PSA & DRE ... yes no

[peter90036]

so whats the scoop, pro cons etc etc doesnt or maybe a little decrease mortality but risks of overdiagnosis and further procedures etc

do you do DREs or PSAs or both to "screen" or patient preference ?

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[brats800]

If you can justify your screening methods based on current guidelines / recommendations (sometimes trumped by your medical group's algorithms etc), then you should be covered.

For prostate CA screenings, I personally use the AUA recommendations (http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm)
1) I do not routinely screen age less than 50 unless they have symptoms, a family history of prostate CA, and/or wish to start screening early after discussing the risks / benefits
2) From age 50 - 70 I usually will do a DRE q2 years. I will do the DRE more often if any acute change in symptoms or if pt wishes. Some patients wish to move the DRE to q3 years if yearly PSA testing is normal.
3) From age 50 - 70 I will discuss the risks benefits of PSA testing. I find that:
- almost all men with a family history and/or symptoms of BPH want to have the PSA testing done.
- almost all men who have been having PSA testing done for the last 5-10 years wish to continue with the screening
- very few men who have not been tested in the past, have no family history, and are asymptomatic wish to have the PSA testing done.

 

[babdoc]

2) From age 50 - 70 I usually will do a DRE q2 years. I will do the DRE more often if any acute change in symptoms or if pt wishes. Some patients wish to move the DRE to q3 years if yearly PSA testing is normal.

And how often does that happen? ;-)

 

[VA Hopeful Dr]

Unless they have a family history, I talk screening risk/benefit over with the patients and let them decide what they want.

 

[brats800]

And how often does that happen? ;-)

Rare, but it happens. Usually it is the "I had a friend with metastatic prostate cancer and never want to go through that" kind of story. Same way I have some women who would prefer to get a pap every 12-18 months even if the guidelines would let them space them further apart.

 

[peter90036]

Unless they have a family history, I talk screening risk/benefit over with the patients and let them decide what they want.

thats what i've been doing but a colleague said basically "omg you don't do DREs !!!"

 

[cabinbuilder]

thats what i've been doing but a colleague said basically "omg you don't do DREs !!!"

I don't do DRE's either. #1 my fingers are too short and I can't reach the prostate #2 I don't think I would know what I was feeling if I could reach that far anyway.

I do the PSA, it's what we have. I have found many prostate cancers with it. Of course there are false positives but I would rather test and be false then not test at all and miss one.

 

[deleted87716]

DRE is not a particularly useful exam, IMO. Lately, rather than saying "Assume the position!" (while snapping my glove for effect) - kidding! - I've just been asking men if they want a DRE. Not surprisingly, many will say "no." As long as they're low risk and don't have any voiding symptoms, I don't push the issue. I just document "Pt. declines DRE" in the note.

 

[babdoc]

Rare, but it happens. Usually it is the "I had a friend with metastatic prostate cancer and never want to go through that" kind of story. Same way I have some women who would prefer to get a pap every 12-18 months even if the guidelines would let them space them further apart.

I was only kidding. I do things pretty much as you do. I use the PSA pretty judiciously. I think I've only ordered a handful in, say, the last year. There's a place for DRE. No one likes them: neither the doctor nor the patient. But it's free. That's pretty darn good if you're going for high-value care. In the right setting it can be an important part of the exam. In my book it's the same to say "I don't do DREs" as it was when an attending I had one time told us "Everyone you admit gets a DRE. I don't care what they're admitted for. They get a DRE."

 

[deleted87716]

I was only kidding. I do things pretty much as you do. I use the PSA pretty judiciously. I think I've only ordered a handful in, say, the last year. There's a place for DRE. No one likes them: neither the doctor nor the patient. But it's free. That's pretty darn good if you're going for high-value care. In the right setting it can be an important part of the exam. In my book it's the same to say "I don't do DREs" as it was when an attending I had one time told us "Everyone you admit gets a DRE. I don't care what they're admitted for. They get a DRE."

Well, in the hospital, the usual reason for doing a DRE is to rule out occult GI bleeding. Hence, the old saying: "There are only two reasons not to do a rectal: either the patient doesn't have an anus, or you don't have a finger."

FWIW, when I ask men if they want a DRE, I usually jokingly add, "It's no extra charge!" Most of them still say no.

 

[Bacchus]

Well, in the hospital, the usual reason for doing a DRE is to rule out occult GI bleeding. Hence, the old saying: "There are only two reasons not to do a rectal: either the patient doesn't have an anus, or you don't have a finger."

FWIW, when I ask men if they want a DRE, I usually jokingly add, "It's no extra charge!" Most of them still say no.

Of course, anus is substituted with a longer A-word.

I've only done one DRE so far in residency and it was mandated by some "state policy" for someone living in a group home. Also have only drawn one PSA, at a patient's request, because of family history. And, of course, it was mildly elevated so I had to order a second which also was elevated which ended up in a urology consult and a PSA that eventually resulted back to normal. Sigh.

 

[deleted87716]

 

[smq123]

And how often does that happen? ;-)

I actually had a patient request one. That was the whole reason for his visit. He had no family history and no symptoms, but literally would not leave the office without one.

Interestingly enough, this was on a Valentine's Day. The working theory was that he was just very, very, very lonely.

 

[smq123]

Of course, anus is substituted with a longer A-word.

