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PER RECTUM EXAMINATION SHOULD NOT BE DONE IN A ROUTINE HEALTH CHECK UP
OP Kapoor
Ex. Hon. Physician, Jaslok Hospital and Bombay Hospital, Mumbai, Ex. Hon. Prof. of Medicine, Grant Medical College and JJ Hospital, Mumbai 400 008.
Gone are the days when prostate used to be examined by so called PR (rectal) examination. It appears to me that it should be given up. What was the surgeon looking for? He was looking for cancer of the prostate which is one of the most common cancers (the incidence rising to 80% after the age of 80 years). If it is so, more the reason the rectum should not be examined with a finger. The only method to diagnose cancer of the prostate early is to do blood PSA (prostatic surface antigen) test. The levels of PSA show a rise in Ca prostate.
Unfortunately, the prostate is very rich in this antigen. Even a single rectal examination can cause a rise in PSA, as can also prostatic infection like prostatitis. Thus, although this test is very sensitive for cancer of the prostate, it is not specific. Yet, I see so many doctors doing rectal examination in a health check up to assure the patient that there is no cancer of the prostate.
The tragedy of an average health check up is that routine PSA is not being done. The modern five star hospitals have started doing it now, only if the patient opts to go for it and if he is ready to spend Rs. 600/- more. If the doctors do not know about PSA test, how do they expect the layman to know about it?
In the last 5 years, I have seen half a dozen patients whose health check up was absolutely normal and yet they were harbouring cancer of the prostate. It was missed because PSA test was not done.
Vice versa, I see so many patients who are diagnosed as cancer of the prostate (after seeing reports of PSA test), without doing the prostatic biopsy. Later on, even if the biopsy report comes normal, these patients develop cancer neurosis. In USA, such patients would take the doctors to court and claim damages.
Yes, if the PSA is raised, not only the biopsy, but preferably multiple 6 quadrant punch biopsy of the prostate should be done to examine six different sites.
In a health check up, if PR examination is going to be done, blood for PSA test must be collected before this examination.
The next reason to examine the prostate is to diagnose BPH (benign prostatic hypertrophy). In my opinion, after the advent of sonography, the palpatory skill of the modern generation of doctors has been blunted, and they are no more able to appreciate "a slightly enlarged prostate" like the older generation (before sonography).
Today we have sonography of the prostate which may be done per abdomen or per rectum. After all this, we have realised that majority of the symptoms of prostate are due to bladder irritability and not the enlargement of the prostate. Of course, patients who have huge enlargement, can develop retention of urine or haematuria or urinary infection (common only in elderly males and hardly ever seen in young patients) and the rectal examination will elicit markedly enlarged prostate.
In practice, I diagnose BPH by symptoms of nocturia, day time frequency of urine, urgency, incomplete evacuation and urge incontinence.
On Sonography, less than 5% of patients show prostate size to be more than 40 gms. In these, Finasteride is then indicated to reduce the size or to see that it does not increase further.
Therefore in my practice prescription of Finasteride is very rare, (Nor do I use the low dose tablet of Finasteride for baldness because it has to be taken life time and in patients who are young and sexually very active) as it may affect their sex life.
Finally, the value of PR examination should not be under estimated. In fact, any patient who complains of constipation or passing blood in stool will be extremely happy to have a rectal examination and proctoscopy done.
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