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Lower urinary tract symptoms with PSA testing following urinary tract infection — MSRA MCQ

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HardPSALower urinary tract symptoms with PSA testing following urinary tract infectionMSRA

A 54-year-old man has had 6 months of nocturia, hesitancy and a reduced urinary stream. Three weeks ago, he developed dysuria, fever and frequency; urine culture grew Escherichia coli. He completed a 7-day antibiotic course 14 days ago and is now asymptomatic, with a negative repeat urine culture. A PSA taken during the acute infection was 4.2 micrograms/L. Digital rectal examination today shows a smoothly enlarged prostate with no focal abnormality. He has not ejaculated, cycled or undertaken vigorous exercise in the preceding 48 hours. He is fit and would accept investigation and treatment if indicated. What is the most appropriate next management step?

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Correct answer: C — Arrange a repeat PSA in 4 weeks and use the result to determine whether suspected cancer pathway referral is indicated

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

The PSA of 4.2 micrograms/L is above the NICE age-specific threshold for a symptomatic man aged 50–59 years (>3.5 micrograms/L), which would ordinarily support suspected cancer pathway referral. However, this sample was taken during a culture-confirmed urinary tract infection, a recognised cause of transient PSA elevation. PSA testing should be deferred until 4–6 weeks after the infection has cleared. As he completed treatment 2 weeks ago and is now clinically and microbiologically clear, repeating PSA in 4 weeks provides an interpretable result. B is attractive because his PSA exceeds the referral threshold, but that threshold should not be applied to a result obtained during acute infection. C is too early and remains within the period in which infection-related PSA elevation may persist. D inadequately addresses a potentially abnormal PSA: treating likely benign prostatic enlargement does not remove the need for timely reassessment once the confounder has resolved. E may form part of secondary-care investigation after referral, but direct MRI is not the appropriate substitute for obtaining a valid PSA result in this primary-care scenario.

Reference: NICE NG12: Suspected cancer: recognition and referral — prostate cancer recommendations (Updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NHS: PSA test (Last reviewed 2 September 2024) — https://www.nhs.uk/tests-and-treatments/psa-test/ Scottish Referral Guidelines for Suspected Cancer — Prostate cancer (Accessed August 2026) — https://www.rightdecisions.scot.nhs.uk/scottish-referral-guidelines-for-suspected-cancer/urological-cancers/prostate-cancer/