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Possible prostate cancer with a potentially falsely elevated PSA result — MSRA MCQ

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ModeratePSAPossible prostate cancer with a potentially falsely elevated PSA resultMSRA

A 62-year-old man presents to his GP with 5 months of nocturia, hesitancy and a reduced urinary stream. He also reports erectile dysfunction. Urinalysis and midstream urine culture are negative. He has no dysuria, fever, pelvic pain, visible haematuria, urinary retention or recent urinary instrumentation. Digital rectal examination finds a smooth, symmetrically enlarged prostate. His PSA is 5.0 micrograms/L. He completed a 60 km cycling event the day before the blood test and ejaculated that evening. He is otherwise fit and would accept investigation and treatment for clinically significant prostate cancer. What is the most appropriate next management step?

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

Reveal the answer and explanation

Correct answer: C — Repeat the PSA after at least 48 hours without cycling, vigorous exercise or ejaculation, and consider suspected cancer pathway referral if it remains above 4.5 micrograms/L

Explanation lettering: C = shown as B · B = shown as C

The PSA result should first be repeated under appropriate pre-test conditions. Ejaculation, cycling and other vigorous exercise during the preceding 48 hours can increase PSA and make the result less accurate. This man’s PSA of 5.0 micrograms/L is therefore not sufficiently reliable to trigger referral immediately. If a properly prepared repeat PSA remains above the NICE age-specific threshold for a man aged 60–69 years (>4.5 micrograms/L), suspected cancer pathway referral should be considered, incorporating his preferences and fitness for treatment. A is inappropriate because it delays clarification of a potentially significant PSA result for 6 months. C is initially attractive because 5.0 micrograms/L exceeds the age-specific threshold, but the sample was taken after two recognised causes of transient PSA elevation. D may be appropriate for bothersome benign prostatic enlargement after assessment, but commencing finasteride before resolving the PSA result may complicate subsequent interpretation and should not defer appropriate cancer assessment. E is inappropriate because there are no symptoms, urinalysis findings or culture evidence of urinary infection or prostatitis; empirical antibiotics are not indicated.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer recommendations (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NHS: PSA test — Preparing for a PSA test (2024) — https://www.nhs.uk/tests-and-treatments/psa-test/?wpmobileexternal=true