Here's What a Digital Rectal Exam Is—and Isn't
At some point, everyone with a prostate gland is going to require a digital rectal exam (DRE)—the dreaded finger in the butt. You may do the right thing and, without prodding, make a DRE appointment for preventive reasons. But if you're hesitant, every man should eventually get a DRE to check the general health of their prostate and screen for prostate cancer or other health concerns.
What is a digital rectal exam?
At its simplest, a digital rectal exam is a procedure in which a doctor uses their finger to examine a person's prostate, lower rectum and other internal organs. It is a key tool used in screening for prostate cancer.
"It's an exam where we put a glove on, we use lots of lubricant, and we insert our finger into someone's rectum," said Brian Keith McNeil, M.D., the associate dean for clinical affairs and the vice chair of the urology department at SUNY Downstate Health Sciences University in Brooklyn, New York. "That's the only way to really feel the prostate."
A DRE takes about 30 seconds, and doctors combine their observations from the exam with the results of a prostate-specific antigen (PSA) blood test to determine next steps, if any.
What do doctors feel for during a DRE?
Doctors use the digital rectal exam to feel for abnormalities in size, shape and density of the prostate.
"We're looking for asymmetry, tenderness, to see if someone's got signs of infection in the prostate or prostatitis [inflammation], and then in terms of cancer screening, nodules, masses, things like that," said Christopher Russell, M.D., a urologist for AdventHealth Medical Group in Orlando.
'They can feel most of the peripheral zone of the prostate, where most prostate cancers develop.'
A healthy prostate should have a texture and density similar to a peeled orange, with some give but not super-soft. A rock-hard prostate raises concerns for cancer—one that is too soft or tender could indicate prostatitis. Doctors cannot reach or feel the entire prostate during a DRE, but they can feel most of what is called the peripheral zone of the prostate, and that is where most prostate cancers develop, McNeil said.
They also assess the size of the prostate, though a large prostate does not in itself indicate any cause for concern. The prostate gland grows during puberty and also later in a man's life, starting in his 30s or 40s. The prostate's typical size is that of a walnut, but it can be as large as a softball and be both healthy and no cause for concern, Russell said.
What do doctors learn from a DRE?
A digital rectal exam can tell a doctor if the patient might have cancer or prostatitis. But the DRE is just part of the picture—to get the full view, the exam must be paired with the PSA blood screening.
PSA is a protein created by both normal and cancerous cells in the prostate. High levels in the blood might indicate the presence of cancer, though not necessarily, because many factors can cause elevated PSA levels. On the flip side, you can have prostate cancer and normal PSA levels.
A DRE or PSA test alone can yield observations or results that may indicate or contraindicate potential cancer: A normal digital rectal exam might be paired with high PSA levels, or a hardened prostate may produce low PSA levels. Doctors need both the DRE and PSA test to get the clearest picture of the situation.
"They go together," McNeil said. "It's kind of like a prostate-cancer-screening sandwich—it's better when you have both components."
If analysis of the combined results of a DRE and PSA test suggest potential cancer, the next steps could be magnetic resonance imaging (MRI) or a biopsy.
Who should get a DRE and when?
As men reach their 50s, the probability of developing prostate cancer increases. The highest number of prostate cancer cases occur in men between the ages of 65 and 74.
The American Urological Association (AUA) recommends shared decision-making for prostate cancer screening (which can include the DRE, PSA testing, imaging and more) for men 55 to 69 years old with average health risks. The AUA advises men younger than 55 with higher risk factors to consider routine screenings. This group includes African American men, men of Caribbean descent, and those with a family history of cancer, such as prostate or breast cancer, in multiple first-degree relatives. The AUA does not recommend routine screening in men between ages 40 and 54 who are at average risk. All of these guidelines generally apply to both PSA tests and DREs.
McNeil, who is Black, was 15 years old when his father died of prostate cancer, so he received his first digital rectal exam when he turned 40 and his next at age 45.
Common DRE misconceptions
A DRE is pretty straightforward, but McNeil noticed some people have misconceptions about the exam.
You need a DRE once you turn 40, or is it 50?
This may be the biggest misconception. Only men deemed at-risk are recommended to get routine prostate screenings before the age of 55, according to the AUA.
The PSA blood test is enough.
Wrong. You can have a normal blood test and still have prostate cancer that could only be detected in a digital rectal exam. You need the DRE and the PSA test to get a full picture.
I feel okay, so I must be totally fine.
You could be wrong, and that's very dangerous.
"There are a lot of guys with prostate cancer that don't feel symptoms at all until it's aggressive," McNeil said.
Symptoms of prostate problems include the frequent urge to urinate, waking up often at night to urinate and struggling to get all the urine out during urination.
But just because you're not experiencing symptoms doesn't mean you're not at risk of prostate cancer. Conversely, the presence of symptoms like these does not mean you have prostate cancer, though you should see a doctor.
Why you shouldn't fear a digital rectal exam
A DRE is a simple procedure, and most men understand what it entails but many first-timers are nervous, Russell said.
"Most guys, especially the first time they get one, are just terrified about having one done and the idea of having something put into their rectum," he said.
They worry the DRE will cause pain but that usually is not the case, and a painful exam is avoidable.
"The people that have a lot of pain and discomfort with doing it are those that are really nervous and anxious and are clamping down," Russell said, comparing the experience to a bowel movement, meaning that if you can relax enough for that, you can relax enough for a DRE. "A finger is so small in reality that most guys aren't that uncomfortable."