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Transient PSA elevation after acute urinary retention and urethral catheterisation — MSRA MCQ

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HardPSATransient PSA elevation after acute urinary retention and urethral catheterisationMSRA

A 68-year-old man attends for review of bothersome nocturia, hesitancy and reduced urinary flow. Twelve days ago he presented to the emergency department with acute urinary retention; 1.2 L was drained following urethral catheterisation. He passed a trial without catheter 5 days ago. Midstream urine culture is negative. He has no fever, dysuria, pelvic pain, visible haematuria, bone pain or weight loss. He avoided ejaculation and vigorous cycling for 48 hours before testing. Digital rectal examination shows a smooth, symmetrically enlarged prostate. PSA, measured 2 days after catheter removal, is 7.2 micrograms/L. He is fit for radical treatment should clinically significant prostate cancer be identified. What is the most appropriate next step in prostate cancer assessment?

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

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Correct answer: B — Arrange repeat PSA in 4 weeks, when 6 weeks have elapsed since catheterisation, and refer if it remains above the age-specific threshold

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

His PSA of 7.2 micrograms/L is above the NICE age-specific referral threshold for a man aged 60–69 years (>4.5 micrograms/L). However, the result was obtained shortly after acute urinary retention and urethral catheterisation. Catheterisation and other invasive urinary procedures can transiently elevate PSA for up to 6 weeks, so this measurement is not suitable as the basis for cancer-pathway referral in the absence of a malignant-feeling prostate or metastatic features. The appropriate sequence is therefore to repeat PSA once 6 weeks have elapsed since catheterisation; persistent elevation should then prompt suspected-cancer referral. A is attractive because the measured PSA exceeds the usual threshold, but it overlooks the major pre-analytical confounder. C bypasses appropriate primary-care reassessment and would not correct an unreliable PSA result. D is inappropriate because finasteride would alter subsequent PSA interpretation and should not be used to defer clarification of a potentially raised PSA. E is unsafe because a benign DRE does not exclude prostate cancer, and the current PSA requires timely reassessment after the transient cause has resolved.

Reference: NICE NG12: Suspected cancer: recognition and referral — Prostate cancer (2021 recommendation; guidance checked August 2026) — https://www.nice.org.uk/guidance/ng12/chapter/recommendations-organised-by-site-of-cancer NHS Scotland Right Decisions: PSA (Reviewed 1 April 2023) — https://www.rightdecisions.scot.nhs.uk/diagnostic-atlas-of-variation-education-toolkit/psa/?organization=national