How is a 68-year-old male with lower urinary tract symptoms (LUTS) and a rising Prostate-Specific Antigen (PSA) level from 1.19 to 2.47 in one year managed?

From the Guidelines

A 68-year-old male with LUTS and a PSA rise from 1.19 to 2.47 in one year should be referred to a urologist for further evaluation, including a prostate biopsy, due to the significant PSA doubling time and concern for possible prostate cancer. The initial management includes a thorough history and physical examination, including digital rectal examination (DRE) to assess prostate size and characteristics 1.

Initial Evaluation and Testing

Before biopsy, additional testing may include:

• Urinalysis to rule out infection
• Post-void residual measurement
• Possibly multiparametric MRI to better characterize suspicious areas 1

LUTS Management

For LUTS management, an alpha-blocker such as tamsulosin 0.4mg daily can be started to improve urinary symptoms. If the prostate is enlarged, adding a 5-alpha reductase inhibitor like finasteride 5mg daily or dutasteride 0.5mg daily may be beneficial for long-term symptom control 1.

Additional Considerations

If the patient has predominantly storage symptoms, an anticholinergic medication like oxybutynin 5mg twice daily or a beta-3 agonist like mirabegron 25-50mg daily could be considered. The rapid PSA rise is concerning because it exceeds the normal age-related increase of 0.04-0.07ng/mL per year, suggesting possible malignancy 1. Even if the biopsy is negative, this patient will need close monitoring with repeat PSA testing every 3-6 months and possibly repeat biopsy if PSA continues to rise 1.

Key Points

• Prostate biopsy is warranted due to significant PSA doubling time
• LUTS management includes alpha-blockers and 5-alpha reductase inhibitors
• Close monitoring with repeat PSA testing and possible repeat biopsy is necessary
• Additional testing, such as multiparametric MRI, may be beneficial in characterizing suspicious areas.

From the FDA Drug Label

In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment. Any confirmed increase from the lowest PSA value while on finasteride tablets may signal the presence of prostate cancer and should be evaluated, even if PSA levels are still within the normal range for men not taking a 5α-reductase inhibitor. To interpret an isolated PSA value in patients treated with finasteride tablets for six months or more, PSA values should be doubled for comparison with normal ranges in untreated men.

The management of a 68-year-old male with lower urinary tract symptoms (LUTS) and a rising Prostate-Specific Antigen (PSA) level from 1.19 to 2.47 in one year may involve:

• Evaluating the PSA level, considering that finasteride tablets reduce serum PSA concentration by approximately 50% within six months of treatment
• Doubling the PSA value for comparison with normal ranges in untreated men if the patient is taking finasteride tablets for six months or more
• Investigating the cause of the rising PSA level, as any confirmed increase may signal the presence of prostate cancer and should be evaluated
• Considering finasteride tablets as a treatment option for LUTS, as they have been shown to reduce the risk of acute urinary retention and the need for BPH-related surgery 2

From the Research

Management of Lower Urinary Tract Symptoms (LUTS) and Rising Prostate-Specific Antigen (PSA) Levels

• A 68-year-old male with LUTS and a rising PSA level from 1.19 to 2.47 in one year requires a comprehensive management approach.
• The patient's symptoms and PSA level increase suggest the need for further evaluation and potential biopsy, as indicated by studies 3, 4, 5, 6.

Diagnostic Evaluation

• Digital rectal examination (DRE) and PSA testing are essential components of the diagnostic evaluation, as they can detect prostate cancer in its early stages 4, 5, 6.
• Transrectal ultrasonography (TRUS) may be used to guide biopsy, but its use is generally reserved for patients with abnormal DRE or elevated PSA levels 4.
• The combination of PSA and DRE can improve the detection of prostate cancer, with PSA detecting more tumors than DRE alone 6.

Biopsy and Treatment

• Biopsy is recommended if the PSA level is greater than 4 μg/L or if DRE is suspicious, even in the absence of abnormal TRUS findings 6.
• The treatment approach will depend on the biopsy results, with options including active surveillance, radical prostatectomy, or radiation therapy 3.
• Radical prostatectomy and radiation therapy have been associated with increased risks of urinary incontinence and erectile dysfunction, highlighting the need for careful consideration of treatment options 3.

Refining PSA Interpretation

• Refinements to PSA interpretation, such as risk and age-based thresholds, PSA density, and PSA velocity, may help improve the diagnostic performance of PSA testing 7.
• These refinements may enable earlier detection of high-grade prostate cancer while reducing the detection of low-grade cancer, ultimately improving patient outcomes 7.