No, Do Not Order a Urogram for Prostatitis Evaluation in the Setting of Elevated PSA
An intravenous urogram (excretory urography) is not indicated for the evaluation of prostatitis in patients with elevated PSA. Upper urinary tract imaging with urography is reserved for specific clinical scenarios unrelated to prostatitis diagnosis, and prostatitis evaluation relies on clinical assessment, urine studies, and potentially prostate imaging—not urography. 1
When Upper Urinary Tract Imaging IS Indicated
According to the American Urological Association, upper urinary tract imaging (ultrasonography or excretory urography) is indicated only when patients present with one or more of the following: 1
- History of upper urinary tract infection 1
- Hematuria (microscopic or macroscopic) 1
- History of urolithiasis 1
- Renal insufficiency (ultrasonography preferred in this case) 1
- Recent onset nocturnal enuresis 1
None of these indications relate to prostatitis evaluation or elevated PSA workup. 1
Appropriate Evaluation for Elevated PSA with Suspected Prostatitis
Initial Assessment
- Exclude active infection first: Avoid PSA testing during active urinary tract infections or prostatitis, as approximately 2 of 3 men with elevated PSA do not have prostate cancer. 2
- Clinical evaluation: Perform digital rectal examination to assess for tenderness, warmth, or boggy consistency suggesting prostatitis. 1
- Urine analysis and culture: The 4-glass or 2-glass test for white blood cell counts and culture are necessary to diagnose bacterial prostatitis. 3
PSA Behavior in Prostatitis
- PSA levels can be dramatically elevated during acute bacterial prostatitis and typically return to normal within 14 days after initiation of antimicrobial therapy. 4, 5
- In chronic prostatitis, PSA elevation may persist despite antibiotic treatment, and this scenario requires further evaluation to exclude malignancy. 4, 6
- Treatment of documented chronic prostatitis with antibiotics and anti-inflammatory drugs can lower serum PSA by approximately 36%, with nearly half of patients normalizing their PSA below 4 ng/mL. 6
Appropriate Imaging for Prostate Evaluation
If imaging is needed for prostate assessment (not urography for upper tracts): 1
- Transabdominal or transrectal ultrasound can evaluate prostate size, shape, and rule out prostatic abscess. 1, 3
- Multiparametric MRI has high sensitivity for clinically significant prostate cancer and should be obtained in most cases before biopsy when cancer remains a concern. 1, 2
- CT is not effective for detecting prostate pathology itself and is reserved for staging advanced disease or detecting metastases. 1
Critical Management Algorithm
If prostatitis is clinically suspected (symptoms, tender prostate on exam, pyuria): Treat with 4-week course of antibiotics and anti-inflammatory agents, then recheck PSA within 2 months. 6
If PSA normalizes after treatment (<4.0 ng/mL): Continue surveillance with PSA testing at appropriate intervals; biopsy is no longer indicated. 2, 6
If PSA remains elevated after treatment: Proceed with prostate biopsy to exclude malignancy, as persistent elevation despite treatment of inflammation suggests possible cancer. 4, 6
If PSA is markedly elevated (>10-20 ng/mL) or digital rectal examination is abnormal: Proceed directly to urologic referral and biopsy consideration regardless of prostatitis, as cancer risk is substantial. 2
Key Pitfall to Avoid
Do not delay cancer evaluation indefinitely with repeated courses of antibiotics. If PSA remains elevated after one appropriate course of treatment for prostatitis, or if clinical suspicion for cancer is high (abnormal DRE, very high PSA, rapid PSA velocity), proceed with definitive evaluation including biopsy. 4, 7 In one study, 25.5% of men with persistent PSA elevation after prostatitis treatment were found to have prostate cancer on biopsy. 6