Assessment

Patient presents with urinary symptoms or has requested PSA testing.

Consider:

  • Lower urinary tract symptoms
  • Infective symptoms
  • Family history of prostate/ovarian/breast cancer
  • Bone pain

Always send MSU at time of PSA testing.

Before having a PSA test men should not have:

  • an active UTI (PSA may remain raised for many weeks) - large effect
  • ejaculated in the previous 48 hours - small effect < 1 mcg/l
  • exercised vigorously in the previous 48 hours - moderate effect 50-90% rise
  • had a prostate biopsy in the previous 6 weeks - large effect
  • had a DRE in the previous 24 hours - very small effect <0.25mcg/l

 

Who to refer

Refer fast track prostate pathway

  • 2 raised PSA < 10 and DRE abnormal
  • 2 raised PSA < 10 with strong family history
  • 2 raised PSA < 10 with significant lower urinary tract symptoms
  • 1 raised PSA > 10 and any of the above
  • 1 raised PSA > 10 and bone pain

Mandatory tests:

  • 2 raised PSA unless initial PSA > 10 and symptomatic
  • Rectal examination
  • U&E
  • MRI Checklist:
    • Presence of shunts/pumps/heart valves
    • Orbital foreign body/shrapnel
    • Cranial surgery/aneurysm clips
    • Claustrophobia
    • Cochlear implant
    • Pacemaker

Exclusion criteria:

  • Unfit for active treatment
  • Patients unable to attend appointments Monday AM
  • Patients who decline/are not able to have DRE
  • these patients can be referred via the existing urology referral pathway

Refer via SCI-Gateway Urology...Fast track prostate referral

Symptoms or signs of Cauda Equina Syndrome need emergency discussion with on-call team

Refer urgent suspected cancer

For patients in whom fast track referral not indicated.

Refer immediately:

  • PSA > 10 and/or DRE abnormal

Defer referral until repeat PSA in 4 weeks:

  • PSA raised for age but < 10
  • Raised PSA but < 10 in context of infection or other suspected benign/temporary cause of rise

Refer urgent suspected cancer if PSA remains elevated at repeat.

Refer via SCI-Gateway...Urology...Urological

Symptoms or signs of Cauda Equina Syndrome need emergency discussion with on-call team

Age-specific PSA ranges

  • Under 60 years < 3.0
  • Age 60-69 < 4.0
  • Age 70-79 < 5.0

In older men consider realistic medicine principles. Routine or no referral may be appropriate.

  • Age 80-85 > 10.0
  • Age 86 and over > 20.0

Who not to refer

  • Raised PSA in context of infection (repeat in 4 weeks and refer if still raised)
  • PSA < 10 with normal DRE (repeat in 4 weeks and refer if still raised)
  • If downward trend could be repeated again after 4 weeks
  • Frail elderly in whom a diagnosis of prostate cancer would not affect their management

Editorial Information

Last reviewed: 04/12/2023

Next review date: 04/12/2025

Author(s): Ian Russell.

Version: 1.1

Author email(s): ian.russell@nhs.scot.

Reviewer name(s): Fiona O'Brien, Fergus Donachie.