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Male LUTS with PSA above the age-specific suspected prostate cancer referral threshold — MSRA MCQ

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ModerateLUTSMale LUTS with PSA above the age-specific suspected prostate cancer referral thresholdMSRA

A 68-year-old man presents with 5 months of bothersome lower urinary tract symptoms: hesitancy, weak stream, daytime frequency and nocturia. His IPSS is 19. Urine dipstick is negative for blood, leucocytes and nitrites. He has no dysuria, fever, perineal pain, visible haematuria or recent urinary instrumentation. Digital rectal examination shows a smoothly enlarged prostate without nodularity. Following counselling, his PSA is 4.7 micrograms/L. He is fit for investigation and states that he would wish to pursue assessment and treatment if clinically indicated. What is the most appropriate next step?

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

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Correct answer: B — Discuss and make a suspected cancer pathway referral for prostate cancer

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

The correct answer is B. In a man aged 60–69 years with possible prostate-cancer symptoms, NICE uses a PSA threshold of more than 4.5 micrograms/L when considering a suspected cancer pathway referral. This patient has LUTS, a PSA of 4.7 micrograms/L, no evidence of UTI or another transient explanation, and would accept investigation; referral via the suspected cancer pathway is therefore the appropriate next step. A benign-feeling DRE does not override an age-specific PSA above the referral threshold. A repeat PSA may be appropriate where there is a likely transient cause of elevation or where clinical uncertainty remains, but it should not delay appropriate referral in this scenario. C is attractive because his symptoms may also reflect benign prostatic enlargement, and alpha blockers can improve moderate-to-severe LUTS; however, symptom treatment should not defer cancer-pathway assessment. D may occur after referral according to local diagnostic pathways, but arranging prostate MRI is not the primary-care action specified by NICE for this presentation. E underestimates the urgency created by the PSA result.

Reference: NICE NG12: Suspected cancer: recognition and referral — Recommendations organised by site of cancer, section 1.6 Urological cancers (Last updated 15 April 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NICE CG97: Lower urinary tract symptoms in men: management — Initial assessment and drug treatment (Last updated 3 June 2015; surveillance reviewed December 2024) — https://www.nice.org.uk/guidance/cg97/chapter/recommendations