Do They Put A Camera In Your Butt To Check The Prostate
Tin can J Gastroenterol. 2009 Jan; 23(1): 37–40.
Linguistic communication: English | French
Exercise patients undergo prostate examination while having a colonoscopy?
Tess Hammett
aneQueen's University School of Medicine, Kingston, Ontario
Lawrence C Hookey
iiGastrointestinal Diseases Inquiry Unit, Queen'southward University, Kingston, Ontario
Jun Kawakami
iiiDepartment of Urology, Queen'due south University, Kingston, Ontario
Received 2008 Mar ii; Accepted 2008 Sep xix.
Abstract
OBJECTIVES:
To determine the charge per unit at which physicians report performing a digital rectal examination and annotate on the prostate gland earlier performing colonoscopy in men 50 to 70 years of age.
METHODS:
A retrospective chart review of all men l to seventy years of age who had a colonoscopy in Kingston, Ontario, in 2005 was completed. It was noted whether each physician described performing a digital rectal examination before the colonoscopy, and if so, whether he or she commented on the prostate.
RESULTS:
In 2005, 846 eligible colonoscopies were performed by 17 physicians in Kingston, Ontario. In 29.2% of cases, the physician fabricated no comment about having performed a digital rectal exam; in 55.eight% of cases, the physician commented on having completed a digital rectal test but said zero about the prostate; and in 15.0% of cases, the medico made a comment regarding the prostate. No doctor consistently commented on the prostate for all patients, and in no circumstances was direct referral to another md or follow-upwardly suggested.
Give-and-take:
A colonoscopy presents an platonic opportunity for physicians to employ a digital rectal examination to assess for prostate cancer. Physicians performing colonoscopies in men 50 to seventy years of age should pay special attention to the prostate while performing a digital rectal examination before colonoscopy. This novel concept may help maximize resources for cancer screening and could potentially increase the detection charge per unit of clinically palpable prostate cancer.
Keywords: Colonoscopy, Digital rectal exam, Prostate cancer, Screening
Résumé
OBJECTIF :
Déterminer dans quelle proportion les médecins disent procéder à un toucher rectal et formuler des commentaires sur la prostate de leurs patients de sexe masculin âgés de l à 70 ans chez qu'ils south'apprêtent à effectuer une coloscopie.
MÉTHODE :
Les auteurs ont analysé rétrospectivement les dossiers de tous les hommes de 50 à 70 ans qui ont subi une coloscopie à Kingston, en Ontario, en 2005. Ils ont vérifié si les médecins avaient mentionné avoir fait united nations toucher rectal avant la coloscopie et, le cas échéant, south'ils avaient formulé des commentaires sur l'état de la glande.
RÉSULTATS :
En 2005, 846 coloscopies jugées admissibles aux fins de la présente étude ont été effectuées par 17 médecins de Kingston, en Ontario. Dans 29,2 % des cas, le médecin n'a pas fait mention d'united nations toucher rectal. Dans 55,viii % des cas, le médecin a signalé avoir fait un toucher rectal, mais sans fournir de renseignements sur l'état de la prostate et dans 15,0 % des cas, le médecin a commenté 50'état de la prostate. Aucun des médecins n'a systématiquement commenté l'état de la prostate chez tous ses patients et aucun northward'a mentionné avoir orienté un patient vers un collègue en vue d'une consultation directe ou d'un suivi.
DISCUSSION :
La coloscopie est 50'occasion idéale d'effectuer un toucher rectal dans le but de dépister le cancer de la prostate. Les médecins qui effectuent des coloscopies chez des hommes de fifty à 70 ans devraient porter une attention spéciale à la prostate lorsqu'ils procèdent au toucher rectal avant la coloscopie. Cette nouvelle mesure permettrait une utilisation plus judicieuse des ressources en matière de dépistage du cancer et augmenterait potentiellement le taux de dépistage des cancers de la prostate palpables.
Prostate cancer remains the leading form of cancer diagnosed in Canadian men, bookkeeping for roughly 27% of all cancers occuring in men and is responsible for the death of over 4000 men annually (1). More thirteen% of Canadian men will develop prostate cancer in their lifetime and approximately 4% volition die from the illness (one). The burden of prostate cancer on social club is considerable; therefore, any measures to reduce mortality are worth considering, especially those that are cost constructive, piece of cake to implement and socially and professionally adequate.
