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Screening and the prostate exam

When to start, how the evaluation works and what the studies show.

Dr. Petronio Melo, urologistCRM-SP 157.598 · RQE 70.275
Reviewed by Dr. Petronio Melo on November 8, 2026
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Quick answer

Screening means looking for prostate cancer in men without symptoms, with PSA and a rectal exam. The Brazilian Society of Urology (SBU) and the European guideline advise starting at 50, or at 45 for Black men and men with a first-degree relative with the disease.1,2 The Brazilian Ministry of Health does not recommend screening the whole population and advises a shared decision with men who ask for the test.3 Both positions include a conversation about risks and benefits.

What screening is

Screening looks for the disease in people without symptoms. Early diagnosis investigates people who already have signs.3

Localized prostate cancer usually causes no symptoms, and that is what justifies looking early.1 On the other side is overdiagnosis, which can lead to unnecessary tests and treatments.1,4

What each organization advises

OrganizationAdvice
SBUIndividual evaluation from age 50, or from 45 for Black men and men with a first-degree relative with the disease2
European guidelineFrom 50, from 45 with a family history or African ancestry, and from 40 with a BRCA2 mutation, with a strategy adjusted to risk1
American guidelinePSA with shared decision-making and intervals adjusted to each man8
US Preventive Services Task ForceFrom 55 to 69, an individual decision: the benefit is small for some men. After 70, the harms are greater7
Brazilian Ministry of Health and INCADo not recommend screening the whole population and advise a shared decision with men who ask for the test3
Three bars with the starting age: 40 with a BRCA2 gene mutation, 45 for Black men or men with a first-degree relative with the disease, and 50 for men in general.
Starting ages from the SBU and the European guideline. The BRCA2 mutation is part of the European advice.

What the studies show

StudyHow it was doneResult
European, 23 years162,236 men aged 55 to 69, with repeated PSA tests13% fewer prostate cancer deaths and 30% more diagnoses. One death prevented for every 456 men invited
CAP, 15 years415,357 men, with a single invitation to a PSA testProstate cancer deaths: 0.69% in the invited group and 0.78% in the other. The absolute reduction was small
Swedish, 202237,887 men invited, with PSA and MRIBiopsying only the lesions seen on MRI halved the number of insignificant tumors: 0.6% and 1.2%

A Cochrane review of five randomized studies found no gain in disease-specific survival. The European guideline notes that two studies showed a favorable effect: the European study and CAP.1 The disagreements come from this picture, and the Swedish study shows one way to reduce harm by using MRI.6

How the prostate exam works

  1. ConversationWe talk about your age, family, symptoms, medications and previous tests.
  2. PSAA blood test, done in a laboratory.
  3. Rectal examWith a glove and lubricant, the doctor feels the part of the prostate next to the rectum. It takes a few seconds and may be uncomfortable.
  4. Next stepWith the results, we decide whether to monitor, repeat the PSA or order an MRI.

The rectal exam is still useful alongside PSA. In about 18% of cases, cancer is found only because the rectal exam is abnormal. In a large European study, an abnormal rectal exam with a high PSA more than doubled the chance of a positive biopsy: 48.6% and 22.4%.1

First signs

Early prostate cancer usually causes no symptoms, which appear later.1 A weak stream, frequent urges to urinate or blood in the urine have several causes and deserve evaluation at any age.

How I approach it

In my practice, before ordering the test, I explain what it can show and what may come next. Once the decision is made, I do the evaluation with PSA and a rectal exam. When there is a family history, I ask who had the disease, at what age and whether there were other tumors, such as breast or ovarian cancer. The interval between tests depends on each man's result and risk.

When to see a urologist

  • From age 50, or from 45 if you are Black or have a first-degree relative with the disease1,2
  • From age 40, if you have a BRCA2 gene mutation1
  • At any age, if you have urinary symptoms or blood in your urine
  • If your PSA is abnormal or rises from one test to the next

Frequently asked questions

At what age should I have a prostate exam?

The Brazilian Society of Urology (SBU) and the European guideline advise starting at 50, or at 45 for Black men and men with a first-degree relative with the disease.1,2 Men with a BRCA2 gene mutation start at 40.1

Is PSA enough, without the rectal exam?

The rectal exam adds information. In about 18% of cases, cancer is found only because the rectal exam is abnormal, whatever the PSA value.1 The rectal exam also helps define the stage and the risk group.1

What are the first signs of prostate cancer?

Localized cancer usually causes no symptoms. They tend to appear later.1 That is why having no symptoms does not rule out the disease.

Why does the Brazilian Ministry of Health not recommend screening?

It considers that screening the whole population increases diagnoses without a significant reduction in deaths and with harm to men's health. The Ministry advises discussing risks and benefits with men who ask for the test.3

Do I need the exam every year?

Not always. The interval depends on your risk and your previous results. The American guideline accepts longer intervals, adjusted to each man.8

Can MRI replace PSA and the rectal exam?

No. The European guideline advises against using MRI as the first screening test.1 It comes later, to help decide about a biopsy.

References

  1. EAU-EANM-ESTRO-ESUR-ISUP-SIOG Guidelines on Prostate Cancer. European Association of Urology; 2026. EAU
  2. Sociedade Brasileira de Urologia. Aconselhamento para o diagnóstico precoce do câncer de próstata. 2020. SBU
  3. Instituto Nacional de Câncer. Ministério da Saúde recomenda o não rastreamento populacional do câncer de próstata. 2023. INCA
  4. Roobol MJ, de Vos II, Månsson M, et al. European Study of Prostate Cancer Screening: 23-Year Follow-up. N Engl J Med. 2025;393(17):1669-1680. PubMed
  5. Martin RM, Turner EL, Young GJ, et al. Prostate-Specific Antigen Screening and 15-Year Prostate Cancer Mortality: A Secondary Analysis of the CAP Randomized Clinical Trial. JAMA. 2024;331(17):1460-1470. PubMed
  6. Hugosson J, Månsson M, Wallström J, et al. Prostate Cancer Screening with PSA and MRI Followed by Targeted Biopsy Only. N Engl J Med. 2022;387(23):2126-2137. PubMed
  7. US Preventive Services Task Force, Grossman DC, Curry SJ, et al. Screening for Prostate Cancer: US Preventive Services Task Force Recommendation Statement. JAMA. 2018;319(18):1901-1913. PubMed
  8. Wei JT, Barocas D, Carlsson S, et al. Early Detection of Prostate Cancer: AUA/SUO Guideline Part I: Prostate Cancer Screening. J Urol. 2023;210(1):46-53. PubMed

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