In a man with an elevated total prostate-specific antigen of 6.06 ng/mL (free PSA 57.5%) and an 8 mm enhancing polypoid lesion on the anterior bladder wall suspicious for malignancy, what is the appropriate next diagnostic and management plan?

Management of Bladder Lesion and Elevated PSA

Immediate cystoscopy with biopsy of the 8mm enhancing polypoid anterior bladder wall lesion is the absolute priority, as this finding is highly suspicious for bladder cancer and takes precedence over prostate evaluation. 1

Primary Focus: Bladder Lesion Management

The enhancing polypoid lesion on the anterior bladder wall requires urgent urologic evaluation:

• Proceed directly to cystoscopy with cold-cup biopsy or transurethral resection of the bladder tumor (TURBT) to obtain tissue diagnosis, as any enhancing polypoid bladder lesion must be considered malignant until proven otherwise 1, 2

• Do not delay bladder evaluation to address the PSA findings, as bladder cancer has immediate implications for morbidity and mortality that supersede prostate concerns 1

Secondary Consideration: PSA Interpretation

Your PSA findings are actually reassuring for prostate cancer risk:

• A free PSA percentage of 57.5% is exceptionally high and strongly suggests benign etiology rather than prostate cancer, as values >15% are associated with lower cancer risk, and your value far exceeds this threshold 1, 3, 4

• The total PSA of 6.06 ng/mL falls in the "gray zone" (4-10 ng/mL) where approximately 25-30% of men have prostate cancer, but the high free PSA percentage dramatically reduces this probability 1, 2

• Free PSA <15% indicates higher cancer risk, while >15% suggests benign conditions like benign prostatic hyperplasia; your 57.5% is strongly protective 1, 4

Prostate-Specific Recommendations

Given the reassuring free PSA percentage:

• Perform digital rectal examination (DRE) to assess for prostate nodules, asymmetry, or firmness—any abnormality would mandate further evaluation regardless of PSA values 1, 2

• If DRE is normal, defer prostate biopsy and instead monitor with repeat PSA and DRE in 6-12 months to assess PSA velocity 3

• Calculate PSA velocity at follow-up: values >0.75 ng/mL/year would increase concern for malignancy despite the favorable free PSA ratio 3, 2

• Prostate biopsy would only be indicated if: PSA velocity exceeds 0.75 ng/mL/year, free PSA percentage drops below 15%, or new abnormality appears on DRE 3, 2

Critical Pitfalls to Avoid

• Do not pursue prostate biopsy before addressing the bladder lesion—the bladder finding has far greater immediate clinical significance 1

• Do not be falsely reassured by the "normal" total PSA range—the bladder lesion requires tissue diagnosis regardless of PSA values 1, 2

• Do not assume the elevated PSA is from prostate cancer—bladder pathology, including bladder cancer, can also elevate PSA levels 1

• Avoid repeat PSA testing to "confirm" the elevation before addressing the bladder lesion—imaging findings of suspicious bladder masses mandate immediate action 2

Diagnostic Algorithm

1. Urgent urology referral for cystoscopy with biopsy/TURBT of bladder lesion 1, 2
2. Concurrent DRE during urologic evaluation 1, 2
3. If DRE normal and bladder pathology is benign: repeat PSA and DRE in 6-12 months 3
4. If bladder malignancy confirmed: stage appropriately and treat per bladder cancer guidelines 1
5. Reserve prostate biopsy for: abnormal DRE, PSA velocity >0.75 ng/mL/year, or free PSA dropping below 15% 3, 2