GPs no longer need to do rectal exam for prostate cancer, argue urologists
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.
Visit Pulse Reference for details on 140 symptoms, including easily searchable symptoms and categories, offering you a free platform to check symptoms and receive potential diagnoses during consultations.
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READERS' COMMENTS [15]
Please note, only GPs are permitted to add comments to articles
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?
Re JP….Dr Chathley is referring to patients with symptoms (“prostatism”), with a normal PSA.
Since 15% of Prostatic Cancers have a normal PSA, then a DRE with a knobbly gland might pick up a few more early cancers.
Dr C has clearly diagnosed a few in his career, as have I.
The researchers may argue that the few extra diagnoses are statistically insignificant, (and many abnormal DREs will indeed turn out to be benign), but then that’s the difference between dealing with populations (statisticians) as opposed to individuals (GPs)
Jeremy – fair question.
I examined the patient because they had ongoing urinary symptoms and were keen to have a PSA blood test. As part of the work-up, I do a digital rectal examination—not just to assess for cancer, but to ensure the presentation is consistent with prostatic hypertrophy rather than, for example, urethral stenosis.
I’ve had two cases where the PSA was normal but the gland felt clearly abnormal. One of those cancers was initially dismissed by urology due to the PSA alone. That diagnosis would have been missed without the examination.
We seem to be moving further and further away from the art of medicine—away from examining patients and toward relying purely on tests. The foundation of good clinical practice has always been: history, examination, then investigations. That sequence has stood the test of time.
My concern with articles like this is that they risk promoting a model where we skip the conversation, skip the exam, and go straight to tests—often after a phone call. At that point, are we not just a step away from being replaced by an AI receptionist?
fully agree Anuj – once we have excluded cancer in a symptomatic man we are usually left managing BPH
would you feel comfortable prescribing tamsulosin, let alone finasteride, without have examined ?
Our Local Eminent Urologist has been arguing the uselessness of DRE for at least a decade.
Management of Prostate Cancer has improved considerably in recent years; more accurate staging, better treatments.
Studies showing limited benefits of screening are no longer relevant as based on outdated practice.
Both breast and cervical screening were introduced without gold-standard randomised trial evidence of benefit, but an NHS prostate screening program could not possibly be introduced without such evidence.
This foot-dragging will inevitably cost lives.
Whiltst I agree with raised PSA argument for no DRE, how far to we go with abandonment of our clinical skills.?
rectal bleeding – PR
post menopausal bleeding -PV.
I am asked on both cancer pathway referrals forms I use to confirm these have been done.
Personally I stlll DRE men with urinary symptoms and normal PSA.. Is finding a prostate the size of an orange still helpful??
I agree that as a screening test for prostate cancer, digital rectal examination (DRE) has limitations as do other screening tests such as PSA. But if the BAUS want to change clinical practice, then they need to work with NHS England and NICE to produce updated guidance for doctors. DRE is recommended by NICE in the assessment of men with lower urinary tract symptoms and still has a role in clinical practice.
I feel that the clinical effectiveness of DRE in detecting prostate cancer is being lost in arguments surrounding mens attitude to their health and prevention of I’ll health. DRE has a definite place in assessing prostate health in relation to urinary symptoms especially with a negative PSA test. Todays secondary care colleagues feel that there is ready access to MRIscans and biopsies in their ivory Tower. I refer back to my old Urology teacher stood by the mantra “If you don’t put your finger in you’ll put your foot in”
as a former Urology registrar — I think it would be clinical negligence by Urolgists if a DRE wasn’t done.
A couple of thoughts.
1. The removal of DRE from the prostate cancer pathway must be part of a re-design of the whole pathway (saliva testing, increased MRI availability). If, combined with the PSA, it represents the best primary care assessment then we do risk negligence by not doing it.
2. This statement is powerful ‘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.’ I could not find the reference. Anyone who has found a Ca prostate on DRE alone will reassure themselves that they caught a near miss BUT if this research is correct then you must balance this against the number of men who did not present due to fear of the rectal exam and suffered for it.
I think for now, I will continue to perform DRE, but would be delighted with a new robust pathway that satisfied both clinical safety and patient experience.
About 2 % of prostate cancers with normal PSA are palpable by exam. Until we are definitely told don’t examine we are still at risk of getting sued
I have noted several prostate cancers over the years via rectal exam, and found 2 rectal carcinoma when looking for a prostate incidentally. In a couple the PSa was normal – but I still referred on clinical suspicion and was right.
It is also usefiul to assess prostate size and measure against severity of symptoms.
As mentioned PR poor detection rate, and PSA poor test, until we have direct access for MRI prosates on all men with urinary symptoms – we should continue to do what has worked well for years,