YOU & WEE UROLOGIC SURGERY and WELLNESS
Jared J. Wallen, MD
A message from Dr. Wallen regarding your Elevated PSA exam:
A diagnosis of elevated PSA can be anxiety provoking. Together we can navigate the next step. There can be multiple reasons that a PSA blood test may be elevated:
- An enlarged prostate (BPH)
- An infection in the prostate or urine
- Prostate cancer
- Inflammation in the prostate or prostatitis
- A recent prostate biopsy or massage
- Bicycling or motorcycle riding
- Recent sexual activity or ejaculation
Sometimes an elevated PSA can be associated with lower urinary tract symptoms such as urgency, frequency, burning or dysuria, urinary retention, incomplete emptying, slow stream, etc and these can be indications that this may be related to an enlarged prostate. The above symptoms in addition to pelvic pain or rectal pain can be indicative of prostatitis. If you know you had a recent infection in the urine or have had any of the above symptoms within 1-2 weeks of your blood test please inform your doctor. Also, always ensure 3-4 days of abstinence prior to your blood test. (No sex or masturbation)
What we know about the PSA is that it, in combination with a yearly digital rectal exam (DRE) is the only way to “catch” prostate cancer prior to very advanced stages of the disease. For high-risk groups, the American Urologic Association recommends shared decision making regarding early screening starting at age 40-45. High-risk groups are anyone who is of African American descent or has a positive family history of prostate cancer. For everyone else who does not fall into the category shared decision-making is made regarding screening with a yearly PSA and DRE exam from the age of 55-70 years or in any situation where the patient has >10-year life expectancy and understands the risks of screening.
If you fall into a category of patients where your elevated PSA is thought to be possibly due to prostate cancer, then you will be recommended to have a Prostate MRI or a Template Prostate Biopsy. We used to go straight to Template Biopsy as in the picture to the picture above. This procedure is essentially 12 small needle pokes through the anterior rectal wall and into the prostate to sample specified areas of the prostate and attempt to understand if any potential cancer is present. There is however approximately a 15-20% chance we miss something with this approach. This can be thought of as a “Blind Biopsy,” and similar if you did 12 needle pokes in a template fashion to an apple, you may find or miss any potential “bad spots” present within the apple.
The potential to miss a small tumor increases with increasing size of the prostate due to the increased size or volume of prostate tissue and thus a smaller percentage of overall tissue sampled with our 12- core template needle biopsy. More commonly nowadays a Prostate MRI is performed first prior to any biopsy. This allows us to “visualize” any potential concerning lesions in the prostate prior to biopsy.
Special Technology can then be used to merge these MRI Pictures with a “live” Ultrasound Image to specifically TARGET the lesion in question. It is important to note that a Prostate MRI by itself cannot Diagnose cancer, and a Patient will still ultimately need a Biopsy to confirm the Tissue Diagnosis of Cancer. Further, Prostate MRI is also an imperfect test. There is about a 20-30% chance that we miss lesions that are very small (less than 1 cm). However, studies have shown that with MRI “vision” and a combined Targeted and Template Biopsy of the Prostate we are better at finding and or ruling out the presence of cancer. We do typically perform both a Targeted (4 biopsy of any lesions on MRI) and Template (as above) at the same time because we have had situations where the MRI lesions come back negative for cancer on Tissue Diagnosis and thus if we had not sampled the rest of the gland in standard template fashion, would be left wondering if there was a problem somewhere else in the gland.
In order to be prepared for your biopsy, please follow the following instructions:
- You should begin taking your antibiotics on the day prior to your test
- You should take an over the counter Fleet enema on the evening before your test at approximately 4-6:00 p.m.
- You should discuss with your doctor to stopping any anticoagulation medications (Coumadin, warfarin, aspirin, Plavix, etc.) you may be on.
- You should bring your filled prescription of Valium 10 mg to the office with you, and remember do not take prior to signing a consent form.
For the most part, patients do very well with biopsies and this is a relatively minor procedure with no major incisions or cuts. Some may have minor local symptoms for a few days. These include blood in the urine, blood in the stool, blood in the semen, burning with urination, soreness in the area of the prostate or with bowel movements, urgency or frequency of urination. There are 2 risks, albeit small in chance, that can require more immediate care… there is about a 3-5% chance of the need for a short-term Foley catheter due to swelling in large prostates that prevent men from urinating after the procedure, and finally, a very small 1-2% chance of severe infection called sepsis. Both of these issues can be rectified by seeking more care at your local Emergency Room. At home after your biopsy please take Tylenol/ ibuprofen for pain relief. You will also be getting an injection of numbing medication in the prostate area prior to the biopsy which will help with pain relief for approximately 48-72 hours. Otherwise, you should take it easy for approximately 3-5 days and no heavy lifting (greater than 10-15 lb.), sexual activity, or strenuous activity for 1-2 weeks. If you are otherwise doing well and can return to work with light-duty activities this can be as early as 3-5 days. I do hope this has helped you better understand the potential causes and standard workup for elevated PSA blood tests or an abnormal finding on Digital Rectal Exam by your Physician.
Rest assured OUR Team will do whatever we can to make this a gentle easy experience.
Jared J. Wallen MD