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Benign prostatic enlargement with LUTS and PSA elevation temporally associated with treated UTI — MSRA MCQ

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HardBPHBenign prostatic enlargement with LUTS and PSA elevation temporally associated with treated UTIMSRA

A 67-year-old man presents with 7 months of bothersome LUTS, predominantly hesitancy, weak stream, intermittency and incomplete emptying. His IPSS is 23. DRE shows a smooth enlarged prostate and ultrasound estimates prostate volume at 48 mL. eGFR is 78 mL/min/1.73 m². Ten days ago, he had culture-confirmed Escherichia coli UTI with dysuria and fever. He completed antibiotics 2 days ago and is now asymptomatic; repeat urine culture is negative. A PSA sample taken on the final day of antibiotics was 5.3 micrograms/L. He has had no recent ejaculation, vigorous cycling, catheterisation or instrumentation. He is fit for investigation and treatment if needed, and requests prompt symptomatic treatment. What is the most appropriate management plan?

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Correct answer: C — Start tamsulosin now and repeat PSA 6 weeks after completing antibiotics, before deciding on finasteride or suspected cancer referral

The PSA result should not currently trigger a suspected cancer pathway referral. Although 5.3 micrograms/L is above the NICE age-specific threshold of 4.5 micrograms/L for a man aged 60 to 69 years with LUTS, the sample was taken during treatment for a proven UTI. Urinary infection can transiently elevate PSA; PSA testing should therefore be deferred until 4 to 6 weeks after the infection has cleared. A repeat measurement at 2 weeks remains too early. His bothersome, severe voiding symptoms can be treated promptly with tamsulosin, which does not materially confound subsequent PSA interpretation. Finasteride is potentially appropriate later because he has a 48 mL prostate and is at risk of BPH progression. However, starting it before establishing a valid repeat PSA is inappropriate because finasteride lowers PSA by approximately 50% and complicates interpretation of the diagnostic baseline. Immediate referral based on the infection-associated PSA risks unnecessary urgent investigation. If the repeat PSA remains above the age-specific threshold, suspected cancer pathway referral should then be considered, alongside his preferences and fitness for investigation.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendations (2015; updated 2021) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NHS: PSA test (Reviewed 2 September 2024) — https://www.nhs.uk/tests-and-treatments/psa-test/ Finasteride 5 mg film-coated tablets — Summary of Product Characteristics (Updated 2025) — https://www.medicines.org.uk/emc/product/13543/smpc