What is the possible diagnosis and next steps for a 62-year-old male with a history of hypertension (on Telmisartan), hyperlipidemia (on Atorvastatin and Clopidogrel), gout (on Febuxostat), undergoing stroke rehabilitation, with a history of allergic reactions to unrecalled antibiotics and TB medication, presenting with a hard structure palpated on digital rectal examination (DRE) at the 3 o'clock position and recent urinary tract infection (UTI)-like symptoms?

Suspected Prostate Cancer with Abnormal Digital Rectal Examination

This patient requires immediate prostate biopsy due to the abnormal DRE finding of a hard structure at the 3 o'clock position, regardless of PSA level, as this represents a highly suspicious finding for prostate cancer. 1, 2

Possible Diagnosis

The hard structure palpated on DRE at the 3 o'clock position represents a concerning finding that warrants immediate further evaluation for prostate cancer. 2

• Nodules or focal induration on DRE are the most concerning findings and constitute an independent indication for prostate biopsy, even if PSA is normal (<4.0 ng/mL). 2

• The combination of recent UTI-like symptoms with an abnormal DRE creates a clinical scenario where PSA interpretation must be cautious, as inflammatory processes can falsely elevate PSA levels. 3

• DRE has limited sensitivity (missing 23-45% of prostate cancers when used alone), but when abnormal findings are present, approximately 50% represent locally advanced tumors. 1

Immediate Next Steps

1. Complete Laboratory Workup

• Obtain serum PSA measurement if not already done, but proceed with biopsy regardless of the result since abnormal DRE alone justifies tissue sampling. 2, 4

• Complete urinalysis and urine culture to confirm resolution of any UTI and assess antibiotic sensitivity. 3, 4

• If UTI is still present, treat with appropriate antibiotics based on culture results, then repeat PSA after infection clearance, as infection can substantially elevate PSA and lead to misinterpretation. 3

2. Imaging Studies

• Order transrectal ultrasound (TRUS) of the prostate to assess prostate size, shape, and guide biopsy of the suspicious lesion. 1, 3

• The patient's history of UTI-like symptoms with urgency suggests upper tract imaging (KUB ultrasound) was already ordered—review these results to exclude concurrent upper urinary tract pathology. 4

3. Prostate Biopsy Protocol

• Perform TRUS-guided prostate biopsy under antibiotic prophylaxis, obtaining a minimum of 8 cores (ideally 12 cores if prostate volume exceeds 40cc) from peripheral and anterolateral zones. 1, 2

• Target the palpable abnormality at the 3 o'clock position specifically during the biopsy procedure. 1

• The biopsy should include systematic sampling of the entire peripheral zone, as 20-35% of tumors will be missed if only the palpable area is sampled. 1

Risk Stratification After Biopsy

If Prostate Cancer is Confirmed:

• Clinical T stage will be determined by DRE findings and guides treatment decisions and risk stratification. 2

• The Gleason score from biopsy, combined with PSA level and clinical stage, will determine whether the patient has low-risk, intermediate-risk, or high-risk disease. 1, 2

• DRE-positive results correlate significantly with Gleason score ≥7 prostate cancer, suggesting potentially more aggressive disease. 5

• If intermediate or high-risk features are present, proceed with staging imaging including pelvic MRI or CT and bone scan to evaluate for metastatic disease. 2

If Biopsy is Negative:

• Maintain close surveillance with repeat DRE at specified intervals, as a negative biopsy does not completely exclude cancer when DRE remains abnormal. 2

• Consider repeat biopsy if DRE findings persist or worsen on follow-up examinations. 2

• The sampling error inherent in prostate biopsies means that aggressive tumors can be missed on initial biopsy. 1

Critical Clinical Pitfalls to Avoid

• Never delay biopsy waiting for PSA normalization after UTI treatment when DRE is abnormal—the DRE finding takes precedence. 2

• Do not interpret the recent UTI symptoms as explaining the hard prostatic nodule; these are separate clinical entities requiring independent evaluation. 3

• The patient's antibiotic allergy history (unrecalled antibiotics and TB medication reaction) requires careful selection of prophylactic antibiotics for the biopsy procedure—consider fluoroquinolone alternatives or aminoglycosides based on local resistance patterns and allergy testing if available. 1

• The patient's stroke rehabilitation status and use of Clopidogrel creates a bleeding risk for biopsy—consult with cardiology regarding temporary discontinuation (typically 5-7 days before procedure) versus continuing based on stroke timing and thrombotic risk. 1

Medication Considerations

• Telmisartan does not require adjustment for prostate biopsy. 6

• Atorvastatin and Febuxostat do not affect biopsy bleeding risk and should be continued. 7

• Clopidogrel management is the critical decision point—balance the thrombotic risk from recent stroke against procedural bleeding risk, typically requiring multidisciplinary discussion. 1