If a man goes to their GP with bothersome urinary symptoms or is worried about prostate cancer, their GP is likely to perform one or both of the investigations below. Today there is much more awareness of prostate cancer and a GP may request a PSA blood test. It is important however to be informed of the potential pros and cons of having a PSA blood test which is not wholly accurate when used on its own for diagnosing prostate cancer.
- A PSA (Prostate Specific Antigen) blood test, measures the level of a protein produced by the prostate gland which can sometimes be elevated in the presence of prostate cancer. As a man ages and his prostate enlarges, the prostate will tend to produce more PSA. Therefore PSA levels can be expected to reach certain levels for men at certain ages (see below).
Although the PSA blood test may be helpful in identifying possible prostate cancer it is not a specific diagnostic test, as levels can be high in people who do not have the condition or due to other underlying conditions which may affect the prostate (see below).
If a man is unsure about having a PSA blood test the following link may be helpful, now updated by Public Health England.
If men know that they are going to have a PSA blood test then it is a good idea to avoid cycling and sexual intercourse/ejaculation for 48 hours beforehand to maximise the reliability of the PSA value.
- A digital rectal examination (DRE), is quick and simple to perform, and involves a doctor inserting a gloved, lubricated finger into the rectum (back passage) to feel if the prostate gland is enlarged or abnormal. A cancerous prostate gland may sometimes feel hard, uneven or have irregular nodules on it whereas a normal prostate will usually feel smooth and even. The DRE can also help identify how much of the prostate has been affected by cancer which can help healthcare professionals decide what sort of treatment may be needed for any prostate cancer that is found.The examination is usually painless but men may experience some slight temporary discomfort.
If these tests show anything abnormal or there is a strong suspicion of prostate cancer, men may be referred to a hospital specialist called a urologist for further investigation.
If a urologist feels that it is important to determine whether prostate cancer is present or not they may recommend a biopsy or sampling of tissue from the prostate under either a local or general anaesthetic. Traditionally this has involved an ultrasound probe being inserted into the rectum to identify the prostate gland and usually 12-16 small needle biopsies of tissue being taken from the prostate (see picture below).
Having a prostate biopsy
In the last few years it has become a much more common practice to use a sophisticated type of MRI scan (multiparametric) to scan the prostate first before taking biopsies. This means that specific areas of the prostate which may contain prostate cancer can be identified prior to biopsy and targeted more accurately. Sometimes transrectal biopsies or transperineal biopsies (biopsies from the area between the rectum and scrotum) will be taken by inserting surgical needles via a metal template at regular 5mm intervals (see below). This is perfomed under a general or spinal (localised) anaesthetic.
After having a biopsy
Like all surgical procedures there is a small risk of infection following a biopsy and men will need to take some antibiotics on a regular basis for a few days after. Biopsies of the prostate will usually cause the prostate gland it to become inflamed and swollen. This may cause some initial discomfort which should gradually improve.
Following a biopsy it is normal to experience some blood in the urine and semen and this may last for 2-4 weeks after the procedure. Men should try and avoid too much strenuous activity for about 5-days after their biopsy such as heavy lifting or gardening which may cause bleeding and delay the healing process. Occasionally inflammation may cause the prostate to swell and temporarily block the flow of urine from the bladder. In this situation men may need to have a special drainage tube called a catheter inserted into their bladder to drain the urine off. If men are experiencing problems passing urine it is important that they seek medical advice. Very rarely infection caused by the biopsy may enter the blood stream and cause a more severe infection which will need to be treated in hospital.
For more information on having a TRUS biopsy from the British Association of Urology Surgeons (BAUS) please click here
My urologist thinks that I may have a urinary infection and has asked me to have a repeat PSA blood test before considering a biopsy.
Urinary infections can cause blood in the urine or an offensive smell. They can also cause the PSA level to become elevated. Bacteria will also usually be present. A biopsy of the prostate can sometimes cause inflammation and infection and may increase the chance of any infection getting into the blood stream. In this situation a urologist will usually prescribe some antibiotics to treat any infection and ask men to have a further PSA blood test at a later date. It is important that this blood test should not be performed for around 6-weeks to allow time for the PSA level to normalize.
I am 84 and my urologist does not want to perform a biopsy. Is this acceptable?
Statistically many men in this age group are likely to have prostate cancer. However at this age, treatment may not be needed as any cancer will usually not reduce their life expectancy. If treatment is needed it will involve men receiving 3-monthly injections of hormones to control and regress any cancer. If the prostate feels abnormal and there is evidence of prostate cancer or a man’s PSA level is high a urologist may not want to perform a biopsy which could cause unwanted side effects when the biopsy results would not alter or change the treatment that is likely at this age.
My PSA level is very high and my urologist feels that I have prostate cancer which has spread to my bones. He has told me that treatment in this situation will only be used to control my symptoms. Do I still need to have a biopsy?
It may be suggested that men have a biopsy in this situation as there are sometimes newer treatments for more advanced prostate cancer that are being evaluated in clinical trials. One of the requirements to take part in a clinical trial is usually definitive evidence of cancer obtained from a biopsy. However in this situation a urologist may only need to take a small number of biopsies from the prostate.
Last reviewed April 2021. Next review 2022.
References available on request.