I've only done one DRE so far in residency and it was mandated by some "state policy" for someone living in a group home. Also have only drawn one PSA, at a patient's request, because of family history. And, of course, it was mildly elevated so I had to order a second which also was elevated which ended up in a urology consult and a PSA that eventually resulted back to normal. Sigh.

I actually did a lot more screening DREs in residency, mostly for the practice of doing DREs. I find prostate exams to be useful in other settings - prostatitis and BPH. My goal was mostly to get comfortable with estimating prostate size through exam. Probably overkill. My boyfriend's a radiation oncologist, so listening to his stories made me a little afraid of the rare prostate cancer with a large nodule without a corresponding rise in PSA, which is also probably where that came from.

I don't do DRE's either. #1 my fingers are too short and I can't reach the prostate #2 I don't think I would know what I was feeling if I could reach that far anyway.

One of my boyfriend's co-residents apparently worked with a rad onc who would make all of his prostate patients get on all four's ("doggy-style," if you will) in order to do their prostate exam. The position, supposedly, brings the prostate closer to the anus so you can palpate everything. I usually don't have a problem reaching the prostate, but this story runs through my mind every now and then. No, I haven't actually tried it out.

 

[cabinbuilder]

Um, NO

 

[Bacchus]

Um, NO

There's just some things I won't do, for the patient's pride. Asking a patient to get on all 4's, unless they're trying to precipitously deliver a baby in fetal distress, is not going to happen.

How do you even explain that to a patient? Excuse me sir, not only am I going to stick my finger up your butt, but I'm also going to do it while you're on your hands and knees. *glove snap*

 

[smq123]

There's just some things I won't do, for the patient's pride. Asking a patient to get on all 4's, unless they're trying to precipitously deliver a baby in fetal distress, is not going to happen.

How do you even explain that to a patient? Excuse me sir, not only am I going to stick my finger up your butt, but I'm also going to do it while you're on your hands and knees. *glove snap*

Patients will do almost anything for their cancer docs, as I have come to find out.

 

[deleted87716]

In medical school, we were taught three different techniques for doing a DRE. The first is the most commonly employed, which is having the patient standing, flexed at the waist to about 90 degrees, with elbows resting on the exam table. The second was lateral decubitus, with legs flexed at the hip and knee. We were told this would provide positioning advantages similar to those described for "doggy style" in that it moves the prostate a bit closer to the examining finger. "Doggy style" itself was never suggested (thank God). The third was lithotomy position (supine, feet in stirrups - like you would position a female for a pelvic exam).

Since then, I've done lateral decubitus only when patients were unable to stand (mostly in the hospital). Unless you really flex their hips, it's no easier to reach the prostate than in the conventional position (IMO), and it puts your arm and finger at an awkward angle unless you sort of turn yourself sideways. I've never done one in lithotomy position, and doubt that would go over well with most patients. I suspect it would be about as well received as doggy style.

I imagine the reason an oncologist could get away with it is that the patient already knows they have cancer, and aren't going to argue with the doctor who is trying to save their life. They would probably assume he's just doing a really thorough exam.

 

[styphon]

If you can justify your screening methods based on current guidelines / recommendations (sometimes trumped by your medical group's algorithms etc), then you should be covered.

For prostate CA screenings, I personally use the AUA recommendations (http://www.auanet.org/education/guidelines/prostate-cancer-detection.cfm)
1) I do not routinely screen age less than 50 unless they have symptoms, a family history of prostate CA, and/or wish to start screening early after discussing the risks / benefits
2) From age 50 - 70 I usually will do a DRE q2 years. I will do the DRE more often if any acute change in symptoms or if pt wishes. Some patients wish to move the DRE to q3 years if yearly PSA testing is normal.
3) From age 50 - 70 I will discuss the risks benefits of PSA testing. I find that:
- almost all men with a family history and/or symptoms of BPH want to have the PSA testing done.
- almost all men who have been having PSA testing done for the last 5-10 years wish to continue with the screening
- very few men who have not been tested in the past, have no family history, and are asymptomatic wish to have the PSA testing done.

I am kind of opposite, I follow the ACS and USPTF guidelines and discuss PSA screening with asymptomatic, I rarely get someone who wants screening.

In people with an immediate family hx of Prostate cancer, I discuss how we do not have enough research in this area for me to recommend for or against.

 

[deleted87716]

I actually had a patient request one. That was the whole reason for his visit. He had no family history and no symptoms, but literally would not leave the office without one.

Interestingly enough, this was on a Valentine's Day. The working theory was that he was just very, very, very lonely.

I missed this post earlier.

That reminds me of a patient we had in the ED when I was a resident. Back then, we had paper charts and a physical chart rack. When you were ready for a new case, you'd just go over to the chart rack and grab the first chart. You weren't supposed to cherry-pick. In one case, however, the chief complaint was "I need a rectal." That chart sat in the rack for a looooong time.

 

[peter90036]

i recently was coerced by the patient's look of "you dont do my yearly DRE u a bad MD"

 

[babdoc]

i recently was coerced by the patient's look of "you dont do my yearly DRE u a bad MD"

...which is pretty much the same as "you don't do my yearly mammo you're a bad doctor." Once a conception is in place that something as ridiculously uncomfortable as a finger in your anus or a breast squished in an X-ray machine is beneficial, I imagine that it is hard to shake it. Maybe people expect that the important tests that prevent them from getting something scary like cancer are just going to be uncomfortable. And if we don't do them, that means we aren't looking for those scary things. And now they're going to get cancer...