47 - PSA 3.0+, Negative MRI, LUTS, biopsy?

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Sorry this is long. About 2 years ago I started having a noticeable increase in LUTS. Getting up a 2-3 times a night, weak stream, particularly after drinking a few drinks, and after holding my urine for a while. I had a phone screen with a urologist who, who suggested a PSA and Floxmax. I did the PSA in April of 2020 and started flomax. The PSA came back at 3.03. I didn't like the flowmax because of the RE so I stopped.

The urologist was of couse concerned about the 3.0+ PSA and ordered a retest a couple weeks later that came back at 3.09. He then suggest a course of antibiotics and a retest about 3 months later. He also wanted to do a biopsy which I did not want to do. The retest came in at 3.22 about 4 months from the first test. I switched to a different urologist who was closer to me and he also wanted to do a biopsy(both with Kaisar NW). I did get into the office and he did a DRE and a cystography. He said my prostate was large but didn't feel anything unusual. The cystography showed my prostate pushing into my bladder and I was clearly peeing through a small slit. He did also see some tribiculation in my bladder. I still refused the biopsy and pushed for an MRI. He begrudgingly ordered the MRI which came back negative. This is now September 2020

The MRI said the following. Curious on other's opinion's here.

*TECHNIQUE: Multiplanar multisequence images of the pelvis were performed. 7.2 cc of Gadavist IV contrast was administered.

FINDINGS:

Prostate gland dimensions: 4.0 x 5.5 x 4.9 cm

Prostate volume:56.1 mL

PSA density: 0.06

Transitional zone:

BPH nodules noted. No suspicious lesion.

Peripheral zone:

No suspicious prostatic lesions. Regions of decreased T2 signal within the peripheral zones are favored to relate to prostatitis.

Extra-prostatic extension:

None

Seminal Vesicles:

Unremarkable

Lymph nodes:

No pelvic lymphadenopathy

Urinary bladder:

Unremarkable.

Bones:

No aggressive osseous lesions

IMPRESSION:

  1. No suspicious prostatic lesions.
  2. No pelvic lymphadenopathy.*

Based on this it seemed that aggressive cancer was unlikely. The urologist agreed that I was probably ok and we agreed to keep checking my PSA every 6 months.

6 months later, now March 2021 I check my PSA and it is 3.09. I had also been taking Quarcetin which is supposed to help with BPH but is also an anti-inflammatory, so that could be the reason my PSA dropped. Happy that it dropped, I didn't think much about it again until I did my next retake. I went a little longer than 6 months and had it taken Nov 1. This time PSA was 3.54 and I had not been taking any supplements. I also made sure to take it easy a couple days before and hadn't ejaculated in about 5 days before. Now I am concerned it went up and by an amount that may be concerning by some accounts.

My doctor's office called and he wants to talk to me about my PSA.

I know my PSA is high for someone my age. I have LUTS and BPH and a 56 mL prostate. PSA density is OK based on my research and my doctor's opinion. My PSA did go up a lot in a 7 month period, but is still only about 0.5 since my first reading about 18 months ago.

What would you guys do? Hold off on a biopsy and keeping watching the PSA? My LUTS is getting to be annoying so I will need to do some kind of procedure at some point to preserve my bladder.

I read there are some other blood tests that are more specific to PC. I could even pay out of pocket for some of these if I can't get Kaiser to order them. Is that an option for that? Should I do another MRI?

No cancer history in my family. I am healthy, non-smoker, exercise a lot.

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  • Edited

    @not_too_shabby, shabby you are head and shoulders above many here dealing with BPH and OAB. Hoping for best in being cancer free for you. By the sound of things you are ahead of the game. How much caffeine, alcohol, or tea do you consume? I also have the obstructive median lobe, creating a 'ball valve effect'. The squeeze caused by the neck protruding into bladder is a real issue and difficult to resolve thru medications. I have had issues with flomax taken with myrbetriq. But have so far escaped the scissors, the flame thrower, the firehose, the enucleation bomb and more. Of all things, I sense the active life style being paramount. Moderation on most things. Happy trails

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  • Edited

    I drink one americano (2 shots espresso + water) in the morning. That is pretty much it for coffee for the day. Occasionally I may make myself a keurig pod if the one cup isn't cutting it. Caffeine definitely increases the urgency issues during the day.

    As far as alcohol, I was drinking a lot on the weekends, maybe 3-4 mixed drinks an evening. I have cut that back dramatically too as drinking too much would cause me to sleep heavy and then wake up in almost full retention due to that ball valve effect. I have cut back to drinking a glass or two of wine. I generally don't drink during the week and try to reserve it for Friday-Sunday.

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  • Edited

    Relax. Trust your MRI, if it was seen by a good radiologist. No need for a biopsy unless PSA keeps growing steadily or next MRI comes back suspicious.

    You are unlucky to have a large median lobe growing into your bladder. You can try Cialis 5mg daily and Saw Palmetto - it helps some to alleviate the symptoms. Keep catheters at home and take them with you when you travel. Seriously - it may save your life.

