Prostate Self-Examination; Digital Rectal Exam at Home:
Teaching Men How to Take More Responsibility for Their Own Health
At the outset we should pose the question, “why is the prostate self-exam needed?” Most men are reluctant to see doctors. We know the digital rectal exam (DRE) may be deterring some men from seeking preventive health checkups. The evidence, which is rather conclusive on this point, is that whenever a hospital or clinic offers free prostate cancer screenings that include both the prostate-specific antigen (PSA) blood test and the DRE, the participation rates from members of the surrounding communities is always much lower than if the PSA blood test is offered alone. Then many more men will participate if the PSA alone is offered.
Instead of badgering these men to “man up” and endure a test they find humiliating, we can offer them an alternative. While some are skeptical of the value of the prostate self-exam, the fact remains these skeptics do not have any other alternative to suggest aside from badgering the men to get prostate exams from their doctors.
The prostate self-exam will have greater value and efficacy when men are educated on how to perform these self-exams. Men have to learn how to do prostate exams by watching videos, available on the Internet, in which physicians demonstrate the technique. They also need to view scores of diagrams of the prostate so they will know what to expect when they perform the self-exam.
We already encourage all men, but especially those between the ages of 15 – 35, to perform monthly testicular self-exam. If men can examine their own testicles, then chances are they are mature and capable enough to check their prostates once they learn how and get some experience examining their own prostates.
Men sometimes think a doctor inserts a finger and then directly touches their prostates. That perception is not correct. The finger (or digit) is inserted through the rectum, but the finger is located then within the bowel, which is separate and distinct from the prostate gland. Essentially the doctor, or the patient in the case of the self-exam, is pressing the wall of the bowel down so that he can feel the posterior surface of the prostate gland beneath the wall of the bowel. However, the wall of the bowel effectively buffers the prostate, so any node or suspicious area must be large enough that it can be felt through this buffer. Ideally, the examiner would like to be able to touch the surface of the prostate directly, but he has to do a close substitute of feeling it through the wall of the bowel.
Issues to Remember
A normal prostate is the size of a walnut. Prostates can enlarge to the size of a lemon. Possible causes for enlarged prostate include Benign Prostatic Hyperplasia, or hormonal imbalance (too much estradiol or dihydrotestosterone), or prostatitis. As men age they enter a period that we call Andropause; it is analogous to menopause in women. During Andropause, which normally lasts through the end of the man’s life, the body produces too little testosterone, which results in an imbalance between testosterone and estrogen.
Estrogen levels in men are measured through the serum estradiol level. Both estradiol and dihydrotestosterone, the powerful form of testosterone, can irritate and cause the enlargement of the prostate. Elevated estradiol levels have been shown in clinical studies to cause prostate cancer; whereas dihydrotestosterone is known to accelerate the growth of prostate cancer but does not appear to cause cancer itself. A third explanation for why a prostate might be enlarged is if the patient has prostatitis.
The prostate feels similar to the pulp of an orange sliced in half. If you feel anything hard like the seed of an orange against the softer pulp, that would be a suspicious area for prostate cancer.
Important Points to Remember
For the prostate self-exam, the finger must be inserted into rectum with palm of the hand down and fingernail on the index finger on top. It will feel much more natural, especially the first time you try this, to insert finger with palm up and nail down. If you were to clean yourself with a bar of soap, you would naturally hold the soap with the palm of the hand facing up and the fingernails pointing down. But you will need to learn to pivot your hand and cause the palm of the hand to face downward and the finger nail up, so that you can feel the prostate using the pad on your finger and not the fingernail. It will feel awkward at least the first five times you attempt to insert your finger in the correct position.
The prostate is not shaped round like a walnut, but instead presents more as the top portion of a heart-shaped object. Most men will find they have a left lobe, a median lobe over which the ureathra passes and effectively bisects the prostate, and a right lobe. With a little bit of practice, you will be able to know which lobe you are touching and any minor differences between the lobes.
When you perform the prostate self-exam at home, you will need to tilt forward so that the prostate will jut outward and can be felt more easily. If you stand up straight, your prostate will point down (in the direction of your legs) and it will be more difficult to feel with the digital rectal exam.
Give yourself a more thorough prostate exam than you are likely to obtain from a family practitioner. Go over every available surface of the prostate at least three times and using different circular motions each time. In the privacy of your own home, take at least one full minute and preferably two minutes to examine your prostate. Your goal is to be able to detect any cancer node (hard surface) the size of a grain of rice. You won’t be able to feel a suspicious node to that degree of detail with a quick wave of the finger one time over the prostate.
So when you visit the family doctor’s office, and the doctor inserts a finger and moves it quickly over the prostate, with the whole check taking three or four seconds, that is not a detail prostate check. Something that cursory could not detect cancer the size of a grain of rice. And that is your goal; your goal is always early detection while any prostate cancer is still small.
Do not attempt prostate self-exams if you are unwilling to take the time to learn how to check the prostate by reviewing clinical practice guidelines available on the Internet. Your health is at risk; trust yourself only if you possess the intellectual capacity to distinguish between normal and abnormal surfaces on soft tissue such as the prostate. If you do not feel you are going to be able to distinguish between normal and abnormal surfaces, then you should not attempt to do this check on yourself.
Benefits of Prostate Self-Exam
The patient is able to check the prostate more regularly than just once per year (earlier detection leads to earlier diagnosis and earlier treatment). You can check your prostate quarterly or whatever frequency you prefer given the state of your prostate, but you do not have to limit yourself to an annual check.
Second, men who educate themselves to learn how to do prostate self-exams can avoid the awkwardness and embarrassment men frequently associate with the digital rectal exam. Third, men can visit the doctor more regularly without concern that they will be asked to submit to a DRE or prostate check on each visit.
The interested reader should view the instructional video associated with this article. The video is found at http://www.michaelguth.com/?p=1155
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