During a digital rectal exam of an older male, the nurse practitioner notes the absence of the median sulcus and a firm, nodular prostate. Based on this finding, what is the most appropriate interpretation?
While a firm, nodular prostate with the absence of the median sulcus during a DRE may ultimately be benign, this is an abnormal finding that warrants further investigation, particularly for prostate cancer. Prostate cancer can cause asymmetry, firmness, or nodularity, which may obliterate the median sulcus. This finding is concerning as malignancies often disrupt the normal architecture of the prostate gland. While BPH commonly causes prostate enlargement, the prostate is usually rubbery and movable, not firm. Prostatitis may present with tenderness or swelling, and although it may result in the loss of the sulcus, the median sulcus is often still palpable. Normal aging can lead to prostate changes, but the absence of the median sulcus is not considered a routine age-related finding. The patient should be referred for diagnostic testing, such as prostate-specific antigen (PSA) levels (not immediately after a DRE as this may obscure results) and potentially a biopsy, to rule out malignancy.
A boggy, tender prostate suggests prostatitis, while a firm, nodular prostate raises concern for prostate cancer. An absent median sulcus can indicate BPH or cancer, but BPH is typically symmetrical and rubbery, not firm. Follow-up with PSA testing and urology referral is recommended if prostate cancer is suspected.