During digital rectal examination for suspected BPH or prostate cancer, which findings are important?

• A. The penis size and scrotal exam are more important.
• B. Prostate size, contour, symmetry, and firmness; a hard, nodular, irregular prostate raises cancer concern.
• C. DRE is optional if PSA is high.
• D. DRE should be avoided in older patients.

Answer: (B)

In a digital rectal exam for suspected BPH or prostate cancer, the important findings are the prostate’s size, contour, symmetry, and firmness. These aspects help distinguish benign enlargement from potential cancer. A prostate affected by BPH is often enlarged but smooth, symmetric, and maintains a normal contour. In contrast, cancer can present as a hard, nodular, irregular area that is asymmetric and may be fixed to surrounding tissues. This induration or nodularity raises concern and prompts further evaluation, such as imaging or biopsy.

PSA testing complements the examination but does not replace it; a high PSA plus a non-suspicious DRE doesn’t rule out cancer, and a concerning DRE finding may lead to biopsy regardless of PSA. The exam is appropriate for patients of older age; there’s no rule to avoid DRE based on age. While the DRE focuses on the prostate, a complete assessment may also consider other aspects of the history and physical, but the critical signs lie in size, contour, symmetry, and firmness of the prostate.