What is the next step for a 53-year-old man with urinary hesitancy, frequency, oliguria, nocturia, a nodular prostate on digital rectal examination (DRE), and an elevated Prostate-Specific Antigen (PSA) level of 9.8 ng/mL?

Management of a 53-Year-Old Man with Suspicious Prostate Findings

Ultrasound-guided prostate biopsy is the most appropriate next step for this 53-year-old man with urinary symptoms, nodular prostate on DRE, and elevated PSA of 9.8 ng/mL. 1, 2

Rationale for Biopsy

This patient presents with multiple concerning findings that warrant immediate diagnostic evaluation:

1. Elevated PSA level (9.8 ng/mL):

   • Significantly above the age-specific reference range of 0-3.5 ng/mL for men in their 50s 2
   • PSA levels >4.0 ng/mL have a 17-32% likelihood of prostate cancer 2
   • At this PSA level (between 4.0-10.0 ng/mL), the risk of prostate cancer is approximately 25% 2

2. Abnormal DRE with nodular prostate:

   • Nodularity on DRE is a strong indication for biopsy regardless of PSA level 1
   • The combination of abnormal DRE and elevated PSA significantly increases cancer risk

3. Urinary symptoms:

   • While symptoms like hesitancy, frequency, oliguria, and nocturia can be consistent with benign prostatic hyperplasia (BPH), their presence alongside elevated PSA and abnormal DRE increases suspicion for malignancy

Biopsy Procedure

• Transrectal ultrasound (TRUS)-guided biopsy is the standard method for obtaining prostate tissue samples when cancer is suspected 1
• A minimum of 8-12 cores should be obtained during the procedure 1, 2
• The biopsy should target the peripheral zone at the apex, mid-gland, and base, as well as laterally directed cores 2
• Extended biopsy schemes (>6 cores) have been proven to identify more cancer at initial biopsy, decreasing the false negative rate from 20% to 5% 2

Why Other Options Are Not Appropriate

• CT scan or MRI of the pelvis: While imaging may be useful for staging after cancer diagnosis, it is not the appropriate initial diagnostic step when prostate cancer is suspected. Guidelines recommend biopsy first when there is abnormal DRE and elevated PSA 2, 1

• Repeat PSA in 1 month: Delaying diagnosis is inappropriate given the combination of abnormal DRE and significantly elevated PSA. This approach risks allowing potential cancer progression 2

• Tamsulosin therapy: While tamsulosin can improve urinary symptoms related to BPH 3, it would not address the underlying concern for malignancy. Starting symptomatic treatment without ruling out cancer would be inappropriate given the abnormal DRE and elevated PSA

Follow-up After Biopsy

If the biopsy confirms prostate cancer:

• Risk stratification based on Gleason score, PSA level, and clinical stage
• Treatment options would include radical prostatectomy, radiation therapy, or active surveillance depending on risk category 2

If the initial biopsy is negative but clinical suspicion remains high:

• Consider repeat biopsy, as false negatives can occur 2
• Studies show that repeat biopsies can detect cancer in 10-21% of patients with initially negative biopsies 4, 5

Potential Complications of Biopsy

• Rectal or urinary hemorrhage (uncommon)
• Infection (uncommon)
• Urinary retention (rare)
• Most complications are transient and well-tolerated 2

The combination of abnormal DRE findings and elevated PSA level in this 53-year-old man with urinary symptoms strongly indicates the need for immediate diagnostic evaluation with ultrasound-guided prostate biopsy to rule out prostate cancer.