Digital rectal prostate exam a ritual of doctor-patient bonding, for good and bad

The practice, and its awkwardness, will come less often into play as U.S. Preventive Services Task Force guidelines now advise against it for men age 75 and over.

By Anna B. Reisman

November 3, 2008

In August, the U.S. Preventive Services Task Force, a government-sponsored panel of medical experts, issued new recommendations regarding prostate cancer screening: Men ages 75 and over should no longer be screened for prostate cancer with the PSA blood test or digital rectal exam.

An unexpected benefit may be an improvement in the doctor-patient relationship. The rectal exam can be one of the odder moments between a patient and his doctor. Not long ago, for example, I saw a 75-year-old for his routine annual visit. Things were not going well for him.

His wife's dementia was worsening daily. She would leave the stove on, accuse him of stealing her things, holler at him day and night. And yet he could not imagine putting her in a nursing home.

His eyes, usually sparkling with delight, were dull. As I examined his heart and lungs, neck and belly, ankles and feet, he heaved a long sigh. I felt gloomy about his wretched situation.

I must have been preoccupied, because when it was time for the rectal exam, I bumbled my words. I asked him to lower his pants, but instead of saying "Lie on the table," I told him to lie on the floor. The patient and I burst out laughing.

Still chuckling, I stepped out of the room so he could get ready. To be sure, my bumble had brought levity to a traditionally awkward moment -- but why, I asked myself, did this encounter have to end with an examination of his anus?

I was drawn to primary-care medicine by the human connection that comes with the white coat and stethoscope, the prospect of people willing to share their everyday thoughts and deepest secrets, and their expectation that I would use this information to help them.

What I didn't fully grasp was that this intimacy also had a critical physical component -- one that came gloved and lubed.

I'd never imagined that performing rectal exams would become a daily reality. Most of my patients are men over 50, which means that I ask them if they'd like to be screened for prostate cancer.

Some inquire whether the PSA (prostate-specific antigen) blood test alone will suffice. I explain that it's most informative to have both the PSA and the digital exam: Some cancers hide in prostate nodules in men whose PSA readings are normal.

So for men under 75 and over 50 (earlier for higher-risk men) who wish to be screened, just as important as the PSA is the old-fashioned, low-tech way with a pair of rubber gloves, a foil packet of lubricating jelly and an index finger.

For years I didn't feel confident in my ability to do a good rectal exam. In medical school, we spent about two months learning the heart exam, maybe one month on the lungs. The rectal exam was granted a single session.

Not surprising: It's one thing for a parade of students to line up, stethoscopes ready, at the bedside of a chatty patient with a heart murmur; it's quite another to find a patient willing to roll over and endure a series of rectal exams by unskilled, anonymous fingers. The result: a culture of squeamishness.

During residency, I did a lot of rectal exams and tried to get a sense of the prostate's normal size and consistency. But often I wasn't sure of myself. Was a slight asymmetry a normal variant or something worrisome?

I probably sent too many patients to urologists earlier in my career because of my self-doubt, but that was better, I suppose, than missing something.

And although plenty of men will hop onto the exam table without hesitation, there's no shortage of reluctant and nay-saying patients, of awkward silences followed by excuses.

One patient I recall stole a glance at my hands, the muscles in his face relaxing ever-so-slightly when he looked at my fingers. "My old doctor," he said, "had thick fingers, like sausages."

Another said, "My other doctor did one a few months ago, I think." And another, "Next time, I promise." Many opt for the PSA without the rectal exam.

Back in my exam room, the patient lay on the exam table in a fetal position, pants down, buttocks exposed, testicles dangling.

I examined his rectal area for internal hemorrhoids, the subtle edge of an anal fissure, the flat cauliflower of an anal wart, and found none.

I touched the precise spot of the anal skin that elicits the mischievously named "anal wink reflex," a test of nerve function. I dabbed my finger with the jelly and eased it in against the muscular resistance until I touched the prostate.

To feel the whole prostate and distinguish between its two lobes, I bent my knees, turned my arm upside down and swiveled my finger to reach the other side of the gland. It was the size of an apricot, smooth and rubbery.

As usual, I grimaced: The rectum has muscles that clench and unclench at the slightest sensation, and it always feels odd to have my finger locked in that tight embrace. It doesn't get more intimate than this.

Then I closed my eyes and focused on all of the nerve endings packed closely in my fingertip. As my finger swept the prostate gland, I felt its normal consistency, its symmetry and, to my relief, not a single nodule.

It was almost a Zen moment: worlds of otherwise hidden information uncovered through careful probing -- earlier, via conversation; now, via a digit.

