Understanding Prostate Exam and PSA Screening

Andrew Siegel MD 9/28/2021

With only a few days remaining in September, prostate cancer awareness month is rapidly coming to an end, so a quick review of prostate cancer screening is in order.

Five Indisputable Facts

  1. Prostate cancer is the most common male cancer (aside from skin cancer).
  2. Prostate cancer causes NO symptoms until it progresses to advanced stages.
  3. Screening aims to detect prostate cancer in its earliest and most curable states.
  4. Screening is as simple as an annual digital rectal examination and a PSA test.
  5. Timely intervention for aggressive prostate cancer results in high cure rates.

The slender examining finger of yours truly, estimated to have performed > 100,000 prostate exams over the years

Digital Rectal Exam (DRE)

“Digital” of DRE refers to the examining finger (digit) used for the prostate exam, typically the dominant index finger.  A gloved, lubricated finger is placed gently within the anus and swept over the prostate contour in order to examine the outer, accessible surface of the prostate and gain valuable information about its health. Although not a pleasant examination, it is brief and not painful. 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. 

Please note well that it is entirely possible to have prostate cancer with a normal PSA (prostate specific antigen), 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. 

Prostate Specific Antigen (PSA)

PSA is a protein produced by the prostate that liquefies semen, aiding the transit of sperm to the egg.  A small amount of PSA leaches from the prostate into the circulation and can be measured. Larger prostates produce more PSA and with aging, PSA gradually rises with the prostate growth that inevitably occurs.

PSA is the best tool available for detecting prostate cancer.  Baseline PSA testing for men in their 40s is useful for predicting the future potential for prostate cancer. 90% of men are found to have a normal PSA.  Of the 10% of men with an elevated PSA, 30% or so will have prostate cancer. Elevated PSA in prostate cancer occurs because of a disruption of the cellular structure of prostate cancer cells, allowing accelerated leaking of PSA from the prostate into the blood circulation.

PSA is prostate organ-specificbut not prostate cancer-specific. Other processes aside from cancer can cause leaking of PSA from disrupted prostate cells and false positive testing (absence of prostate cancer in men with high PSA). These include prostatitis(inflammation of the prostate), benign prostatic hyperplasia(BPH, anenlargement of the prostate gland), prostate manipulation (e.g., a vigorous prostate examination, prostate biopsy, prolonged bike ride, ejaculation, etc.).  False negative testing may also occur (presence of prostate cancer in men with low PSA).

The most informative use of PSA screening is when it is obtained on a year-to-year basis, which provides more meaningful information than a single, out-of-context PSA.  Because PSA values can fluctuate from lab to lab, it is always a good idea to try to use the same lab for the testing. Generally, PSA will increase by a small amount every year, reflecting benign prostate growth. If PSA accelerates at a greater rate than anticipated, further evaluation is indicated.

Men age 40 and older who have a life expectancy of 10 years or greater are ideal for PSA screening. There is little sense in doing PSA screening in men with life expectancy less than 10 years because prostate cancer rarely causes death in the first decade after diagnosis and other medical issues often will do so before the prostate cancer has a chance to. The age at which to stop screening needs to be individualized, since “functional” age trumps “chronological” age and the decision to screen should be a collaboration between patient and physician.

PSA circulates in a “free” form, and a “complex” form in which the PSA is bound to a protein. The free PSA/total PSA ratio can be of predictive value (similar to the predictive value of HDL cholesterol/total cholesterol). The higher the free PSA/total PSA ratio, the greater the chance that benign prostate enlargement is the source of the elevated PSA.

Prostate biopsy is indicated if there is concern for, or suspicion of the possibility of prostate cancer—most commonly based upon a PSA elevation, PSA acceleration, an abnormal digital rectal exam, or an abnormal MRI (magnetic resonance imaging).

Bottom Line: After age 40, please get a prostate checkup–including a prostate exam and a PSA blood test–annually. It truly can be lifesaving!

Wishing you the best of health,

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A new blog is posted weekly. To receive a free subscription with delivery to your email inbox visit the following link and click on “email subscription”:  www.HealthDoc13.com

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.  He is the co-founder of PelvicRx and Private Gym.  His latest book is 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 is now available 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

PROMISCUOUS EATING— Understanding and Ending Our Self-Destructive Relationship with Food

MALE PELVIC FITNESS: Optimizing Sexual and Urinary Health

THE KEGEL FIX: Recharging Female Pelvic, Sexual, and Urinary Health

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