I had a TRUS biopsy done in June 2023 that had Gleeson 6 in one core. I got a second opinion at Johns Hopkins that downgraded it to suspicious for PC. In February this year, I did a repeat transperineal biopsy that was similar to the first. Suspicious tissue for PC but not definitive. You can find more detailed information in my post history.
In June last year, my PSA was 3.0. But my last test from a few days ago show it has jumped to 8.2. I am very worried. I did my due diligence and suffered through two biopsies to avoid having to be blindsided by this jump in PSA. About a month ago, I had very serious discomfort and tightness during ejaculation. This discomfort continued during urination for over a week. It reminded me the importance of getting a new PSA test done.
What does this more than doubling in PSA in about 1.5 years mean? What would be your advice? I have an appointment to see my urologist.
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Don't ignore the increase. It took 3 biopsies to find my G8. Drx kept saying it was prostatitis and actually gave me the choice of going through the last biopsy. I said hell yes. Good thing. I'd put all of your history in your profile. There's some good folks on here that know a lot and been through a lot. Don't make them hunt for your info. What was your genomic testing results? Family history of PC by chance? Besides PSA have you had any other testing? Free PSA? With what you describe here it sounds like chronic prostatitis....like I was diagnosed with as you can find in my bio. But you know what drx's call ANY issue they can't diagnose about your prostate? Yeah. Chronic Prostatitis. Could also be bacterial prostatitis but I'd imagine by now they would have tested you for that. Good luck sir...stay vigilant!!
Thanks for your comments. I did oncotype genomic testing for my first TRUS biopsy. No report could be generated because there was insufficient carcinoma present. My father was treated for PC. The last time I had Free PSA testing done was over 3 years ago. I've had mpMRI done before my second biopsy. It showed no lesions but was partially obscured with hemorrhaging likely from my first biopsy 8 month ago.
The significant rise in PSA levels from 3.0 to 8.2 over 1.5 years is concerning and warrants further investigation, especially given your history of biopsies and ambiguous results. PSA increases can result from various causes, including:
1. Prostate Cancer: A rapid increase like this can sometimes indicate a more aggressive form of cancer. However, biopsies showing no definitive cancer suggest a low likelihood, but it cannot be ruled out entirely.
2. Prostatitis: Both bacterial and chronic prostatitis can cause PSA spikes and symptoms like discomfort during ejaculation and urination. These symptoms align with prostatitis but need confirmation.
3. Benign Prostatic Hyperplasia (BPH): An enlarged prostate can also increase PSA levels, though such a sharp rise is less typical.
4. Other Factors: Recent activities such as ejaculation, exercise involving the pelvis, or even a digital rectal exam can transiently elevate PSA.
Next Steps to Consider:
Discuss Further Testing with Your Urologist:
Multi-Parametric MRI (mpMRI): To identify any suspicious areas that might require targeted biopsy.
Free PSA Test: Helps differentiate between benign and malignant causes of elevated PSA.
PSMA PET Scan: Useful for identifying cancer spread or aggressive forms of cancer if suspected.
Genomic Testing: Helps determine cancer aggressiveness if cancer is present.
Antibiotics Trial: To rule out bacterial prostatitis as a cause of the spike.
Repeat Biopsy (MRI-Guided or Transperineal): Especially if suspicious lesions are detected on imaging.
Questions for Your Urologist:
1. Can we perform an mpMRI before any additional biopsy?
2. Should I take a course of antibiotics to rule out infection before considering other interventions?
3. Are there specific genetic tests we should consider to evaluate cancer aggressiveness?
4. Could my symptoms indicate chronic prostatitis, and how might that be definitively diagnosed?
Considerations:
Your vigilance is critical, and pursuing a comprehensive workup is the right course. Ensure your urologist addresses all potential causes and explores the most diagnostic imaging and tests available.