I wiped my finger on the stool-sample card and discarded my gloves. The old man looked over his shoulder from the table, the twinkle in his eyes returned. "Does this mean we're friends?"

There's nothing like an awkward joke to defuse an awkward moment. But thanks to the U.S. Preventive Services Task Force, there may now be fewer of both.

My Sentiments Exactly

With a Buzz Cut, I Can Take on Anything

GOT a buzz cut last July, four days before radical open surgery to remove my cancerous prostate. I told family and friends that I did it for reasons of ease and style: I wanted to avoid the heartbreak of hospital hair, that lank and greasy thatch that repels visitors.

But I was lying.

In a time of utter vulnerability — having already weathered three months of post-diagnosis ups-and-downs — I needed the primal ferocity that a buzz cut proclaims. I needed to look like a soccer thug or an extra from “Prison Break” to help get me through surgery, the physical indignities of post-op life, and my subsequent radiation and hormone therapy. I still do. My prostate cancer and its treatment have transformed me — in body and spirit — and the buzz cut has helped me cope with those changes.

I agree with the late Anatole Broyard, who wrote in his memoir “Intoxicated by My Illness,” “It seems to me that every seriously ill person needs to develop a style for his illness.” And the buzz is what I want to wear, what I need to wear, in this wicked waltz with cancer.

I’m an optimist, but not a day goes by in which I don’t wonder whether I’m going to die before I ever imagined. The buzz cut helps me scowl, glower and say “No!” to that thought.

Broyard, a New York Times literary critic who died of prostate cancer, also wrote, “Only by insisting on your style can you keep from falling out of love with yourself as the illness attempts to diminish or disfigure you.”

In some ways, I’ve already fallen out of love with my old self.

There’s a book-jacket photo taken of me early last year, before I learned that I had cancer, and I can’t stand to look at it. Can’t bear to look at my floppy mop of Glen Campbell hair, the innocent grin. I want to smack that cheery and naïve face and bellow: “Boy, you don’t know nothin’!”

That poor guy, at age 50, doesn’t yet know that he has cancer, that it will prove to be shockingly aggressive and that, among other indignities, his libido will take a sabbatical (on Ibiza, I hope).

For me, the buzz cut is a visible bulwark against the tide of emasculating side effects caused by the treatment for prostate cancer.

Wearing my buzz, hiking boots and a rugby shirt, I don’t feel like prey to the cancer. I can still fix my wife with my blue eyes, drop my voice into a Barry White register, and say, “Hey, baby.”

It was only after the fact that I learned that my hair-shearing reaction to having cancer wasn’t so unusual. I understood that the buzz cut spoke of a new me. It still reminds me that I’ve been tempered in the crucible of cancer, that I have changed.

But it’s also part of a muted tradition that’s consistent with the transformation, transition and trauma that I’ve gone through.

Nuns and monks cut their hair, as do saints and rape victims. Soldiers, prisoners and mental patients have their hair cut for them. And issues of hair and appearance are often uppermost in the minds of cancer patients.

“The challenge with cancer is to find a new sense of self,” said Dr. Robert Klitzman, an associate professor of clinical psychiatry at Columbia University Medical Center, “because the narrative of yourself has been disrupted.”

Dr. Klitzman, who has explored issues of serious illness and appearance in several books, most recently “When Doctors Become Patients,” added, “Often, when a woman wears a scarf instead of a wig, she’s owning her cancer, not resisting it.”

That idea of ownership is crucial. My treatment hasn’t made my hair fall out, but partly I wear the buzz to show solidarity with my sisters-and-brothers-in-disease who have no choice.

And the buzz lets me set the social terms of how I face the disease. I’m not interested in the wan and weepy Romanticism of the 19th century in which the patient stoutly wastes away in a soft bed of pity-whispers.

I’m not interested, either, in keeping stoic secrets, in which cancer becomes the fetus of shame buried in the root cellar, or the insane uncle shut in the attic of fear.

Secrets were an epidemic in my rural New Hampshire family — silences about cancer and alcoholism, about bastards and near-bastards — and those secrets and silences killed people.

The buzz grants me the power to look people in the eye and matter-of-factly say: “I have cancer.” Most people who know me will tell you that my current feral style — looking like some vintage N.F.L. middle linebacker — doesn’t reflect my personality.

I am basically a cream puff. But I like the contradiction, the tension, that the buzz cut seems to represent between my inner and outer lives.

The buzz cut is a kind of veil or, perhaps, a mask hiding my secret identities: one of which is being a cancer patient.

