That Pesky Prostate

A few days ago I sent in an SMS post about how testing for prostate cancer is often both futile and potentially dangerous.  I wondered why we test for prostate CA at all.  Today, the most respected group advisory group for preventive medicine in the country – the U.S. Preventive Services Task Force – officially recommended that men over the age of 75 not check for prostate cancer using the PSA or digital (read: El Finger) rectal exam.

For those aged 50-75, they take the same wimpy position that the American Academy of Pediatrics takes on circumcision, which is, loosely, “Well durn, if we’d a knowed we’d a said sowed.”  That is, they have no recommendation for or against testing in that age group.  Prior to 50, they recommend not checking unless there is a strong family history or other reason to worry.

Here’s an interesting (and confounding) factoid:  Thanks to the PSA test, the amount of prostate cancers detected has soared over the past 30 years.  The thinking is not that prostate cancer is suddenly rising, but that improved detection has led to much greater identification of the disease.  Sounds pretty good, right?  Modern medicine doing us right, right?  Well, it would be a good thing if we knew how to do anthing about prostate cancer.  The fact is that while the number of prostate cancers detected has risen dramatically, the number of deaths from the disease has remained exactly the same for the past 50 years.

So, prostate cancer detection is like identifying an incoming asteroid that will destroy the planet.  ‘Lotta good it will do you.

The Rectal Is Dead…Long Live The Rectal

My R-1 presented a case this morning, describing a 58 year old woman with left lower abdominal pain. Tradition holds that, in these situations, you get the patient’s name, ask a few other inconsequential questions, and then immediately jam your finger into their rectum.

O.K., that’s hyperbole. But from the perspective of an intern, sometimes that’s exactly how it seems.

“We have a 58 year old lady with left lower quadrant pain wh-”

“Did you do a rectal?”

So, the rectal exam looms over the entire patient encounter, tapping impatiently on the back of your skull until you finally relent and just get it over with. Not to be crass (although I’m post-call and feeling a little punchy), but doing a rectal – especially the first few – is a little like I remember the first kisses of my high school girlfriends (all 2 of them). At some point, The Kiss becomes the elephant in the room. I know I’m about to drop her off at her house, and I know we’re at that point where I have to kiss her or walk away, and so I procrastinate and ask all kinds of stupid questions to delay the inevitable.

rectal.jpgBut unlike a kiss (which is more like a rectal exam than you might think…so don’t think about it), I have never wanted to do a rectal exam. As medical students and interns, however, the exam is not only expected…it’s DEMANDED. One sure way to get torn up by an attending is to skip the rectal exam. Here’s a few of the things you’re supposed to be able to learn from the simple “digital sweep”:

– if there’s feces in the “rectal vault” and whether it’s hard (suggesting constipation) or soft
-if there’s blood (have to smear your finger on a test-card after the rectal exam, which isn’t pretty looking or smelling.
-if there’s external hemorrhoids
-if there’s rectal sphincter tone (if not, worry about major neurological trauma or stroke)
-if there’s polyps
-theoretically you can identify a fissure which can be a major source of bleeding
-you can check the prostate on males and feel for nodules (has almost no statistical correlation to prostate cancer, but we do it anyway in this country)

So, that’s a lot of stuff you can figure out with a simple rectal exam. Today, my intern failed to do the exam. He failed to “remember” it the other day as well. The ire of our attending was impressive as a result, but still, I think my intern will “forget” to do the exam on his next patient as well. Here’s some reasons why:

-the exam is an outmoded test that isn’t necessary – only old-school docs still do it
-it often stinks
-it makes everyone uncomfortable – doc and patient
-I can’t think of many places I’d less like to be
-modern imaging and a good history give you just as much information
-it really, really stinks

sunfinger.jpgThere was a time when every patient who came to the ER got a rectal by a hapless med student or intern. It was like they just wandered around the unit with an extended finger, a box of gloves and some KY, looking into every exam room. These days, even many ER docs don’t do the exam. Same for the admitting internists. The truth is that many physical exam techniques are becoming extinct, much to the dismay of the Old Guard who believe that you can diagnose everything from a triple-A to a spinal abscess with a good stethoscope and a tongue depressor. Back in the day, the physical exam was just about all a doctor had to diagnose serious disease. These days, we have all kinds of nifty tools that, yes, cost bajillions of dollars but spare us the ignominy of coating our fingers with someone else’s feces. Frankly, to most of us, it’s worth it.