Although information technology may seem intuitive that screening for prostate cancer would have value to patients and the wellness intendance system, this thing is anything but straightforward. There are currently no clear and consistent guidelines as to if and how prostate cancer screening should be performed. Withal, the present consensus is that if screening is accounted appropriate for a given private, both a prostate-specific antigen (PSA) test and a digital rectal examination (DRE) should be performed to all-time find the presence of cancer (ii–5). Many Canadian men older than fifty years of historic period are choosing to be screened for prostate cancer, and based on their age, life expectancy, personal behavior about cancer screening and by experience with cancer, these same men are probably more likely to also choose screening for colorectal cancer. Colorectal cancer is the third most common cancer diagnosed in Canadians and is the 2d near mutual cancer-related crusade of death in men (6). Similar to prostate cancer, approximately xc% of colorectal cancers diagnosed in 2006 were in individuals 50 years of age and older (6).
Colonoscopy is an important and frequently used screening tool in the diagnosis of colorectal cancer. A colonoscopy is often preceded past a DRE to detect masses in the anal canal and lower rectum. This presents an opportunity to complete the more invasive portion of screening for prostate cancer, which has lower patient credence than the PSA blood test (7). However, it is unclear how many physicians are commenting on the prostate during the pre-endoscopy DRE, and whether those physicians who practise comment on the prostate practise so consistently with every patient they examine. Because there are no published guidelines that recommend that physicians performing colonoscopies pay particular attention to the prostate during the DRE, the present study was aimed at determining the proportion of physicians who practice annotate on the prostate while performing a pre-endoscopy DRE.
METHODS
The nowadays retrospective chart review investigated all men fifty to 70 years of age who had a colonoscopy performed in Kingston, Ontario, in 2005. This historic period group was chosen based on the United States Preventive Job Strength'due south recommendations considering these men stand for the population for which prostate cancer screening is nigh relevant. Over 98% of all prostate cancers occur in men 50 years of historic period or older. Patients who, either based on age or significant medical problems, have a life expectancy of less than 10 years, are unlikely to benefit from screening based on the more often than not lengthy natural history of the affliction (eight).
Patients were identified past a review of the endoscopy database at the endoscopy unit of Hotel Dieu Hospital, Kingston, Ontario. All outpatient colonoscopies performed in Kingston are performed through this unit. Each colonoscopy performed was noted, regardless of whether it was the only procedure or one of several procedures a given patient had undergone in 2005. Procedures in which a DRE was clearly non indicated – for example, in which the scope was inserted into the patient'due south colostomy – were excluded from the study. For each procedure, the patient's demographics were recorded, forth with the date, the doctor, the indication(south) and the result(s). Most important, it was noted whether the physician described performing a DRE before the colonoscopy, and if and then, whether he or she commented on the prostate. If the doc noted any concerns, it was recorded whether any remark was made regarding recommended follow-up or referral to another physician.
Before conducting the present written report, ethics approval was obtained from the Enquiry Ethics Board of Queen'south University, Kingston, Ontario.
Statistics
Descriptive statistics were used, including mean, median, SD and range, depending on the data distribution. For the statistical analysis, the SPSS fourteen.0 (SPSS Inc, USA) package was used.
RESULTS
In 2005, 846 eligible colonoscopies were performed in Kingston, Ontario. The hateful (± SD) historic period of patients on the date of their procedure was 59.7±5.8 years (range 50 to 70 years). Seventeen different physicians performed the procedures, ix were gastroenterologists and eight were general surgeons; 58.ii% of endoscopies were performed by gastroenterologists and 41.8% past general surgeons.
The 3 main reasons why patients had colonoscopies were for colorectal cancer screening, with or without a family history of the disease (32.0%); for a alter in bowel habits such every bit rectal bleeding, diarrhea or abdominal pain (29.4%); and for colorectal cancer surveillance (25.1%). Together, these fabricated upwardly 86.v% of cases. In 37.8% of cases the bowel was establish to be normal and in 42.0% of cases, polyps, either adenomatous or hyperplastic, were establish. Colonic malignancy was detected in three.1% of cases.
The dr. did not report performing a DRE in 247 cases (29.2%), did report performing a DRE only said zero about the prostate in 472 cases (55.8%), and made a comment regarding the prostate during a DRE in 127 cases (15.0%) (Figure 1). Of the 127 procedures in which a DRE (including a prostate examination) was reported, the physician noted that the prostate was normal or benign in 82 cases (64.half-dozen%) and the medico noted mild to moderate enlargement of the prostate, with or without induration, simply without nodules in 37 cases (29.1%). The other cases in which a DRE with prostate examination was performed are described in Tabular array one. In no cases were direct referrals fabricated or follow-upward suggested.
