A 71-Year-Old Man With Urinary Problems

Gerald W. Chodak, MD

Disclosures

March 14, 2017

Discussion

Because the patient was bothered by his loss of sleep, the urologist prescribed an alpha-blocker and a 5-alpha reductase inhibitor (finasteride) and scheduled a follow-up examination in 1 month. The alpha-blocker is used to decrease the outlet resistance of the bladder and relax the pelvic musculature. The 5-alpha reductase inhibitor shrinks the prostate but may take 3-5 months to start working. These two drugs are often prescribed together to maximize the effects of both. The patient was instructed that taking finasteride will decrease the PSA by 50%; this needs to be taken into consideration at the next blood test.

At follow-up, the patient's urinary symptoms had improved. He continued on the medications and was asked to return in 6 months. At that visit, his symptoms remained stable. He was asked to return again 6 months later.

During the next visit, the urologist performed another PSA test; the result was 3.8 ng/mL. The patient stated that he had sexual intercourse the night before the examination. He returned in 1 week after refraining from sex for 1 day, and the PSA test was repeated; the result was 3.6 ng/mL.[1]

A prostate biopsy was recommended because the patient's PSA level did not actually decline. Normally, finasteride should drop the PSA by about 50%, thus yielding a "real" PSA of 7.2 ng/mL; this value is a dramatic increase from 2.4 ng/mL.

A 12-core biopsy was performed after suitable anesthesia and a prebiopsy antibiotic. The results showed a Gleason score of 3+3 cancer in two cores, each occupying less than 50% of the core (Figure 2). The PSA density was calculated at 0.14. No staging tests were performed.[2]

Figure 2.

The reason for performing staging tests is to determine whether a patient is suitable for local therapy. Whereas routine testing for metastases was formerly performed on every new case of prostate cancer, doctors have started to question whether such tests are necessary. Now, obtaining these tests makes little sense, given that the odds of finding metastases are lower than the false-negative rates of the tests. On the basis of PSA measurement, DRE, and biopsy results, the odds of cancer that spreads to the bones is less than 1%.

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