From the Guidelines
The next step for this 56-year-old male with urinary frequency, negative urinalysis, and elevated PSA of 8 ng/mL should be referral to a urologist for prostate biopsy. The elevated PSA level raises concern for possible prostate cancer, especially in the context of urinary symptoms. According to the NCCN clinical practice guidelines prostate cancer early detection, version 2.2015 1, approximately 30% to 35% of men with serum PSA between 4 to 10 ng/mL will be found to have cancer.
Key Considerations
- The urologist will likely perform a digital rectal examination (DRE) to assess prostate size, consistency, and nodularity, followed by a transrectal ultrasound-guided prostate biopsy to obtain tissue samples for pathological examination.
- The negative urinalysis helps rule out infection as a cause of his symptoms, making the elevated PSA more concerning.
- Prompt evaluation is important as earlier detection of prostate cancer, if present, allows for more treatment options and potentially better outcomes.
- The patient should be counseled that the biopsy procedure typically takes about 20-30 minutes and may cause temporary discomfort, minor bleeding, and risk of infection.
Additional Recommendations
- Local anesthesia can decrease pain/discomfort associated with prostate biopsy and should be offered to all patients 1.
- Biomarkers that improve the specificity of detection, such as percent free PSA, 4Kscore, or phi, may be considered in selected cases to further define the probability of high-grade cancer 1.
From the FDA Drug Label
- 1 Effects on Prostate Specific Antigen (PSA) and the Use of PSA in Prostate Cancer Detection In clinical studies, finasteride tablets reduced serum PSA concentration by approximately 50% within six months of treatment.
The patient's PSA is 8, which is elevated. To interpret this value, it should be doubled for comparison with normal ranges in untreated men, since the patient is not currently taking finasteride.
- Next step: The patient should undergo further evaluation for prostate cancer, such as a biopsy, given the elevated PSA level 2.
From the Research
Next Steps for a 56-Year-Old Male with Urinary Frequency and Elevated PSA
- The patient presents with urinary frequency and an elevated PSA level of 8, but a negative urinalysis.
- Given the elevated PSA level, the next step would be to consider further diagnostic tests to rule out prostate cancer.
- According to the study by 3, the addition of multiparametric magnetic resonance imaging (mpMRI) before prostate biopsy can reduce the detection of low-grade tumors while improving the detection of clinically significant prostate cancer.
- The study by 4 also highlights the importance of mpMRI in the diagnosis and treatment of prostate cancer, stating that it has become a fundamental tool in the management of prostate cancer.
- Another option to consider is a diagnostic transurethral resection of the prostate (TURP), as suggested by the study by 5, which can help to evaluate bladder outlet obstruction and provide histological examination.
- However, the study by 6 notes that TURP is typically considered for patients with bladder outlet obstruction and minor lower urinary tract symptoms, and may not be the best option for this patient.
- The study by 7 suggests that mpMRI can help to improve the detection and characterization of prostate cancer, and can be used to select patients for active surveillance or treatment planning.
- Overall, the next step for this patient would likely be to undergo an mpMRI to further evaluate the prostate and guide future management decisions 3, 4, 7.