Percentage of cases in which the doc reported performing a digital rectal exam (DRE) earlier colonoscopy (70.8%) and in which the physician commented on the prostate while performing a DRE (15.0%)
Tabular array 1
Nature of comments made past physicians on the prostate during a digital rectal examination before colonoscopy (north=127)
| Annotate | n (%) |
|---|---|
| Prostate was normal or benign | 82 (64.6) |
| Prostate was mildly or moderately enlarged, with or without induration, but without nodules | 37 (29.1) |
| Prostate could not be found considering patient had previously had prostate cancer treated with a prostatectomy | 3 (2.iv) |
| Prostate was nodular; however, patient said it was being followed past his family medico or urologist | 2 (1.6) |
| Prostate could not exist observed due to the patient's large size | 1 (0.8) |
| Prostate was significantly enlarged; clear documentation of this was made in the procedure note | i (0.8) |
| Prostate was enlarged and nodular; no reference to this being of concern | 1 (0.8) |
Of the 17 physicians who performed the colonoscopies, 1 did not report a DRE and two rarely reported a DRE; five physicians never commented on the prostate while performing a DRE and only two commented on the prostate in the majority of their cases (Table two). The rates of annotate on the prostate during DRE varied considerably amid physicians from 0% to 59.3% of cases. On boilerplate, gastroenterologists reported a DRE before a colonoscopy more oft than did general surgeons (78.6% of cases compared with 66.7% of cases, respectively); however, general surgeons were more than than twice every bit likely as gastroenterologists to comment on the prostate while performing a DRE (32.2% of cases in which a DRE was performed compared with 14.0% of cases, respectively). Overall, general surgeons were approximately twice equally likely as gastroenterologists to written report both a DRE and comment on the prostate (21.5% of cases compared with x.4% of cases, respectively).
TABLE 2
Frequency at which physicians reported a digital rectal examination (DRE) before colonoscopy, and frequency at which a comment was made regarding the prostate during the DRE
| Doc performing colonoscopy | Procedures in which a DRE was reported, n (%) | Procedures performed in which a DRE was reported and in which a annotate regarding the prostate was fabricated, n (%) | Total procedures performed, n |
|---|---|---|---|
| ane. Gastroenterologist | 65 (100.0) | 32 (49.2) | 65 |
| two. Gastroenterologist | xl (100.0) | 3 (vii.5) | xl |
| 3. Gastroenterologist | 63 (96.9) | 0 (0.0) | 65 |
| 4. General surgeon | 82 (96.v) | 47 (57.3) | 85 |
| 5. Full general surgeon | 27 (93.1) | xvi (59.3) | 29 |
| vi. General surgeon | 94 (93.1) | 8 (8.v) | 101 |
| 7. Gastroenterologist | 23 (92.0) | 0 (0.0) | 25 |
| eight. Gastroenterologist | 75 (xc.4) | 6 (eight.0) | 83 |
| 9. Full general surgeon | 25 (86.2) | three (12.0) | 29 |
| ten. General surgeon | six (85.vii) | ii (33.3) | 7 |
| xi. Gastroenterologist | 13 (81.iii) | 0 (0.0) | 16 |
| 12. Gastroenterologist | 37 (66.i) | vii (xviii.9) | 56 |
| thirteen. Gastroenterologist | 24 (50.0) | two (8.3) | 48 |
| 14. Full general surgeon | 1 (33.3) | 0 (0.0) | 3 |
| 15. Gastroenterologist | 23 (24.5) | ane (4.3) | 94 |
| 16. Full general surgeon | 1 (1.0) | 0 (0.0) | 99 |
| 17. Full general surgeon | 0 (0.0) | 0 (NA) | 1 |
| Total | 599 (70.viii) | 127 (21.2) | 846 |
DISCUSSION
The primary issue of the nowadays retrospective nautical chart review was that 70.8% of physicians who performed a colonoscopy reported a DRE before the process; however, just xv% commented on the prostate. No dr. commented consistently on all patients, and full general surgeons were more likely to report a DRE and comment on the prostate than gastroenterologists. Approximately ane-third of physicians who reported a DRE and commented on the prostate noted that the gland was mildly to moderately enlarged, with or without induration, but none of these physicians made any note virtually recommended follow-up or referral.
