Differentials
| Presenting Feature | What might it be? | What might I find? | |
|
Enlarged Prostate |
Benign prostatic hyperplasia (BPH) |
RF: older age >50 years old, family hx, diabetes, alcohol, high caffeine intake.
Nocturia, frequency, hesitancy, weak flow, terminal dribble, incomplete voiding. Examination: smooth, symmetrical, enlarged prostate, loss of central sulcus. |
|
|
Irregular Prostate |
Prostate cancer |
RF: older age, family hx, black African or Caribbean, anabolic steroid.
May be asymptomatic. May present with LUTS similar to BPH, haematuria, erectile dysfunction, weight loss, bone pain, night sweats. Examination: hard, irregular, asymmetrical prostate. |
|
|
Tender Prostate |
Prostatitis |
RF: older age, STI, UTI, urinary catheters, prostate intervention e.g., biopsy.
Chronic prostatitis – dysuria, hesitancy, frequency, pelvic pain, sexual dysfunction, painful bowel movements. Symptoms > 3 months. Acute bacterial prostatitis – as above, acute, systemic symptoms e.g., fever. Examination: tender, boggy, swollen prostate, perineal discomfort. |
|
|
Prostate abscess |
RF: diabetes, immunosuppression, untreated/under-treated prostatitis.
Culprit organisms: e.coli, staphylococcus. Similar clinical presentation to acute prostatitis. Examination: similar to prostatitis, fluctuant area of abscess may be palpable. |
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Checklist
| Preparation | Wash – Name – Explain | |
| Chaperone | ||
| Position patient lying on left side with knees drawn up | ||
| Ask patient to cover with sheet | ||
| Digital Rectal Examination | Expose perianal area | |
| Put on gloves | ||
| Lubricate finger | ||
| Part buttocks | ||
| Insert finger into rectum | ||
| Locate prostate on anterior rectal wall | ||
| Size | ||
| Sulcus | ||
| Consistency | ||
| Tenderness | ||
| Finishing | Withdraw finger | |
| Wipe away excess lubricant from patient | ||
| Re-cover patient | ||
| Wash hands |
Explanation
Preparation
“I have been asked to carry out an examination of your prostate gland. This involves feeling the prostate through the rectum with my finger. You will feel some pressure and cold jelly, but it should not be painful. You can ask me to stop at any time. There will be a chaperone present whilst I carry out this examination. Are you happy for me to do that?”
Ask the patient to undress from the waist down and position them lying on the examination couch on their left side, with their knees drawn up to the chest.
Cover the patient with a blanket until you are ready to start the examination.
Digital Rectal Examination
Put on gloves for the examination. Expose the patient and check that they are comfortable.
Apply lubricating jelly to the index finger of the dominant hand. Part the buttocks.
Ensure the patient is ready and position your finger at the posterior aspect of the patient’s anus. Insert your finger into the rectum.
Locate the prostate gland on the anterior rectal wall and evaluate the following:
- Size – the normal prostate is approximately the size of a walnut.
- Central sulcus – the groove that sits between the two prostate lobes; this may be lost if the prostate is enlarged.
- Consistency
- Tenderness (e.g., prostatitis, prostate abscess)
Normal prostate consistency is smooth, firm, rubbery, and symmetrical. An irregular, hard, or nodular prostate should raise concern for prostate cancer, whereas a boggy, swollen prostate may indicate prostatitis.
Withdraw your finger and wipe away any excess lubricating jelly with tissue paper.
Finishing
Thank the patient and allow them to cover themselves. Wash your hands.
Depending on the examination findings, you may wish to carry out further investigations, including blood tests (e.g., prostate-specific antigen), urine dipstick, screening for sexually transmitted infections, or referral for specialist management (e.g., urology).
Last updated Aug 2025
Head to members.zerotofinals.com for practice OSCE stations, including an interactive checklist, specific cases and clinical findings.
