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National trends in the use of PSA, urinalysis, and digital rectal exam for evaluation of lower urinary tract symptoms in men

  • James Doolin 1,
  • Zachary A Reese 1,
  • Kenneth J Mukamal 1
1 Department of Medicine, Beth Israel Deaconess Medical Center, 330 Brookline Ave., Boston, MA, 02215, USA

Publication: World Journal of Urology, May 2020


The purpose of this study was to describe the practices of primary care physicians (PCPs) and urologists in their implementation of the 2010 American Urological Association (AUA) recommendations for the management of benign prostatic hyperplasia (BPH) in a nationally representative sample.


Data collected from 2008 to 2015 in the National Ambulatory Medical Care Survey (NAMCS) were used. Men aged 45 and older who presented with either a new complaint or exacerbation of lower urinary tract symptoms (LUTS) were included. Primary outcomes were the prevalence and determinants of prostate-specific antigen (PSA) testing, urinalysis (UA), and digital rectal exam (DRE), as all three were included in the AUA guidelines during the time period studied. In logistic regression analyses weighted to reflect national estimates, potential determinants of adherence for each testing modality were examined.


Between 2008 and 2015, 878 visits met inclusion criteria, corresponding to 14,399,121 ambulatory visits for new or exacerbated LUTS. Weighted prevalence estimates were 24% for PSA testing (95% CI: 19-29%), 61% for urinalysis (95% CI: 56-66%), and 18% for DRE (95% CI: 15-23%). Age ≥ 75 years was associated with lower prevalence of testing for all three tests, and region was associated with different testing estimates for PSA and UA. Patients referred to urologists were more likely to receive a DRE, although overall rates of DRE decreased per additional year of data.


Adherence to AUA guidelines for evaluation of LUTS in ambulatory visits was low in a nationally representative sample of Americans, particularly for PSA testing and DRE, suggesting substantial discordance between guidelines at the time and practice patterns. Practice patterns also differed by age and region. These discrepancies encourage increased education of providers in the implementation of the guidelines, particularly since they have been updated recently.