Before making whatever recommendations based on our findings, one must consider the current thinking regarding prostate cancer screening. The extent of the benefit of screening for prostate cancer has non yet been established. The uncertainty hinges on the fact that screening for prostate cancer has non still been directly linked to reduced mortality rates and increased quality of life, although certain trends bespeak to the fact that it will. Well-nigh notably, over the by 15 years, reduced incidence rates for prostate cancer with distant metastases at the time of diagnosis and reduced prostate cancer mortality rates have been noted (9). Recently, a large-scale, 12-year study has shown a reduced take chances of mortality associated with active treatment of low- to intermediate-risk prostate cancer in men 65 to eighty years of age compared with observation lone (10). It appears that this debate will proceed for some fourth dimension as we anticipate the results of two large randomized clinical trials (11,12) that are currently testing prostate cancer screening in an attempt to obtain definitive evidence that screening reduces prostate cancer mortality rates.
The office of the DRE in prostate cancer screening is likewise a contentious effect. Although PSA testing has been shown to be a more sensitive and specific screening method for prostate cancer (a sensitivity of 72.1% and specificity of 93.2% [using a minimum PSA of four.0 ng/mL] compared with a sensitivity of 53.2% and specificity of 83.6% with the DRE), the DRE has been shown to find cancer in some men with PSA levels beneath 4.0 ng/mL (xiii,14). Furthermore, dual modality screening has been shown to detect 83.four% of cancers in an early, localized state (xiii). The effectiveness of the DRE is also believed to be skill-related in that urologists seem to accept amend accuracy than other physicians. Moreover, when a patient has repeat examinations, the DRE has been shown to be more than sensitive (15). These latter points suggest that there is potential to increase the sensitivity and specificity of the DRE. General surgeons and gastroenterologists perform high volumes of DREs, and thus, could be an ideal subset of physicians who can monitor abnormalities of the prostate. Patients with an aberrant DRE who are diagnosed with prostate cancer are defined every bit having higher local disease staging than those detected with PSA screening alone; and local disease staging is an independent predictor of disease recurrence (xvi). It is also known that elevation of PSA levels precedes clinically detectable affliction by a number of years. Consequently, those patients with clinically palpable disease are at higher risk of suffering morbidity from prostate cancer and therefore more likely deserve case detection efforts (17).
Despite reservations, many Canadian men are choosing to exist screened for prostate cancer, and considering of their shared demographics, there is likely much overlap between these men and those requesting screening for colorectal cancer. It therefore appears logical to investigate means to combine the screening for these two malignancies. Furthermore, some studies (18) have even shown an increased incidence of prostate malignancies in patients with colorectal cancer, and vice versa. Information technology is believed that the biological association betwixt colorectal cancer and prostate cancer may be based on shared genetic or environmental adventure factors, or a combination of the two. Genetic and epidemiological studies (ie, of families with hereditary nonpolyposis colorectal cancer and of children of men diagnosed with prostate cancer before 70 years of historic period) point to a genetic footing. Ecology factors, such as a loftier fatty diet, a high body mass index and booze consumption, take besides been linked to an increased risk for developing both malignancies (18).
CONCLUSION
Although the present study demonstrated that not all physicians reported a DRE earlier colonoscopy, the majority did. Therefore, it seems reasonable to train physicians to pay more attending to the prostate during DREs and to ensure comments are made on any irregularities noted. Endoscopy-coupled screening for prostate cancer with DREs could complement a PSA test performed past a patient's family physician on another occasion. Interestingly, it has been observed that in sure patients, colonoscopy tin can increase serum levels of PSA every bit well as the PSA ratio, near significantly inside the first 24 h afterward the procedure, but even inside the week that follows (19). Therefore, to avert falsely elevated PSA levels and PSA ratio, it is appropriate to perform PSA testing before a colonoscopy or some fourth dimension afterward the procedure, especially in those patients with a history of borderline PSA levels. Based on the results of the present written report, it is recommended that physicians performing a colonoscopy in men fifty to 70 years of age, pay special attention to the prostate while performing a DRE before the endoscopy.
Acknowledgments
Student inquiry grant awarded to Tess Hammett by the Mach-Gaensslen Foundation of Canada. Thank you to the Mach-Gaensslen Foundation of Canada for providing funding for this projection.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2695146/
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