In the Era of mpMRI and PSMA PET/CT: Does Digital Rectal Examination Still Matter?

[BACKGROUND] With the increasing integration of multiparametric MRI (mpMRI) and 68Ga-PSMA PET/CT into the diagnostic and staging algorithms of prostate cancer (PCa), digital rectal examination (DRE)-a once foundational and cost-effective physical examination-has gradually become marginalized in daily clinical practice. However, the continued relevance of DRE in the modern imaging era remains uncertain. This study aimed to reassess the diagnostic value of DRE in the context of contemporary imaging tools, particularly mpMRI and PSMA PET/CT.

[METHODS] This retrospective analysis included 164 patients diagnosed with prostate adenocarcinoma via transrectal ultrasound-guided biopsy. All patients underwent DRE before biopsy, and 151 received mpMRI while 62 underwent PSMA PET/CT. mpMRI findings were reported using PI-RADS v2.1, and SUVmax values were recorded from PET/CT reports. Radical prostatectomy was performed in 156 patients. The relationship between DRE findings and imaging parameters, biopsy results, and pathological staging was analyzed using multivariate statistics and ROC curve analyses.

[RESULTS] DRE findings were benign in 100 patients and suspicious for malignancy in 64. Suspicious DRE was significantly associated with higher PI-RADS scores, greater lesion size, elevated SUVmax, and clinically significant PCa (p  <  0.001 for all). Each one-point increase in PI-RADS was associated with a twofold rise in the likelihood of a positive DRE. ROC analyses identified a 13.5 mm lesion size and an SUVmax of 15.1 as predictive thresholds for DRE positivity. Suspicious DRE also correlated with advanced pathological stage (≥ pT3) (p < 0.001).

[CONCLUSION] Despite the rise of advanced imaging techniques, DRE remains a valuable adjunctive tool in identifying high-risk and advanced PCa. When interpreted alongside mpMRI and PSMA PET/CT findings, DRE provides additional clinical insight, supporting its continued role in risk stratification rather than screening in the modern diagnostic workflow.