But to be honest, I don’t think I’m hiding anyone. We are, all of us, a bundle of apparent contradictions. Even though I’m a dreamy pragmatist, I need the guy with the glare, the shaved skull and the brutishly broad forehead to help me through the day.

I walk into Balonze Barber Shop in Upper Montclair, N.J., every three weeks and tell the owner, Dennis, that I want the “one-zero” buzz, which is even shorter and tighter than the traditional No.1.

As I settle into the familiar chair, Dennis clicks the blade into place, then flicks on the shears. In a way, that chair and the soothing hum of the clippers are just as important a part of my cancer treatment as the TomoTherapy machine in which I received my seven weeks of radiation.

I revel in the smell of alcohol and shaving cream, shiver at the scritch-scratch-scritch of the straight-edge razor on my neck and sideburns. Dennis is preparing me for the next three weeks, the way James Bond gets prepped for a mission.

Besides the faux surface ferocity, the buzz cut also energizes me, puts an extra bounce in my step. And that metamorphosis also carries me back to childhood, when I’d get my summer “whiffle” cut.

So, too, it’s oddly redolent of the Monkees, neighborhood stickaburr fights and going to the stock car races at Star Speedway in Epping, N.H.

In the Bible, Jacob was renamed Israel after wrestling with an angel of the Lord. And, after wrestling with the dark angel of prostate cancer, I, too, have a new name: Cancer Patient and eventually, I hope, Cancer Survivor.

A new name demands a new look, a new style. In my case, it demands the “one-zero” buzz.

The Impossible Calculus of PSA Testing

New York Times editor Dana Jennings writes every Tuesday about coping with an advanced form of prostate cancer.

By Dana Jennings


Prostate cancer and its treatment breed anger and confusion among the men who have it and those who love them. And in the wake of studies released last week that question the value of screening for prostate cancer, I find myself even angrier and more confused.

I’m angry because the two studies confirm my gut feeling – based on comments to this blog and on the stories of many men I know – that millions of men, especially those in their late 60s and beyond, have received unnecessary prostate cancer treatments that have, at the very least, damaged their bodies and lives, if not outright ruined them.

I’m confused because I’m the statistical exception. I’m the one man in 49 whose life may have been saved because I had the PSA blood test. Most prostate cancers are slow and lazy. But my doctors and I learned after I had my prostate surgically removed last July that my cancer was shockingly aggressive. There’s a good chance that it would’ve killed me if I hadn’t been screened. And, to be blunt, it might yet.

Basically, the two large studies – one American, one European – found that screening tests for PSA, or prostate specific antigen, do a great job of discovering prostate cancer. But that knowledge doesn’t translate into many lives saved, the studies state, and for many men it can lead to needless treatment that diminishes quality of life.

My biggest problem with the studies – and, of course, this is the nature of such studies – is that they reduce me and all my brothers-in-disease to abstractions, to cancer-bearing ciphers. Among those dry words, we are not living, breathing and terrified men, but merely our prostate cancers, whether slow or bold.

The most chilling sentence I’ve read in the past week is this one from The New York Times: “In each study, the two groups were followed for more than a decade while researchers counted deaths from prostate cancers, asking whether screening made a difference.”

The researchers counted “deaths,” not men who had died. As Charlie Brown once said to Lucy as she detailed his baseball team’s shortcomings: “Tell your statistics to shut up.”

My own experience with prostate cancer started pretty typically. My PSA was elevated more than a year ago. That fact led to a biopsy last spring, and on April 7 I learned that I had prostate cancer.

It was determined that my cancer was a probable Stage 1, and that my Gleason score was a 6 or 7 on a scale of 10, with 10 being the worst possible number. It appeared that I had an “ordinary” case of prostate cancer. My doctors recommended surgery. In my case, because of previous operations, I had a radical open prostatectomy.

Now, cancer is a powerful card for any doctor to play. Cancer is a serpent in our bodies that we cannot abide. When most of us learn that we have cancer, we want it out right now. We want it annihilated. And for me, surgery was the right decision, because it was only through the post-op pathology report that we learned that my cancer was an aggressive Stage 3 – a T3B – and that my Gleason was an ominous 9. I was actually that somewhat rare man who could die from prostate cancer, not just with prostate cancer. There are still about 30,000 men who die each year from the disease.

Even so, I will still tell you that I was damaged by the surgery, with impotence and incontinence being the major issues; those were also complicated by my follow-up treatments of radiation and hormone therapy.

And given the findings in these two studies, if my case had been typical, if the cancer had been the slow-growth kind and confined to the prostate, I would feel like an absolute fool for having gone through the physical indignities caused by surgery.

