What is the plan of care for a 67-year-old patient with an enlarged prostate, elevated Prostate-Specific Antigen (PSA) levels, and urinary symptoms, currently managed with a suprapubic catheter?

Management Plan for 67-Year-Old Patient with Enlarged Prostate, Elevated PSA, and Suprapubic Catheter

For a 67-year-old patient with an enlarged prostate, elevated PSA levels, and a suprapubic catheter, the recommended plan of care should include prostate biopsy to rule out prostate cancer, followed by appropriate medical or surgical management based on biopsy results.

Initial Evaluation

• Obtain a complete PSA history to evaluate the pattern and velocity of PSA increase, as PSA velocity changes ≥1.0 ng/ml/year warrant immediate investigation, even if absolute PSA is within normal range 1
• Perform digital rectal examination (DRE) to assess prostate size, consistency, and presence of nodules or asymmetry that might suggest malignancy 2
• Review the patient's medical history, including family history of prostate cancer, which lowers the threshold for biopsy 3
• Evaluate the severity of lower urinary tract symptoms (LUTS) using a standardized tool like the American Urological Association Symptom Score 4
• Consider transrectal ultrasound (TRUS) to assess prostate size, shape, and configuration, which may guide treatment options 2

Diagnostic Workup

• Prostate biopsy is indicated due to the elevated PSA levels, as approximately 1 in 3 men with elevated PSA have prostate cancer 2
• The biopsy should be performed under transrectal ultrasound guidance with a minimum of 8-12 core samples 2
• If PSA is >10 ng/ml, the probability of prostate cancer exceeds 50%, making biopsy particularly important 2
• Consider measuring free PSA percentage if PSA is in the 4-10 ng/ml range to further assess cancer risk 2
• If initial biopsy is negative but clinical suspicion remains high, consider repeat biopsy, especially if PSA continues to rise 2

Management Based on Biopsy Results

If Biopsy Confirms Prostate Cancer:

• Staging should include full blood count, alkaline phosphatase, creatinine, and serum total PSA 2
• Bone scintigraphy is recommended if PSA >15 ng/ml or if Gleason score is >4+3 2
• Treatment options should be discussed based on cancer stage, grade, and patient's overall health:
  • For localized disease (T1-2 N0/X M0/X), options include radical prostatectomy, radiation therapy, or active surveillance 2
  • For low-risk disease (T1-2a, Gleason <6, PSA <10 mg/l), active surveillance may be appropriate with 99% disease-specific survival at 8 years 2

If Biopsy Shows Benign Prostatic Hyperplasia (BPH):

• Medical therapy with 5-alpha reductase inhibitors like finasteride should be considered to reduce prostate volume and improve urinary symptoms 4
• Finasteride has been shown to decrease prostate volume by 17.9% over 4 years and significantly improve urinary symptoms 4
• Consider combination therapy with an alpha-blocker and finasteride, which reduces the risk of BPH progression by 67% compared to placebo 4
• For patients with suprapubic catheters due to urinary retention, surgical intervention should be considered 4
• Holmium laser enucleation of the prostate (HoLEP) can be beneficial for debulking large prostates, improving urinary symptoms, and reducing PSA levels 5

Management of the Suprapubic Catheter

• Evaluate the reason for the suprapubic catheter placement and determine if it can be removed following treatment 2
• If the catheter was placed due to urinary retention from BPH, medical therapy with finasteride may reduce the risk of continued urinary retention by 57% 4
• Surgical intervention (TURP or other minimally invasive procedures) should be considered if medical therapy fails to allow catheter removal 2

Follow-up Plan

• Monitor PSA levels every 3-6 months, with special attention to PSA velocity 1
• For patients on medical therapy for BPH, assess symptom improvement after 6 months of treatment 4
• If prostate cancer is diagnosed and active surveillance is chosen, regular PSA testing and periodic repeat biopsies are necessary 2
• For patients who undergo surgical intervention, follow-up should include assessment of urinary symptoms, flow rate, and post-void residual volume 2

Important Considerations

• Elevated PSA may result from various causes including prostate cancer, BPH, and prostatitis 6
• In cases of suspected prostatitis, a trial of antibiotics may be considered before biopsy, as antimicrobial treatment can lower PSA levels in some cases 6
• False-positive PSA elevations are common, with approximately 2 of 3 men with elevated PSA not having prostate cancer on biopsy 2
• Age and comorbidities should be considered when determining the aggressiveness of evaluation and treatment, as men older than 75 years may have little to gain from extensive PSA workup 2