Background: Digital rectal examination (DRE) is a straightforward, cost-effective, practical, and time-honored physical examination method that plays a valuable role in the detection of prostate cancer (PCa). Nevertheless, with the advent of the prostate-specific antigen (PSA) era, the necessity of performing DRE has become a subject of debate. Our aim was to investigate the diagnostic efficacy and adjunctive role of DRE in a population (Prostate Imaging Reporting and Data System (PI-RADS), PI-RADS >= 3 or PSA >= 4 ng/mL)<br />suspected of PCa.<br />Methods: Five hundred and ninety-seven patients with suspected PCa requiring referral for biopsy were prospectively enrolled consecutively from February 2020 to May 2021. All patients received DRE and corresponding clinical diagnosis by a urologist before biopsy. According to the collected clinical and pathological information, the diagnostic performance of DRE in different PSA stratifications, and its association with tumor location and Gleason score (GS) were statistically analyzed.<br />Results: Among patients with suspected cancer, the diagnostic accuracy of DRE was 63.45%. Compared with central zone or transition zone tumors, the recall rate of peripheral zone PCa with DRE-positive<br />results was higher (65.50% vs. 34.55%). DRE-positive results were significantly correlated with GS >= 7 PCa (P<0.001), and the average GS of DRE-positive PCa patients was significantly higher than that of DRE-<br />negative (7.92 vs. 7.11, P<0.001).<br />Conclusions: DRE may help physicians further judge the necessity of biopsy in patients with elevated PSA, and preliminarily estimate the location and invasiveness of the tumor. However, it is still necessary to<br />explore the value of DRE in a normal PSA po