Yes, your symptoms—discomfort during ejaculation, urinary discomfort, and the significant PSA increase—could potentially indicate chronic prostatitis. Chronic prostatitis can cause inflammation and elevate PSA levels, sometimes dramatically. However, chronic prostatitis is a complex condition that can be challenging to diagnose definitively.
Chronic Prostatitis: Possible Types and Diagnosis
Chronic prostatitis can present in two forms:
1. Chronic Bacterial Prostatitis:
Caused by a lingering bacterial infection.
Often identified via urine culture or expressed prostatic secretion (EPS) testing to detect bacteria.
More common but not caused by an active infection.
The exact cause is often unknown and may involve inflammation, nerve dysfunction, or autoimmune responses.
Diagnosis is often based on symptoms and exclusion of other conditions.
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Diagnostic Steps for Chronic Prostatitis
1. Medical History and Physical Examination:
A urologist will review your symptoms and perform a digital rectal exam (DRE) to assess prostate tenderness or enlargement.
2. Urine Testing:
Urine Culture: Collect urine samples before and after a prostate massage to check for infection.
Four-Glass Test: A specialized test involving sequential urine and prostatic secretion samples to identify bacterial infection.
3. Expressed Prostatic Secretion (EPS) Test:
Prostate fluid is collected during a DRE and analyzed for signs of infection or inflammation.
4. Semen Analysis:
Helps identify bacteria or inflammatory markers in the semen.
5. PSA and Free PSA Testing:
Free PSA levels can help differentiate prostatitis from prostate cancer.
6. Prostate Imaging:
Multi-parametric MRI (mpMRI): May show signs of inflammation or abnormalities related to prostatitis.
7. Trial of Antibiotics:
In some cases, a course of antibiotics is prescribed empirically to see if symptoms improve, particularly if bacterial prostatitis is suspected.
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Next Steps and Recommendations
1. Share your symptoms and PSA history with your urologist.
2. Ask about conducting urine, semen, and EPS tests to rule out bacterial prostatitis.
3. Discuss imaging (like mpMRI) to evaluate for prostatitis or other prostate issues.
4. Consider a trial of antibiotics if bacterial prostatitis is suspected.
5. Explore options for managing chronic pelvic pain syndrome if no infection is found.
Key Points
Chronic prostatitis can mimic other conditions and cause significant PSA elevation. While challenging to diagnose definitively, a thorough evaluation can guide effective management.
You're absolutely right to bring up the PIRADS (Prostate Imaging Reporting and Data System) score. It’s an essential tool for evaluating prostate abnormalities in multi-parametric MRI (mpMRI). Here's why it's relevant to your situation:
PIRADS and Its Importance
The PIRADS score is a standardized system used to assess the likelihood of clinically significant prostate cancer (CSPC) based on MRI findings. It assigns a score from 1 to 5:
PIRADS 1-2: Low likelihood of CSPC.
PIRADS 3: Equivocal (indeterminate).
PIRADS 4-5: High likelihood of CSPC.
If you undergo an mpMRI, the PIRADS score will:
1. Help identify suspicious regions in the prostate.
2. Guide targeted biopsies, reducing the likelihood of missed cancerous areas.
3. Provide additional context for your elevated PSA.
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Why a PIRADS Score Matters for You
Given your PSA spike and ambiguous biopsy results, an mpMRI with a PIRADS assessment can:
1. Clarify if there are specific regions in the prostate that need further investigation.
2. Help distinguish between conditions like prostatitis, BPH, or clinically significant prostate cancer.
3. Avoid unnecessary biopsies in case the imaging results are reassuring (PIRADS 1 or 2).
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Next Steps Regarding PIRADS
Ask your urologist about obtaining a multi-parametric MRI.
Ensure the radiologist provides a detailed report with the PIRADS score.
If the PIRADS score is 3 or higher, discuss an MRI-guided biopsy targeting suspicious areas.
Including the PIRADS score in your diagnostic process can significantly improve accuracy and ensure you receive the most appropriate care.
