What Happened to Getting a Doctor’s Finger in Your Butt?
Reading Time: 5 minutesIt Was the Procedure Men Feared More Than Any Other. Why Has It All but Disappeared?, Men were taught to fear it for decades. I was a little shocked what happened when I asked why it never happened to me., Prostate cancer: It was the procedure men feared m
It’s a rite of passage for men. You’re in your 40s, you’re at your annual checkup, and suddenly you hear the snap of a rubber glove. The doctor slathers on some lube and tells you to bend over. Boom—a finger right up your butthole.
The digital rectal exam, or DRE, has long been used to screen for signs of prostate cancer—the most common non-skin cancer in men, killer of over 30,000 a year. Most men understand that’s important. We may even know fathers or uncles or friends who’ve suffered from prostate cancer. But it’s still a little bit of a shock to be probed so intimately by a person you only see once a year, at most. The DRE is so infamous a procedure that it’s turned into a kind of folk knowledge, a proto-meme every guy hears about long before it happens to him. It’s the subject of uncomfortable jokes in the locker room, in the examination room, and in Hollywood. Who can forget M. Emmet Walsh lubing up before enthusiastically plugging Chevy Chase in Fletch?
But at my most recent physical, my longtime primary care physician did not seem to be prepping for the probe. I’m pushing 50. When I asked—a little hesitantly—she told me that she’s phased out the DRE for her patients in favor of a blood test that, while not foolproof, is less likely to result in false-positive results. And she’s not the only one. I soon learned that thanks to a wave of research on the benefits of blood screening and the drawbacks of the digital exam, the DRE is nearing extinction as a screening tool. While I doubt anyone, doctor or patient, will miss the DRE, the test had so much mythology associated with it that its quiet death felt a little shocking. The doctor’s not gonna stick a finger up my butt anymore? All that for nothing?
‘Before we had a really good blood test, the rectal exam was really the only way we had to screen the prostate for cancer,’ Adam Weiner, a urologic oncologist at Cedars-Sinai in Los Angeles, told me. In the exam, the physician inserts a finger in a patient’s rectum and presses against the prostate from the back. ‘You’re looking for nodularity—a bump that’s firmer than the area around it,’ Weiner said.
The day med students learn the DRE has long been ‘a special day,’ as Weiner put it: ‘Nobody misses it, as you can imagine.’ Paid medical actors serve as subjects as the students practice the test—not only the actual prostate exam but the bedside manner that makes the exam easier, specifically ‘what you’re saying and how you’re positioning the patient.’
Because prostate cancer is such a threat, for many years, screening with the DRE was a standard part of every primary care physician’s job. Daniel Stone, a PCP in Los Angeles, recalled one of his med school instructors telling a classmate who’d expressed distaste at the idea of a DRE, ‘If you don’t do the rectal exam, you’re the asshole.’
After doing such exams their whole career, doctors assured me, they do not find DREs onerous or particularly gross. Sure, they don’t love them—mostly because they make patients so nervous—but they’re fine. ‘My patients will often say, ‘Oh, I feel sorry for you, having to do that exam,’ ‘ Stone said. He reminds them that he’s been performing DREs for 30 years: ‘It’s like looking in your ears or your mouth,’ he tells them.
That jocular sympathy expressed by patients is illustrative: The digital rectal exam just plain makes men nervous. Many try to defuse their anxiety with jokes in the exam room. ‘Probably a third of the men who get the exam say ‘Oh, my favorite part,’ ‘ Stone said. ‘That’s almost routine.’ My PCP told me she often had men jokingly (but also not jokingly) note the smallness of her fingers. Though the discomfort of a DRE pales in comparison to what basically any woman endures in a garden-variety OB-GYN appointment, many men have long viewed the exam as a barely bearable indignity. I certainly heard it described this way by wincing older relatives, often accompanied by casual homophobia or a feeble joke about prison rape. (‘Doc, you ever serve time?’ Fletch cracks.)
That internalized homophobia has always seemed, to me, to lie at the heart of DRE anxiety. Someone’s puttin’ their finger in my butt … and what if I enjoy it? But obviously, being gay does not somehow make a person likely to have a great time during their prostate exam. ‘Gay men do not tolerate or like digital rectal exams more than straight men do,’ Stone said. ‘That mythology is ridiculous. Nobody likes a rectal exam.’
Nobody likes a rectal exam, and yet there’s also something oddly reassuring about it. Any doctor who conducts it, I would sometimes think, must be really dedicated to my health. That means that as screening standards have changed, some patients might worry that their health is at risk—especially as doctors, under ever-growing pressure, cut appointments shorter. ‘It can be a real problem, explaining you’re not doing this anymore,’ Weiner said. ‘You’re not shortchanging them of care!’
In fact, the research is unequivocal in its findings that as a screening test, the DRE is not that useful. (How unequivocal? Ask the authors of the 2023 study titled ‘Digital Rectal Examination Is Not a Useful Screening Test for Prostate Cancer.’) These days, the gold standard of prostate-cancer screening is the PSA blood test, which identifies a protein primarily made by the prostate. Elevated levels of that protein may indicate a cancer; to follow up, a urologist will order other blood tests and, typically, a prostate MRI. (They may also perform a diagnostic DRE, just to be thorough.)
The problem with GPs conducting DREs, Weiner told me, was that while a family doctor might have a lot of experience conducting the test, that doesn’t mean they are particularly good at identifying a cancer. ‘This person is seeing all sorts of patients for hundreds of different diagnoses,’ Weiner said. ‘Their familiarity with what a concerning prostate feels like is much less than a urologist’s.’ What’s become clear, he said, is that physicians conducting DREs are fairly likely to deliver false-positive results: ‘So then these men have to see a urologist, and that leads to unnecessary anxiety, unnecessary further care, perhaps an unnecessary biopsy.’
That’s not to say that PSA blood tests are perfect. Even those tests generate false positives, such that in recent years there’s been real debate as to whether any screening for prostate cancer has benefits worth the risk of overdiagnosis. Currently, the U.S. Preventative Services Task Force suggests that men between 55 and 70 discuss whether to screen with their doctor—but if they do screen, it should be with a blood test rather than a DRE. And doctors I spoke to told me that the majority of general practitioners they know no longer use the DRE as a screening tool.
The test is not totally extinct, however. Old habits die hard. My doctor told me she knows at least one GP in her practice who found a prostate cancer early in his career and, as a result, still swears by the DRE. Even Daniel Stone, who’s used PSA blood tests most of his career, still offers the digital exam as part of a physical for men 50 and over. ‘I’m kind of an old-fashioned doctor,’ he said. ‘I just think it makes for a complete exam.’ He finds that while patients don’t enjoy the procedure, it does increase their confidence in his care. ‘That’s the thing about a rectal exam,’ he said. ‘It does show a doctor’s determination to go to the ends of the earth’—here he chuckled—’or elsewhere, to ensure your health.’
On the other hand, Stone said, his own doctor doesn’t give him a DRE during checkups. ‘And I don’t volunteer,’ he allowed. ‘ ‘Hey! What about my rectal exam?’ ‘
Reference: https://slate.com/technology/2024/08/prostate-cancer-symptoms-screening-finger-test.html
Ref: slate
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