A finger or not? Prostate examinations by non-urologists at a South African academic institution

According to the South African (SA) National Cancer Registry 2009, prostate cancer is the most commonly diagnosed solid-organ cancer in SA men: the incidence increases at ~3% every year, with 1/26 men developing prostate cancer in their lifetime and five men dying every day. Screening for prostate cancer by performing a digital rectal examination (DRE) adds to the sensitivity and specificity of serum prostate-specific antigen (PSA) testing and is an important component of the assessment for the early detection of prostate cancer.

To ascertain whether doctors who are not in the field of urology perform DREs and PSA testing to screen for prostate cancer, where indicated, and to determine the reason, if any, why doctors do not perform prostate examinations.

Doctors (including specialists and primary care practitioners) who consulted adult male patients in the emergency departments and polyclinics of three academic hospitals were included in the sample and asked to complete an anonymous questionnaire. Doctors with specialist urological training were excluded from the sample. The questionnaire included the following aspects: gender, year of graduation and university, current position, knowledge of PSA screening and DRE, whether these were being performed, and reasons for non-performance.

The response rate was 303/350 participants. Fifty-nine percent of the respondents were female. The median duration of experience was 5 years. The mean (standard deviation) knowledge score with regard to screening was 56.1% (20). The PSA test alone was most frequently done (35%), followed by asking the patient about urinary tract symptoms (28%). In contrast, DRE of the prostate, alone or combined with a PSA test, was performed less frequently (13.2% and 10.6%, respectively). Some of the most common reasons for not performing a DRE included: 'It's more convenient to do a PSA test'; 'Urologists will examine the prostate anyway'; 'No privacy in the emergency department/admission ward'; 'Prostate exam is not relevant to my practice'; 'There is not enough time'; and 'The practitioner forgets'. Doctors with >7 years of working experience are the least likely to do a DRE.

Performance rates of DRE and PSA testing by doctors who are not urologists are very low, which may have significant clinical implications. It is recommended that SA prostate cancer screening guidelines are necessary to change practice with regard to this condition.