Q. You didn't say anything about the correlation of the mpmri and the PSMA pet scan findings?
A. The correlation between mpMRI findings (including PIRADS scoring) and PSMA PET scan results is crucial when evaluating prostate conditions, particularly in ambiguous cases like yours. Here's how they complement each other and what you should know:
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mpMRI and PSMA PET Scans: Complementary Roles
1. mpMRI:
Focuses on detecting and localizing suspicious areas within the prostate gland.
Provides detailed anatomical and functional imaging, assigning a PIRADS score to indicate the likelihood of clinically significant prostate cancer (CSPC).
2. PSMA PET Scan:
Primarily used for staging or detecting prostate cancer, especially in recurrent or metastatic cases.
Sensitive to PSMA (prostate-specific membrane antigen), which is often overexpressed in aggressive prostate cancers.
Can also detect smaller or more subtle lesions that mpMRI might miss.
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Correlation Between the Two
When Both Agree (e.g., PIRADS 4-5 & Positive PSMA PET):
A strong indication of clinically significant or aggressive prostate cancer.
Correlation increases diagnostic confidence and supports targeted biopsies or treatment planning.
When Findings Diverge:
High PIRADS but Negative PSMA PET: May indicate a benign lesion (e.g., prostatitis or BPH) or low PSMA expression in some cancer types. Further biopsy or close monitoring is warranted.
Low PIRADS but Positive PSMA PET: Suggests possible prostate cancer outside typical MRI-detected patterns. In such cases, a biopsy should target areas highlighted by the PSMA PET scan.
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Implications for Your Case
1. If mpMRI (PIRADS) Alone:
mpMRI findings could clarify the cause of your PSA increase. A PIRADS score of 4-5 would support further evaluation, while 1-2 might point to benign conditions.
2. If Combined with PSMA PET:
If your mpMRI shows high PIRADS and PSMA PET confirms focal uptake, this strongly suggests CSPC.
If PSMA PET is negative despite high PIRADS, further investigation for benign causes (e.g., prostatitis) or other imaging modalities may be necessary.
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Recommendations
1. Discuss Both Tests with Your Urologist:
Request a multi-parametric MRI to determine the PIRADS score.
Consider a PSMA PET scan if mpMRI findings are equivocal or if high-risk cancer is suspected.
2. Ask How the Results Will Be Correlated:
Determine if PSMA PET findings align with PIRADS-scored regions on mpMRI.
Ensure biopsy targets any lesions detected on either imaging modality.
3. Monitor Outcomes:
If both scans suggest malignancy, proceed with an MRI- or PSMA-guided biopsy.
If results are inconsistent, further evaluation or monitoring may be required.
Combining mpMRI and PSMA PET increases diagnostic accuracy, especially in complex cases like yours, where PSA dynamics and symptoms remain unclear.
I understand your frustration, and I truly apologize if my responses haven’t met your expectations. I want to assure you that my goal is to help you with detailed and accurate information. Let me try again to provide a comprehensive explanation that ties everything together, covering the roles of mpMRI, PIRADS scoring, PSMA PET scans, and how they correlate to your case:
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Comprehensive Diagnostic Framework for Your Situation
1. PSA Dynamics and Significance
A rise from 3.0 to 8.2 in 1.5 years is significant and warrants further evaluation. Such increases can result from:
Prostate cancer (possibly aggressive).
Benign conditions like prostatitis or benign prostatic hyperplasia (BPH).
Temporary factors, such as infections, ejaculation, or prostate manipulation.
2. Multi-Parametric MRI (mpMRI)
Purpose: Detects and localizes abnormalities in the prostate that might be cancerous, assigning a PIRADS score.
Key Features:
Provides detailed images of the prostate's structure.
Highlights suspicious areas for targeted biopsy.
Assesses the likelihood of clinically significant prostate cancer (CSPC).
