families.

When teaching medical students, urologists often use hand anatomy to explain what the prostate feels like under different circumstances.  Turn your hand so that the palm is up and make a fist. The normal prostate feels like the spongy, muscular, fleshy tissue at the base of the thumb, whereas cancer feels hard, like the knuckle of the thumb.

DRE in conjunction with the PSA (prostate specific antigen) blood test are the best means of screening for prostate cancer. Detection rates for prostate cancer are highest when using both tests, followed by PSA alone, followed by DRE alone.

The pathological features of prostate cancers detected on an abnormal DRE are, in general, less favorable than those of cancers detected by a PSA elevation. In other words, if the cancer can be felt, we tend to worry about it more than if it cannot be felt, as it is often at a more advanced stage.

Please note really well: It is entirely possible to have prostate cancer with a normal PSA, the only clue being an abnormal DRE. The PSA blood test is NOT a substitute for the DRE. Both tests provide valuable and complementary information about prostate health. 

Case Study: 50-something-year-old male referred for evaluation of frequent urination. His DRE revealed asymmetry, with the right side firmer than the left.  PSA 2.2. He underwent ultrasound-guided prostate biopsy with the following biopsy report:


Interpretation: The biopsy shows an aggressive cancer that requires treatment.  The urinary frequency has nothing to do with the prostate cancer, since most early prostate cancers cause no symptoms, hence the need for screening DRE and PSA.  Had this man not had the DRE and only had the PSA, this cancer would be missed and the potential for cure lost.  

For more info: Understanding prostate biopsy reports

Gleason prostate cancer grading system

Bottom Line:  The DRE can be life-saving, so please “man up” and endure the momentary unpleasantness.  Prostate cancer is the most common malignancy in men (aside from skin cancer) and can be discovered on the basis of an abnormal DRE, even in the face of normal PSA.

Wishing you the best of health in 2020 and beyond,

2014-04-23 20:16:29

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Dr. Andrew Siegel is a physician and urological surgeon who is board-certified in urology as well as in female pelvic medicine and reconstructive surgery.  He is an Assistant Clinical Professor of Surgery at the Rutgers-New Jersey Medical School and is a Castle Connolly Top Doctor New York Metro Area, Inside Jersey Top Doctor and Inside Jersey Top Doctor for Women’s Health. His mission is to “bridge the gap” between the public and the medical community. He is a urologist at New Jersey Urology, the largest urology practice in the United States.

The content of this entry is excerpted from his new book, PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families

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Video trailer for Prostate Cancer 20/20

Preview of Prostate Cancer 20/20

Andrew Siegel MD Amazon author page

Prostate Cancer 20/20 on Apple iBooks

PROSTATE CANCER 20/20: A Practical Guide to Understanding Management Options for Patients and Their Families is now on sale at Audible, iTunes and Amazon as an audiobook read by the author (just over 6 hours). 

Dr. Siegel’s other books:

FINDING YOUR OWN FOUNTAIN OF YOUTH: The Essential Guide to Maximizing Health, Wellness, Fitness and Longevity



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2 Responses to “Prostate Cancer With a Normal PSA: A Digital Rectal Exam Can Be Life-Saving”

  1. Dan Says:

    A DRE is what first detected my prostate cancer, quickly followed by PSA tests and a biopsy to confirm the findings. I’m a firm believer in the benefits of a DRE as a result.

    I’ve shared my story with others, and it never ceases to amaze me how many men are afraid of getting a DRE and absolutely refuse to so. I know you were injecting humor into an awkward situation, but telling folks you passed out won’t encourage them to get tested.

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