Should Prostate-Specific Antigen (PSA) levels be checked in patients with erectile dysfunction?

PSA Testing in Erectile Dysfunction

PSA testing should be offered to men with erectile dysfunction who are over 50 years of age with at least a 10-year life expectancy, or when PSA measurement may change the management of their erectile dysfunction symptoms. 1

Rationale for PSA Testing in ED

The American Urological Association (AUA) guidelines provide specific recommendations regarding PSA testing in men with erectile dysfunction (ED). While ED itself is not directly linked to prostate cancer, there are important considerations:

• ED and prostate conditions often coexist in older men
• PSA testing helps exclude prostate cancer as a potential underlying cause of symptoms
• PSA levels can guide treatment decisions for ED, particularly when considering testosterone therapy

When to Test PSA in ED Patients

PSA testing should be offered to:

1. Men with ED who are over 50 years old with at least a 10-year life expectancy 1
2. Men for whom knowledge of prostate cancer would change management 1
3. Men for whom PSA measurement may influence ED treatment decisions 1
4. Men being considered for testosterone therapy, as PSA and digital rectal examination have additional significance in this context 1

Age-Specific Considerations

The approach to PSA testing should consider age-specific reference ranges:

• For men 40-49 years: 0-2.5 ng/mL (White men); 0-2.0 ng/mL (African-American and Asian-American men) 1
• For men 50-59 years: 0-3.5 ng/mL (White men); 0-4.0 ng/mL (African-American men); 0-3.0 ng/mL (Asian-American men) 1
• For men 60-69 years: 0-4.5 ng/mL (White and African-American men); 0-4.0 ng/mL (Asian-American men) 1

Special Considerations in ED Management

Testosterone Therapy and PSA

PSA testing is particularly important when considering testosterone therapy for ED:

• Baseline PSA should be established before starting testosterone therapy 2
• PSA levels are inappropriately low in hypogonadal men and may mask underlying cancer 2
• PSA should be monitored after initiating testosterone treatment 2

Inflammation and PSA in ED

Men with ED and benign prostatic hyperplasia (BPH) may have prostatic inflammation that affects PSA levels:

• Prostatic inflammation can cause spurious rises in PSA levels 3
• Men with the highest levels of prostatic inflammation (measured by IL-8) have greater degrees of ED 3
• This may lead to unnecessary prostate biopsies if not properly evaluated 3

Clinical Approach to PSA Testing in ED

1. Initial Evaluation:

   • Perform digital rectal examination (DRE) to exclude locally advanced prostate cancer 1
   • Offer PSA testing to appropriate candidates based on age and life expectancy 1

2. Interpreting Results:

   • Consider age-specific reference ranges 1
   • Evaluate PSA velocity (change over time) when appropriate 1
   • For men on 5α-reductase inhibitors (finasteride, dutasteride), PSA values should be doubled for comparison with normal ranges 4

3. Follow-up Actions:

   • Abnormal DRE findings warrant immediate urologic referral regardless of PSA level 5
   • PSA increases of ≥1.0 ng/mL in any 12-month period recommend immediate biopsy 5
   • PSA increases of 0.7-0.9 ng/mL in one year recommend repeat PSA in 3-6 months 5

Pitfalls and Caveats

1. False Positives: Approximately 25% of men with BPH have serum PSA greater than 4 ng/mL 1

2. Medication Effects: 5α-reductase inhibitors (finasteride, dutasteride) reduce PSA by approximately 50% within six months of treatment 4

3. Risk Assessment: PSA testing alone may not be sufficient; consider additional factors such as:

   • Free/total PSA ratio
   • PSA velocity
   • PSA density
   • Family history
   • Ethnicity 1

4. Unnecessary Biopsies: Inflammation associated with ED can cause PSA elevation without cancer, potentially leading to unnecessary biopsies 3

While routine screening for prostate cancer in men with ED is not universally indicated 6, targeted PSA testing based on age, risk factors, and treatment considerations remains an important component of comprehensive ED management.