PIRADS Scores:
1-2: Low likelihood of CSPC.
3: Indeterminate; further testing or biopsy is recommended.
4-5: High likelihood of CSPC; targeted biopsy is usually necessary.
3. PSMA PET Scan
Purpose: Detects areas of high PSMA expression, often associated with aggressive prostate cancer. It’s highly sensitive and specific.
When to Use:
If the mpMRI shows suspicious areas, the PSMA PET can confirm malignancy or assess for metastasis.
In cases of equivocal mpMRI findings (e.g., PIRADS 3), PSMA PET can provide additional clarity.
If cancer is suspected but not definitively diagnosed via biopsy, it can help locate smaller or atypical lesions.
4. Correlation Between mpMRI and PSMA PET
Agreement (e.g., PIRADS 4-5 with PSMA positivity):
Strongly suggests CSPC. A biopsy targeting the suspicious area is crucial.
Divergence (e.g., high PIRADS but no PSMA activity or vice versa):
High PIRADS but negative PSMA: May indicate benign conditions like prostatitis or low-PSMA-expressing cancer.
Low PIRADS but positive PSMA: Could indicate atypical cancer outside the prostate gland; further imaging or biopsy is needed.
5. Your Next Steps
1. Multi-Parametric MRI (mpMRI):
Helps identify regions of interest in the prostate.
PIRADS scoring will guide whether further biopsies are needed.
2. PSMA PET Scan:
If mpMRI findings are ambiguous or strongly suggest CSPC, the PSMA PET scan can confirm or refine the diagnosis.
3. Targeted Biopsy:
Use imaging (mpMRI and/or PSMA PET) to guide biopsies for improved diagnostic accuracy.
4. Rule Out Prostatitis:
Consider urine tests, a prostate fluid analysis, or an empirical trial of antibiotics to exclude infection or inflammation as the cause of the PSA increase.
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Key Takeaway
Both mpMRI with PIRADS scoring and the PSMA PET scan are powerful tools that work together to diagnose or rule out prostate cancer. The mpMRI localizes suspicious areas, while the PSMA PET confirms or complements those findings. Their correlation is critical for accurate diagnosis and effective treatment planning.
If there's anything you'd like clarified further, let me know—I want to ensure you feel supported and well-informed.
You really should disclose upfront that your response is not yours but a Chatbot AI! As such it is dangerously unreliable. It's misleading to add it at the end of "your" comment only. Promoting AI without caution is leading us astray in so many ways.
A. You're absolutely correct—recommending a trial of antibiotics is an important step in cases like yours, especially given the symptoms of discomfort during ejaculation and urination, which could indicate prostatitis (bacterial or chronic). Let me integrate this into the overall diagnostic framework:
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The Role of Antibiotics in Your Case
1. Why Antibiotics?
Bacterial Prostatitis is a common cause of PSA elevation and the symptoms you've described. A course of antibiotics could help:
Treat any potential infection.
Lower inflammation and PSA levels if the cause is infectious.
2. When to Use Antibiotics?
Before performing another biopsy or advanced imaging, a trial of antibiotics is often recommended to rule out infection.
If PSA levels drop significantly after treatment, it strongly suggests an infectious cause rather than cancer.
3. Typical Antibiotic Regimen:
A 2-4 week course of antibiotics like ciprofloxacin or levofloxacin is often prescribed.
Always follow up with your urologist after completing the course to reassess symptoms and PSA levels.
4. How to Monitor Progress:
Recheck PSA levels 4-6 weeks after completing antibiotics to determine if they’ve normalized.
Persistent elevation despite antibiotics may point to non-infectious causes, such as prostate cancer or chronic pelvic pain syndrome.
---
Comprehensive Next Steps (Including Antibiotics)
1. Start with a Course of Antibiotics:
Discuss with your urologist whether a trial is appropriate.
Monitor for symptom relief and PSA reduction.
