skip to main content

Raised PSA with low-suspicion MRI — MSRA MCQ

Instant feedback + full explanation. One question, done properly.

HardPSARaised PSA with low-suspicion MRIMSRA

A 62-year-old man is reviewed in urology following referral for a persistently raised PSA. He has no urinary infection, has not ejaculated or cycled vigorously within 48 hours of either test, and has had no recent urinary instrumentation. PSA measurements 5 weeks apart are 5.8 micrograms/L and 6.0 micrograms/L. Digital rectal examination is benign. Multiparametric MRI shows a Likert score of 2 and a prostate volume of 36 mL. He is fit, has an estimated life expectancy of more than 10 years, and wishes to pursue investigation if clinically indicated. What is the most appropriate next management plan?

Educational content. Not a substitute for clinical judgement or local policy.

Reveal the answer and explanation

Correct answer: D — Repeat PSA in 3 months and offer prostate biopsy if it remains raised, because the PSA density is greater than 0.15 nanogram/mL/mL

Explanation lettering: B = shown as A · C = shown as B · A = shown as C · E = shown as D · D = shown as E

The PSA density is 6.0/36 = 0.167 nanogram/mL/mL, exceeding the NICE example threshold of 0.15 for strong suspicion of clinically significant prostate cancer. A low-suspicion MRI (Likert 1 or 2) reduces, but does not eliminate, the likelihood of significant disease. In a person with raised PSA, no previous biopsy and sufficient fitness for diagnosis and treatment, NICE recommends repeating PSA after 3 to 6 months and offering biopsy where suspicion remains strong, including when PSA density exceeds 0.15. A is appropriate only when suspicion is low after repeat PSA assessment; this PSA density is not low risk. B is premature because NICE specifies repeat PSA at 3 to 6 months before the biopsy decision in this MRI-negative pathway. C incorrectly treats a Likert 2 MRI as exclusionary and delays reassessment beyond the recommended interval. D is inappropriate: finasteride is not a diagnostic test, may suppress PSA interpretation, and there is no indication here to start it for bothersome benign prostatic enlargement.

Reference: NICE NG131: Prostate cancer: diagnosis and management, recommendation 1.2.11 (2019) — https://www.nice.org.uk/guidance/ng131/chapter/Recommendations