When to Refer Elevated PSA to Urology

Refer immediately to urology if PSA is >10 ng/mL, as this confers a >67% likelihood of harboring prostate cancer regardless of other findings. 1

Immediate Urology Referral Criteria

Refer urgently (within days) for any of the following:

PSA >10 ng/mL – approximately 50% have organ-confined disease, with this percentage decreasing substantially as PSA rises 1, 2
Abnormal digital rectal examination (DRE) – proceed directly to urology regardless of PSA level 1, 2
PSA velocity ≥0.5 ng/mL per year in men aged 60-69 years 1
PSA increase ≥1.0 ng/mL in any 12-month period regardless of absolute PSA value 2

Refer for consideration of biopsy when:

PSA 4.0-10.0 ng/mL with normal DRE – approximately 25% of men in this range have prostate cancer on biopsy 1
PSA ≥2.5 ng/mL in men aged 50-59 with additional risk factors (African American race, first-degree relative with prostate cancer before age 65) 1
Failure to achieve 50% PSA decrease on finasteride/dutasteride, or any PSA increase while on these medications 2

Always repeat PSA before referral unless >10 ng/mL or DRE is abnormal:

Use the same laboratory and assay (laboratory variability ranges 20-25%) 1
Wait 2-3 weeks under standardized conditions: no ejaculation for 48 hours, no prostatic manipulation, no urinary tract infection 1
Rule out prostatitis – dramatic PSA elevations can occur with infection, though cancer risk remains even after treatment 3, 4

When PSA is 4.0-10.0 ng/mL, use these parameters to refine the decision:

Percent free PSA <25% increases cancer likelihood – men with cancer have lower free PSA proportions than those with BPH 1, 5
PSA density >0.15 ng/mL/cc (PSA divided by prostate volume on imaging) predicts clinically significant cancer 1
PSA velocity >0.75 ng/mL per year for PSA 4-10 ng/mL (requires 3 consecutive measurements over 18-24 months) 2, 5
PSA velocity >0.35 ng/mL per year for PSA <4 ng/mL is suspicious 2

Men aged 50-70 years:

Refer if PSA exceeds age-specific thresholds: 3.5 ng/mL for ages 50-59,4.5 ng/mL for ages 60-69 6
African American men have higher baseline PSA levels – use adjusted ranges: 0-4.0 ng/mL for men in their 50s, 0-4.5 ng/mL for men in their 60s 7

Men aged >70 years:

Refer only if PSA >10 ng/mL, abnormal DRE, or PSA ≥3.0 ng/mL in very healthy men with minimal comorbidity and life expectancy >10-15 years 1, 2
Men aged 75+ with PSA <3.0 ng/mL have only 0.2% risk of prostate cancer death and should not be referred 1

Do not empirically treat with antibiotics in asymptomatic men with elevated PSA – this has little value and does not reduce the need for biopsy, though cancer risk persists even if PSA normalizes 1, 4
Do not delay referral for PSA >10 ng/mL – the cancer detection rate is too high to justify observation 1
Do not refer men with limited life expectancy (<10 years) – they will not benefit from cancer detection and will only experience harm from biopsy and potential overtreatment 3, 1
Avoid prostate biopsy for at least 3-6 weeks after any prostatic manipulation as biopsy itself causes substantial PSA elevation 1

Urology will typically perform:

Multiparametric MRI before biopsy to improve detection of clinically significant disease 1
Transrectal ultrasound-guided prostate biopsy with 10-12 cores under antibiotic prophylaxis if MRI shows suspicious lesions (PI-RADS 4-5) or if PSA remains elevated without MRI findings 3, 1
Risk of febrile infection from biopsy is approximately 4% 1