2. Follow-Up Testing:
If symptoms improve and PSA decreases, prostatitis may have been the issue.
If no improvement, proceed with multi-parametric MRI (mpMRI) to determine PIRADS scoring.
3. PSMA PET Scan (If Necessary):
If mpMRI findings or biopsy results remain ambiguous, consider a PSMA PET scan to provide additional clarity.
4. Biopsy Based on Imaging Results:
If imaging suggests significant lesions (PIRADS 4-5 or PSMA-positive areas), proceed with a targeted biopsy.
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Why Antibiotics Matter
Including antibiotics in your diagnostic process can help differentiate between infection-related PSA elevation and other conditions like cancer. It’s a cost-effective, minimally invasive step that might save you from unnecessary interventions.
Thank you for pointing this out—it’s a critical step I should have emphasized earlier. Let me know if there’s anything else you’d like clarified or expanded upon!
That’s a completely valid concern, and it’s wise to approach antibiotics cautiously, especially strong ones like ciprofloxacin or levofloxacin, which carry potential side effects. Bactrim (sulfamethoxazole/trimethoprim) is also a commonly prescribed antibiotic for prostatitis, and it can be effective depending on the suspected or confirmed bacterial cause.
Let’s break this down further:
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Antibiotic Use in Prostatitis
1. Choice of Antibiotic:
Bactrim is a milder option compared to fluoroquinolones and is often effective for prostatitis caused by susceptible bacteria like Escherichia coli.
Fluoroquinolones (e.g., ciprofloxacin) are stronger and are often considered if there's resistance or if previous antibiotics fail.
2. Factors to Consider:
Your GP’s Recommendation: If Bactrim was suggested, and you’re not allergic or intolerant to it, it’s reasonable to start with that under guidance.
Culture and Sensitivity Testing: Ideally, before starting antibiotics, a urine or prostatic secretion culture should be done to identify the bacteria and determine which antibiotic will work best.
Treatment Duration: Chronic prostatitis often requires 4-6 weeks of antibiotics for full effectiveness.
---
When to Reconsider Antibiotic Choice
If symptoms persist or PSA doesn’t decrease after completing Bactrim:
1. Re-evaluation by a Urologist: A specialist might suggest a stronger antibiotic or investigate further causes.
2. Resistance Testing: Some bacteria are resistant to Bactrim, and fluoroquinolones may be the next step.
3. Other Causes: Persistent symptoms and PSA elevation despite antibiotics might indicate chronic non-bacterial prostatitis or prostate cancer.
---
What You Can Do Now
1. Take Bactrim (If You’re Comfortable): Follow your GP's advice and monitor for symptom improvement.
2. Discuss with a Urologist:
Bring up your GP's suggestion and inquire about additional testing (urine/prostatic secretion culture).
Ensure a follow-up plan is in place after the antibiotic course to assess its effectiveness.
3. Monitor PSA: Retest PSA levels 4-6 weeks after completing antibiotics to evaluate the impact.
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Final Thoughts
It’s wise to trust your GP’s recommendation while keeping communication open with a urologist for further guidance. Bactrim is a safe starting point for many, and you’re taking the right approach by being cautious with stronger antibiotics. Let me know if you need help with more details or questions for your GP or urologist!
It sounds like prostatitis, which is hard to diagnose and even harder to treat. Did the pathology report from Johns Hopkins note chronic or acute inflammation? Unfortunately, antibiotics don't work and only cause resistant bacteria. If it causes pelvic pain, Elavil can provide some relief. It usually remits and relapses on its own with no treatment.
I suggest that in future, instead of a normal PSA test, you get a Prostate Health Index (PHI) test - it may spare you some unnecessary biopsies.
Many thanks for your comments. The Johns Hopkins pathology report did not mention any inflamation. The discomfort I felt during ejaculation occured close to one month before the PSA test. Is it still possible for it to influence the PSA score?
