Is it time to retire the digital rectal exam?

Scott Wylie is a 4th year medical student at the University of Glasgow.

Paul McNamara is a GP and honorary clinical lecturer at the University of Glasgow.

The digital rectal exam (DRE) is a mainstay of the GP’s assessment of prostate symptoms and has been for decades.¹ Due to its perceived diagnostic power in prostate cancer, the most common malignancy in men in the UK,² the examination became a cornerstone of routine medical check-ups, cementing it as a staple of general practice.³

The DRE’s popularity among GPs, however, has waned in recent years,³ and The British Association of Urological Surgeons (BAUS) has called for the exam to be omitted from primary care’s assessment of prostate cancer.⁴ Asking, ‘Is it time to retire the DRE?’ allows for reconsideration of patient assessment with a view to improving patient experience and prostate cancer detection rates. Exploring arguments around the DRE’s utility in primary care also probes the underwritten societal and cultural beliefs that make the DRE a significant talking point, allowing us to consider moving past these too.

Despite its long history of use, the DRE is known to have poor diagnostic value, with sensitivity and specificity of 51% and 59%, respectively, when performed in primary care.⁵ These numbers suggest excessive false positives and negatives, meaning that the DRE fails to detect many cancers yet flags many benign conditions.

One study found only three prostate cancers on further investigation after 57 ‘suspicious’ DREs, suggesting that 54 of these 57 men (95%) were subjected to magnetic resonance imaging or biopsy unnecessarily due to a falsely positive rectal exam.⁶

The issues that contribute to these figures include variable training in DREs in medical schools, poor confidence in identifying prostate nodules, small tumours that are impalpable, and the fact that ‘inter-examiner reliability’ in DREs is only considered ‘fair’.⁵

In addition, one in six prostate tumours are located on the anterior portion of the gland, a region left completely unexamined in DREs.⁶ Despite this, the National Institute for Health and Care Excellence guidelines state that a DRE should be performed, alongside prostate-specific antigen (PSA), before referral to secondary care.⁷

Based on these issues with DREs, the BAUS argued for a move away from this examination to a PSA-driven referral pathway to secondary care. Alongside Prostate Cancer UK, they called for the DRE to be removed from primary care assessment of potential prostate cancer.⁴

This is based, not only on the evidence against DRE’s efficacy, but also on evidence affirming men’s negative perceptions of the examination, which deter them from attending their GP.⁴

In summation, it is argued that the DRE is a barrier to presentation despite the exam having little clinical importance for the assessing GP; thus a positive PSA without a DRE should become the new norm for suspected prostate cancer referrals.⁴

It must be noted that societal perceptions of, and stigmas around, the DRE are varied and complex. Some men, as they age, see the DRE as a routine exam carried out to heighten their chances of survival and give peace of mind, thus they accept the idea of this intimate examination. Others believe that, as many men ‘fear’ the DRE, confronting this and taking responsibility for their health asserts their masculinity.⁸

These beliefs are, however, outnumbered by more conservative feelings of ‘embarrassment’ and ‘dread’. Men struggle to overcome stigma and fear the intimacy of the DRE is ‘violating’, threatening their masculinity and sexuality. Many also confess to not being aware of PSA testing and believe the DRE to be the only method of prostate cancer screening and diagnosis, thus they avoid presentation. Those aware of DRE’s poor sensitivity also often question why they should present for such an intimate examination if results are inconclusive.⁸

These issues highlight the danger of the continued use of DREs and are an argument for a move away from the exam in primary care to prevent late presentation and diagnosis. Suggested alternatives include PSA-driven referral, where any PSA ≥3.0 ng/mL is referred without DRE,⁴ and novel techniques such as salivary genetic testing.⁹ This would require change to referral pathways where the tick-box for DRE is removed, both literally and metaphorically. Comprehensive public education would also be essential to make this change effective in encouraging more men to be screened for prostate cancer.

The fallibility of PSA testing, however, must be considered too as it also has poor sensitivity and specificity.¹⁰ A move to PSA-focused referral might promote overdiagnosis and overburden secondary care services, thus change to referral guidelines must consider this evidence. Furthermore, PSA-negative tumours make up 15% of prostate cancers,¹⁰ and so DREs may still have a place in the assessment of a normal PSA in the presence of red flag symptoms.

By retiring the routine DRE and removing stigma around prostate cancer screening, men may be more likely to present to their GP earlier. This change, however, while positive and which may improve cancer detection, does not fully appreciate patients’ reluctance to present.

Research suggests that late presentation cannot be attributed solely to fear of DREs but to fear of diagnosis and to fear of the medical profession generally.⁸ Some men believe that simply visiting their doctor is ‘unmanly’ as it makes them appear ‘vulnerable’ while others are utterly averse to receiving bad news, especially that which is cancer related, thus they avoid diagnosis altogether.⁸ Prostate cancer specifically is ‘perceived to potentially jeopardise a man’s manhood’ as it represents failure of the male reproductive system and the resulting management, which may cause impotence, is seen as emasculating, a failure of virility.⁸

Political scientist, Cynthia Daniels, argues that ‘the male reproductive body is seen as less susceptible to the hazards of the world than the female reproductive system’, thus insult, or disease, undermines masculinity.¹¹ These are further important reasons for men’s failure to present.

In light of these issues, the efficacy of a move away from the DRE is questionable as the issue of prostate cancer screening is clearly embedded in a far deeper and intricate cultural phenomenon surrounding male reproduction, health, and masculinity. Any change in referral guidance on the use of DREs in primary care should be, and ultimately will be, evidence-based to improve patient outcomes.⁴ Acknowledging issues with the DRE, however, also recognises and affirms damaging cultural assumptions surrounding men’s health. A positive by-product of discussions around prostate cancer screening may be the opportunity to challenge these beliefs and thus instigate change, not only in medical guidance, but in cultural stigmas too.

Deputy Editor’s note: see also https://bjgplife.com/the-flood-gates-of-asymptomatic-prostate-cancer-screening/

References
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7. National Institute for Health and Care Excellence (NICE). Suspected cancer: recognition and referral. NG12. London: NICE, 2025. https://www.nice.org.uk/guidance/ng12/chapter/Recommendations-organised-by-site-of-cancer#urological-cancers (accessed 18 Jun 2025).
8. James LJ, Wong G, Craig JC, et al. Men’s perspectives of prostate cancer screening: a systematic review of qualitative studies. PLoS One 2017; 12(11): e0188258.
9. Wilkinson E. Saliva test for prostate cancer risk is more accurate for screening, study suggests. Pulse 2025; 15 Apr: https://www.pulsetoday.co.uk/news/clinical-areas/renal-medicine-urology-mens-health/saliva-test-for-prostate-cancer-risk-is-more-accurate-for-screening-study-suggests (accessed 18 Jun 2025).
10. NICE. Prostate cancer: how should I assess a person with suspected prostate cancer? 2025. https://cks.nice.org.uk/topics/prostate-cancer/diagnosis/assessment (accessed 18 Jun 2025).
11. Daniels CR. Exposing men: the science and politics of male reproduction. Oxford: Oxford University Press, 2006.

Featured photo by Lorenzo Turroni on Unsplash.