Hardness in Digital Rectal Exam: Prostate Health Insights

Hardness on digital rectal examination?

Hello Doctor: My father is 56 years old.
Last November, he experienced fever and frequent urination.
Initially, he visited a clinic, where the physician performed a digital rectal exam and noted abnormalities, prompting a referral to the hospital.
His PSA level was 7.8, leading to a transrectal ultrasound biopsy (TRUS biopsy) with 19 cores taken.
On January 12, 2016, his PSA was rechecked at 5.6, and the biopsy results indicated benign prostatic hyperplasia (BPH) with the following findings: 1.
Prostate, right lateral, needle biopsy, benign prostate tissue with granulomatous inflammation.
2.
Prostate, right medial, needle biopsy, granulomatous inflammation.
3.
Prostate, left medial, needle biopsy, benign prostate tissue.
4.
Prostate, left lateral, needle biopsy, benign prostate tissue.
However, because the physician noted that my father's prostate felt hard (palpable nodule over the left lobe close to the apex), he expressed concern and recommended another blood test in two months to determine whether an MRI should be performed.
In late February, my father underwent a full-body health check, and his PSA was 4.3.
Today, on March 17, my father returned for a follow-up, and his PSA was 6.2.
The physician believes my father's levels are still high and that the digital rectal exam felt quite firm, so an MRI is scheduled for April.
My father wakes up once at night to urinate, but he reports no discomfort during urination.
Therefore, I would like to ask the doctor: does a firmer feel during a digital rectal exam necessarily indicate cancer? The physician also mentioned that calcification could be a possibility, so I would like to understand why calcification occurs (is it due to pathological changes?).
Thank you for your assistance!

Venassa, 20~29 year old female. Ask Date: 2016/03/17

Dr. Liu Jiaju reply Urology

Since prostate biopsy is a sampling examination, a normal result may indicate that there is truly no issue, but it could also mean that the tumor is too small to be detected in the sample.
If the PSA levels continue to rise after the biopsy, it is advisable to perform another biopsy for confirmation.

Reply Date: 2016/03/17

More Info

Understanding the implications of hardness detected during a digital rectal exam (DRE) is crucial for assessing prostate health, especially in the context of your father's recent medical history. The DRE is a common procedure used by healthcare providers to evaluate the prostate gland for abnormalities, including enlargement, tenderness, or hardness, which may indicate various conditions, including benign prostatic hyperplasia (BPH) or prostate cancer.

In your father's case, the findings of a hard nodule on the left lobe of the prostate during the DRE, combined with fluctuating PSA levels, raise important considerations. While a hard nodule can be a sign of prostate cancer, it is not definitive on its own. Conditions such as BPH, prostatitis (inflammation of the prostate), or even calcifications can also lead to hardness. The presence of granulomatous inflammation in the biopsy results suggests that there may be an inflammatory process at play, which could contribute to the hardness felt during the exam.

Prostate calcification can occur for several reasons. It may be a result of chronic inflammation, previous infections, or even age-related changes in the prostate tissue. Calcifications can sometimes be benign and not indicative of cancer. However, they can also be associated with underlying pathology, including chronic prostatitis or prior trauma to the prostate. The formation of calcifications is a complex process that can involve the deposition of calcium salts in the prostate tissue, often as a response to inflammation or tissue damage.

Regarding the PSA levels, it's important to note that while elevated PSA can be associated with prostate cancer, it is not exclusively indicative of malignancy. Various factors can influence PSA levels, including age, prostate size, recent sexual activity, and certain medical procedures. The fluctuations in your father's PSA levels—from 7.8 to 5.6 and then to 6.2—suggest that further monitoring is warranted. The decision to perform an MRI is a prudent step, as it can provide more detailed imaging of the prostate and help identify any suspicious areas that may require further investigation.

In summary, while hardness detected during a DRE can be concerning, it does not automatically indicate prostate cancer. The context of the findings, including PSA levels and biopsy results, is essential for a comprehensive assessment. It is crucial for your father to continue working closely with his healthcare provider to monitor his prostate health, undergo the recommended MRI, and discuss any further diagnostic options that may be necessary based on the results. Regular follow-ups and open communication with his physician will be key in managing his prostate health effectively.

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