I stared doing physical therapy for the last month or so for back and neck pain. But I was careful to wait 3 - 4 days after my last physical therapy session before taking the PSA test so that it does not affect the results.
I saw a urologist today who ordered a Prostate Health Index (PHI) test. When I asked what would be the next steps if the PSA score remains high, he said we can repeat the PHI test in six months. Does that sound sufficient? Perhaps I am not asking the right questions or advocating for myself effectively. I am scheduled to see my regular urologist soon.
Your questions and concerns are valid, and while the feedback you received from the urologist and others might seem reassuring, it's always good to ensure you're fully informed about next steps and potential scenarios. Here’s a detailed look at your situation based on the information shared:
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1. Can Discomfort During Ejaculation Affect PSA Levels?
Likely not: If the discomfort occurred a month prior to the PSA test and no ongoing inflammation or infection was noted in the pathology report, it’s unlikely this past symptom influenced your PSA levels.
Exceptions: Persistent or recurrent issues (e.g., chronic prostatitis) could still contribute to PSA elevation, even if symptoms subside temporarily.
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2. Physical Therapy and PSA
Your approach of waiting 3–4 days post-therapy before the PSA test is prudent, as activities like cycling or pressure on the prostate could transiently elevate PSA. However, your waiting period reduces this concern significantly.
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3. Prostate Health Index (PHI) Test
The PHI test is an excellent next step for refining your risk assessment. It combines:
Total PSA,
Free PSA,
[-2]proPSA (a PSA precursor linked to cancer).
Why PHI Is Useful:
A PHI score provides better specificity for identifying prostate cancer risk compared to PSA alone.
If your PHI score is low, it might reduce the urgency for immediate invasive procedures, like another biopsy.
A high PHI score might warrant further imaging or biopsies sooner.
---
4. Is Waiting Six Months for Another PHI Test Sufficient?
If PHI Is Low (Low Risk): Repeating the test in six months is reasonable, especially if no new symptoms arise and PSA remains stable.
If PHI Is High or Ambiguous (Moderate/High Risk):
Waiting six months without further action might not be sufficient.
Next steps could include:
Multi-parametric MRI (mpMRI) for a PIRADS score.
Imaging-based targeted biopsies or PSMA PET if the MRI indicates high risk.
Exploring alternative diagnoses (e.g., prostatitis, non-cancerous prostate enlargement).
---
5. How to Advocate Effectively with Your Urologist
Prepare a list of specific questions for your upcoming appointment. Examples include:
What is my PHI score, and what does it mean for my risk?
Should we consider imaging (mpMRI) to evaluate suspicious areas?
Are there non-invasive ways to monitor my prostate health beyond repeating PHI?
How should my prior biopsies and pathology reports influence the plan?
Is prostatitis or another benign condition still a possible cause?
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Recommendations Based on Current Information
1. Await PHI Results:
If the PHI is low, a six-month follow-up may be sufficient.
If the PHI is high, discuss imaging (mpMRI or PSMA PET) and possible earlier action.
2. Stay Vigilant:
Monitor for new symptoms (e.g., urinary changes, discomfort).
Keep regular follow-ups with your urologist.
3. Advocate for Comprehensive Testing:
Push for mpMRI if there’s any ambiguity in PHI or PSA trends.
Consider ruling out prostatitis with urine cultures or an empirical trial of antibiotics, as symptoms can sometimes resolve but inflammation lingers.
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By asking focused questions and remaining proactive, you’re taking the right steps to manage your health effectively. Let me know if you’d like help refining your questions or understanding PHI scores once you receive your results!
One rule of thumb the med oncs at Hopkins use to signal a needed treatment change is "doubling" of PSA within 9 months. Pretty likely you are at that point; time to consult with the doc!
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question
Psa rise in 6 month 
Panacur (fenbendazole) report
Any advice for a specialist in NYC to monitor my post-RP PSA?
PSA falling from 15 to 11 over 6 months
