Teaching medical students digital rectal examination: a randomized study of simulated model vs rectal examination volunteers.

OBJECTIVES: To determine if using a digital rectal examination (DRE) human volunteer improves medical students' confidence in performing DRE in comparison to using a simulated model alone. PARTICIPANTS AND METHODS: Medical students underwent randomization into one of two groups: a control group who underwent standard teaching and an intervention group who underwent standard teaching plus further tuition involving a DRE volunteer. Standard teaching involved a 30-min lecture and a practice DRE on a simulation model. The intervention group additionally observed a tutor demonstrating DRE on a volunteer, then conducted a DRE themselves under supervision. Before and after teaching, both groups completed a survey comprised of three questions. The primary endpoint was confidence in performing a DRE, which was assessed according to the sum of the scores from the three questions. RESULTS: In total, 48 students were randomized, 22 to the control group and 26 to the intervention group. The groups were well matched prior to teaching DRE (P = 0.76) After the DRE tutorial, students in the intervention group were more confident in knowing the indications for DRE (P = 0.001), more confident in their technique for performing DRE (P < 0.001) and more confident in their ability to assess findings accurately at DRE (P < 0.001). The primary outcome measure, overall confidence (sum of the scores from all three questions) in performing DRE, was significantly better in the intervention group (score 10/15 vs 14/15; P < 0.001). CONCLUSION: This study showed that teaching DRE with the assistance of volunteer patients improves inexperienced students' confidence in performing DRE, and the incorporation of such training should be considered in the DRE education programme.

Impact of multiparametric magnetic resonance imaging on risk group assessment of patients with prostate cancer addressed to external beam radiation therapy.

PURPOSE: To investigate the impact of multiparametric magnetic resonance imaging (mpMRI) on risk group assessment of patients with prostate cancer (PCa) initially addressed to external beam radiation therapy (EBRT). MATERIALS AND METHODS: We prospectively performed mpMRI (3.0Tsystem) in 44 patients addressed to EBRT, using a multiparametric protocol (high-resolution multiplanar T2-weighted, diffusion-weighted and dynamic contrast-enhanced imaging). Risk group was assessed in accordance with the National comprehensive cancer network (NCCN) categories, by combining prostate-specific-antigen level, Gleason score and the T-stage as established by digital rectal examination (clinical risk assessment; c-RA) versus mpMRI (mpMRI-risk assessment; mpMRI-RA). The agreement between c-RA and mpMRI-RA was investigated using Cohen's kappa. RESULTS: Patients were included in very low/low risk, intermediate risk, high risk, very high risk and metastatic NCCN categories in 10 (22.7%), 18 (40.9%), 15 (34.1%), 1 (2.3%) and 0 cases using c-RA vs. 8 (18.2%), 14 (31.8%), 14 (31.8%), 4 (9.1%) and 4 (9.1%) cases using mpMRI-RA, respectively, with only moderate agreement (k=0.43). mpMRI-RA determined risk downgrading in 2/44 patients (4.5%), and risk upgrading in 16/44 patients (36.3%). After mpMRI, EBRT remained indicated in all patients. CONCLUSION: mpMRI changed clinical risk stratification in about 41% of patients with PCa, with potential impact on EBRT planning.

Careful assessment key in managing prostatitis.

Prostatitis is a common condition estimated to affect up to 30% of men in their lifetime, it is most prevalent in men aged between 35 and 50. Prostatitis is subclassified into: acute bacterial prostatitis, chronic bacterial prostatitis, chronic pelvic pain and asymptomatic inflammatory prostatitis. Acute bacterial prostatitis presents with acute onset pelvic pain which may or may not be related to voiding, lower urinary tract symptoms, sometimes haematuria or haematospermia and systemic symptoms such as fever and rigors. A documented history of recurrent urinary tract infections is the key feature of chronic bacterial prostatitis. Duration of symptoms > 3 months defines chronicity. The key symptom of chronic pelvic pain syndrome is pain. Patients may describe pain during or after ejaculation as their predominant symptom. Clinical assessment includes a thorough history and examination. A digital rectal examination should be performed after a midstream urine (MSU) sample has been collected for urine dipstick, microscopy and culture. The prostate should be checked for nodules. In acute bacterial prostatitis the MSU is the only laboratory investigation required. Chronic pelvic pain syndrome may be multifactorial and part of a more generalised pain disorder. Pelvic floor muscle abnormalities, altered neuroendocrine pathways, chemically induced inflammation, bacterial infection, autoimmune processes, dysfunctional voiding as well intraprostatic ductal reflux mechanisms have all been identified in men with chronic pelvic pain syndrome.