Doctors can tell you and tell you that impotence and incontinence are probable side effects. But until you actually experience them as man trying to regain his life, you have no idea what those multisyllabic curses truly mean.

In our competitive medical marketplace, there is no shortage of surgeons out there who aggressively promote themselves and who do a volume business in prostates. But these two studies indicate that maybe that volume should be reduced.

So, I sit here in limbo. And I wonder whether I’ll be that rare man who ducks death from a cancer that would’ve killed him – because I got screened. But all I can confess to you, in all honesty, is this: I’m still angry and confused.

Spirituality and Health in Hospital: perspectives of patients and visitors

Results of a spirituality and health survey conducted at Prince of Wales Hospital...

Do spirituality and religious beliefs affect health? Over 80% of people surveyed at Sydney's Prince of Wales Hospital think that health is affected by beliefs, and that these beliefs become more important when a person is ill. Whether it is “God's healing”, “inner strength”, “living right” or “a placebo effect”, respondents agreed that spirituality and religion has an impact on the way we view health, illness, loss and recovery.

Preliminary analysis of the hospital-wide survey of 228 patients and their family members, found that religious rituals and/or spiritual practices were observed by nearly 79% of respondents, and 74% felt them to be of moderate or strong importance. Of this group, 68% said they would want to continue them if/when they were in hospital for reasons such as “it's who I am”, “I need spiritual refreshment”, “to help the healing process”, “something familiar in an unfamiliar environment”, and “to help my family cope with my illness”.

Respondents identified different ways in which their beliefs affected their health. Many felt their attitude or emotional state was enhanced, eg “peace of mind”, “giving me hope”, “it brings comfort and strength”, “understanding”, “calming', “it reassures me I am not on my own”. Others described a direct impact on their general health or recovery from illness, eg “as a result of my faith I have remained healthy”, “helps the individual to heal faster”, “I'm getting better – God has answered my prayers”.

Some respondents talked about their beliefs having a preventive affect, eg. “it's protected me not to take alcohol, smoke, etc.”, and “I gave up smoking, drugs, premarital sex and other health hazards”. There was also feedback about the potential for beliefs to have a negative affect on health, eg “all my wrong-doings in life are reflected in my poor health”, “if I felt my illness was divine punishment it might make me worse”.

The survey attempted to disentangle the concepts of religion and spirituality. Patients and visitors were asked to define the concepts, and then state how they see themselves. This enabled respondents to identify their beliefs more flexibly than traditional surveys allow. The findings supported increasing national evidence that Australian society is becoming less religious, but more spiritual. (1) (see Figure 1 below)

Overall, the survey found that 74% of respondents had spiritual or religious beliefs of some kind, a figure that tallies with the 2001 census in which 74% of the population stated they had a religious affiliation (2). However, in the hospital survey, 1/3 of these (24% of all respondents) did not identify as religious, only spiritual. Twenty one percent of respondents selected more than one description from the list of major religions and spiritual beliefs. This supports growing evidence that, for many people, beliefs are not as rigidly defined and neatly categorised as previously thought. (3)

Over 70% of respondents felt it was helpful for hospital staff to know about their religious and/or spiritual beliefs, and said it was alright for staff to ask them. This contradicts the popular idea that patients find it intrusive to be asked about their beliefs (4). Nearly 40% of people who completed the survey said they would like to speak to a chaplain, “it's strengthening to be with people who share your beliefs”; while a further 17% thought they might like to see a chaplain, depending on their situation, “if I feel that I might need support and comfort”.

Diversity Health and the Chaplaincy Department at Prince of Wales are currently using survey data to develop education initiatives and resources designed to support staff in their understanding of, and response to, the diversity of people's religious and spiritual beliefs, practices and wishes.

For more information, contact Julieanne Hilbers, Diversity Health Coordinator, Prince of Wales Hospital, on (02) 9382 3306 or email: julieanne.hilbers@sesiahs.health.nsw.gov.au

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(1) Bouma, G. (2002). Globalization and recent changes in the demography of Australian religious groups:1947 to 2001. People and Places , 10(4), 17-23.

(2) Peach, H. (2003). Religion, spirituality and health: how should Australia's medical professionals respond? Medical Journal of Australia , 178, 86–88.

(3) Tacey, D. (2003). The Spirituality Revolution: the Emergence of Contemporary Spirituality Sydney: HarperCollins

(4) Post, S; Puchalski, C; Larson, D. (2000). Physicians and Patient Spirituality: Professional Boundaries, Competency, and Ethics. Annals of Internal Medicine , 132, 578-583