GPs should no longer have to do rectal exams when trying to diagnose prostate cancer as it is a ‘poor test’ for detection, leading urologists have argued.
The British Association of Urological Surgeons (BAUS) has called for the end of digital rectal examinations (DRE) in men with suspected prostate cancer, denouncing its efficacy and necessity.
In a joint statement published 9 June with men’s health charity Prostate Cancer UK, BAUS said that the DRE adds no ‘clinical value’ but it still being offered to men despite its ‘poor ability to detect cancer’.
The statement stresses to GPs that if a patient has a raised PSA result, then there is no requirement for a DRE in order to make a referral. BAUS has pledged to work with NHS England and other relevant stakeholders to advise GPs further on this.
Research commissioned by Prostate Cancer UK last year showed that men with a PSA level above the referral threshold (≥3.0ng/mL) do not need to have a DRE prior to referral to secondary care, and that the DRE has ‘limited benefit’ as a screening tool in primary care.
Today’s statement pointed out that the methods for diagnosis of prostate cancer have improved substantially with the introduction of new biopsy techniques and MRI scans.
‘A clinician using their finger to feel the prostate is a legacy of the historic pathway; it does not add clinical value but can be a major deterrent to men coming forward for checks.
‘In a cash-strapped, time-poor NHS, it makes no sense to do a test unless it could change clinical decision making,’ it said.
RCGP chair Professor Kamila Hawthorne responded to the statement, saying it was ‘absolutely vital’ that up-to-date and evidence-based methods were used to detect prostate cancer, given its high rate in the UK.
However, she did point out that DREs can still be carried out if a patient has a negative PSA but the GP is still concerned about their symptoms.
She said: ‘At present, guidelines state that the Prostate Specific Antigen (PSA) test alone is not reliable enough to detect prostate cancer that needs treatment as it has a false negative rate of about 15%, which means some cases can fall through the gaps.
‘If a patient has a negative PSA test result but their GP is still concerned about their symptoms, then a digital rectal examination can help to identify potential prostate cancer.
‘With the Transform Trial underway, it is sensible to wait for the evidence to become available before we change current clinical practice and move away from DRE altogether.’
The BAUS also indicated that the DRE held a certain level of stigma and was a deterrent to men coming forward with symptoms to their GP.
‘Because of this, not only is it ineffective at finding prostate cancer, it’s also deterring men from speaking to their GP about prostate cancer risk and testing – condemning many to get a late, incurable diagnosis.
‘Evidence shows that fear of rectal exams is the greatest barrier to men taking action by talking to their GP about the PSA blood test.’
Research commissioned by the BAUS revealed that nearly a quarter (24%) of UK men would rather talk about the weather, politics, or social issues with friends than talk to their GP about urological conditions or symptoms they may be facing.
A survey of 1,010 men showed that over a third of men (39%) would avoid discussing issues with a healthcare professional because they worried that their symptoms were not serious enough to warrant a doctor’s appointment.
Among those who said they would avoid discussing issues with a healthcare professional, the fear of embarrassment (35%) and receiving bad news or a serious diagnosis (31%) also played its part in men not seeking medical advice.
The findings informed the association’s new ‘Check In, Don’t Check Out’ awareness campaign, launched today, to encourage men to feel more comfortable talking to their GP about their urological health.
The campaign, coinciding with Men’s Health Awareness Week, highlights the ‘stigma and taboo’ attached to men’s health – particularly with urological issues such as blood in urine or semen, prostate enlargement, testicular pain, erectile dysfunction or incontinence.
Professor Ian Pearce, consultant urologist at Manchester University NHS Foundation Trust and president of BAUS said: ‘These findings are a real wake-up call. Far too often, we see men ignoring symptoms or delaying seeking advice from their GP because they’re embarrassed or think it’s not serious enough.
‘We are urging men to know their bodies, know what is normal for them – whether that’s checking for lumps and bumps or noticing that they’re urinating more often – and to check in with a healthcare professional, don’t check out and think it’s not urgent or important enough.
‘Our message is simple: checking in on your health today could save your life tomorrow. A conversation with your GP could spot an urgent issue and lead to an early diagnosis, with treatment options and outlooks vastly improved as a result.’
Earlier this year, health secretary Wes Streeting told MPs that he would like to see a national screening programme in place for men at high risk of prostate cancer, though he stressed that any decisions need to be ‘evidence-based and evidence-led’.
Last month, a Pulse survey revealed that a quarter of GPs are ‘strongly supportive’ of an NHS prostate cancer screening programme, but many highlighted issues with PSA testing alone being ‘inadequate.’
In April, UK researchers reported that an at-home saliva test assessing genetic risk of prostate cancer was more accurate at detecting clinically significant disease than PSA level or MRI.
The Government launched a call for evidence in April to support its first-ever Men’s Health Strategy, looking at prostate cancer as well as mental health, cardiovascular disease and type 2 diabetes.
While the move to simplify prostate cancer referral pathways is understandable, I strongly caution against abandoning digital rectal examination (DRE) entirely in primary care. In my clinical practice, I have encountered two patients within the last five years whose PSA levels were within normal range, but who were ultimately diagnosed with prostate cancer based on suspicious findings during DRE. In one of these cases, the urology service initially declined referral due to a normal PSA, underlining the critical role of clinical judgement and examination findings beyond biochemical thresholds. Emerging evidence supports this caution. A study by Mottet et al. (EAU Guidelines, 2023) reaffirms that while PSA is a valuable tool, it has limitations in sensitivity—especially in detecting anterior or high-grade tumours that may not elevate PSA early in disease. NICE NG131 (Prostate cancer: diagnosis and management) also recognises the diagnostic value of an abnormal DRE in patients with lower urinary tract symptoms or at risk of prostate cancer, irrespective of PSA levels. Removing DRE from primary care risks delaying diagnosis in PSA-negative but clinically significant cancers—particularly in socioeconomically deprived groups where late-stage presentations are already more common. Until non-invasive risk stratification tools are proven to reliably replace clinical examination, DRE remains a vital part of the diagnostic armamentarium.
RCGP says Consultant Urologists don’t know what they are talking about.
DRE is a poor screening test; PSA is a poor screening test;
perhaps we should send all men for screening MRIs ?
About time. I’ve been saying this for years. I can’t detect a prostate cancer on examination with a normal PSA – Dr Chathley – you can? Why did you do a DRE at all?