Advances in diagnostic assessment of fecal incontinence and dyssynergic defecation.

Disorders of the anorectum and pelvic floor affect approximately 25% of the population. Their evaluation and treatment have been hindered by a lack of understanding of underlying mechanism(s) and a working knowledge of the diagnostic advances in this field. A meticulous evaluation of anorectal structure and its function can provide invaluable insights to the practicing gastroenterologist regarding the pathogenic mechanism(s) of these disorders. Also, significant new knowledge has emerged over the past decade that includes the development of newer diagnostic tools such as high-resolution manometry and magnetic resonance defecography as well as a better delineation of the clinical and pathophysiologic subtypes of constipation and incontinence. This article provides an up-to-date review on the role of diagnostic tests in the evaluation of fecal incontinence and constipation with dyssynergic defecation.

The quantification of levator muscle resting tone by digital assessment.

The biomechanical properties of the puborectalis muscle are likely to be important for pelvic organ support. However, neither elasticity nor its clinical correlate, muscle resting tone, have received much attention to date. We therefore conducted a prospective study to test a newly developed resting tone scale for validity and reproducibility. Ninety-eight patients underwent a physical examination including prolapse staging and palpation of the levator ani. They were also assessed by 4D translabial ultrasound for levator hiatal dimensions and prolapse assessment. Resting tone was negatively associated with anterior and posterior compartment prolapse. An independent test-retest series yielded a weighted kappa of 0.55 (CI 0.44-0.66), implying "moderate" repeatability. Resting tone of the puborectalis muscle can be determined by digital palpation. It is moderately repeatable and associated with pelvic organ prolapse. Palpation of resting tone may be a useful new tool for assessing women with pelvic floor dysfunction.

Cost-effectiveness of percent free PSA for prostate cancer detection in men with a total PSA of 4-10 ng/ml.

OBJECTIVE: To assess the cost-effectiveness of two diagnostic strategies for prostate cancer in men with prostate-specific antigen (PSA) levels of 4-10 ng/ml and normal digital rectal examination (DRE). DESIGN: Cost-effectiveness analysis was performed using a decision tree model. Data collection and a systematic review of patients at the Urology Department (Carlos Haya Hospital) were made. 101 patients over the age of 40 with PSA levels of 4-10 ng/ml and normal DRE were selected. Transrectal ultrasound-guided prostate biopsy (TRUS-Bx) and percent free PSA testing prior to TRUS-Bx were performed. The outcome measures used were the incremental cost-effectiveness ratio, and costs were calculated through activity-based costing. The effectiveness was measured by means of the number of detected cases, test utility and actual cases (detected cases minus lost cases). RESULTS: Using base-case analysis, the strategy of percent free PSA + TRUS-Bx was found to be the most cost-effective. The incremental cost-effectiveness ratio for free PSA + TRUS-Bx compared with TRUS-Bx was EUR 2,277.40. Strategy 2 (TRUS-Bx) would be more cost-effective if the cost of percent free PSA increased to EUR 21.64 or if prostate cancer prevalence increased to 26%. CONCLUSIONS: The use of percent free PSA prior to TRUS-Bx is the most cost-effective diagnostic strategy. However, this result is very sensitive and strategy 2 (TRUS-Bx) would be more cost-effective if the cost of the percent free PSA increased to EUR 21.64 or if the prevalence of prostate cancer increased to above 26%.