OBJECTIVE: To present a case in which the initial diagnosis of spinal metastasis secondary to prostate cancer was established from findings of the digital rectal examination (DRE) and serum prostate-specific antigen (PSA) analysis. CLINICAL FEATURES: A 79-yr-old black male was seen after suffering from low back pain for 1 month. Urinary frequency and nocturia were associated symptoms. Abnormal findings on the DRE and serum PSA determination suggested a preliminary diagnosis of spinal metastases secondary to prostate cancer. Subsequent referral for biopsy and bone scan yielded the final diagnosis of prostate adenocarcinoma with spinal metastasis. Radiographs of the lumbosacral spinal region were inconclusive and results of routine laboratory tests (CBC, ESR, U/A) were within normal limits. INTERVENTION AND OUTCOME: The patient was referred for medical palliation of his condition. A bilateral orchiectomy was performed along with oral antiandrogen administration. At a consultation 8 months postoperatively, he reported to be free of pain. CONCLUSION: At least 40% of newly diagnosed cases of prostate cancer can be expected to have metastasized at the time of initial discovery. Routine use of DRE and serum PSA in patients complaining of low back pain who are at high risk for prostate cancer is recommended. However, mass screening with DRE or PSA in asymptomatic males is not recommended. There are no prospective studies showing evidence that mass screening for prostate cancer will reduce the mortality or morbidity rates from the disease.