    Considering your relatively young age, you need to start gathering information about a surgical procedure. Doctors are really concerned about cancer (and PSA is their only indicator albeit very unreliable), which you probably don't have (based on your history above), but they rarely mention urine retention. After you have been in retention - your choice is between a catheter or a surgery and the damage to your bladder and kidneys is unpredictable.

    There are no reliable tests for prostate cancer. For your peace of mind you can ask for free PSA or PCA3 but they only give idea of its probability.

    The only useful test you can have is the combination of Flowrate and ultrasound with Post-void residual - this will measure your flow and the amount of urine remaining in your bladder. If the former is below 10 ml/sec and and the latter is above 100 ml - start seeing urological surgeons.

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  • Edited

    You raise a good many symptoms and tests. Good for you.

    As someone who was Dx'd and treated for PCa (Gleason 9) and went through a whole lot of crap by way of treatment, I must say that the best advice I can offer from the get-go is to follow Allondon's very important statement:

    **

    Trust your MRI, if it was seen by a good radiologist

    **

    A radiologist who SPECIALISES in prostate imaging makes all the difference in correctly interpreting what he/she sees. A generalist radiologist is not as experienced when reading the scans may reach the wrong conclusion, which in turn may lead to no treatment, wrong treatment or incorrect treatment.

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  • Edited

    At 63 my PSA has risen from 3.7 at age 50 to 10.9 now. My last MRI came back benign. My prostate size is 95g and of course I have LUTS and am currently considering Rezum or TURP with my consultant. Tamsulosin reduced urinary issues initially but as my prostate gets bigger and my PSA gets higher I may need something other than more drugs. I previously had 2 biopsies and my advice, given your comparably low PSA and having a clear MRI would be to avoid the biopsies completely. The biopsy is like a needle in a haystack anyway and my experience of biopsies was very unpleasant, I had continual infections and a large jump in my PSA immediately after my biopsies. It's obviously up to you, but as others have said; Trust your MRI, in my opinion its far more accurate than a biopsy and saves a totally unnecessary invasive procedure. If there was any concern on the MRI they would have suggested a biopsy.

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  • Posted

    Nothing new to report. My doctor wants to discuss my PSA the end of January(soonest appointment). Since that is so far away, I'll probably do another PSA right before we talk to see if the PSA was just a blip or if it's back on the rise again. I started taking Quarecetin again which seems to have helped my urinary symptoms. At this point, I am trusting my MRI as others have suggested.

    Answering someone's question, I don't have any pain to speak of, just LUTs symptoms, the worse being if I hold my urine too long where my stream can be very weak.

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  • Posted

    thank you for your updates shabby. I too am a young man( 38 years old) with similar symptoms. i’ve noticed my stream slow down over the past couple of years especially when my bladder is full ie when I wake up in the morning (if i make it through the night). I also get a little bit of a burning sensation in my bladder when I hold it in for too long. it’s often the feeling that wakes me up in the middle of the night. did your doctor ever explain why having a full bladder causes slow flow? does your flow improve throughout the day or when your bladder is not full to capacity? Lastly, I know you may have mentioned it in your first post but looking back at it when do you think your Symptoms began? Thank you for any information you can share much appreciated

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  • Posted

    I had prostate problems where I struggle to pee my psa reading 3.5 then had another one 8 weeks later came back 2.12 but doctor put me on some tamsulosin as a precaution..you prostate is fine and a normal reading for your age

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  • Posted

    hey Shabby,

    sounds like you're onto it and your story is very very similar to mine. My first ever PSA at 44 was 2.2, not high but not normal, 6 months later PSA was 3.8. At this stage i was told to see a urologist who wanted an mri and a biopsy. Now i was young fit and healthy with no symptoms and considered a biopsy overkill for my situation so i did another PSA, this time back to 2.2. I had the mri, which stated "widespread low signal peripheral zone most in keeping with prostatitis". I thought i could now relax. The urologist said to me "i strongly advise a biopsy as your psa isnt normal. I ignored him and kept checking PSA every 6 months for next 2 years. it varied between 3 and 3.5, then suddenly at age 46 it went to 8.2.

    At this point i thought fine i better get a biopsy. Result gleason 9 PC. The good news is that i recovered and was cured by surgery alone. over 5 years undetectable ultra sensitive PSA.

    The one clue that probably didnt add up to mine being benign was the freePSA % which in my case was under 10 consistently.

    My advice. Its probably benign but dont bet with your life on the mri and just put it to bed once and for all with a biopsy.

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    • Posted

      by the way, the mri was read by someone that was supposed to be the best. Even my 2nd urologist that did the operation acknowledged that he was surprised by the mri considering what was actually there and stated that the person that wrote the report is highly regarded. They can only report on what they see. If you have widespread signal like i did it will make it hard to identify specific areas

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    • Edited

      Thanks for the reply. Your story isn't one I wanted to read. Glad you are recovered from your PC though.

      When you were 44, did you have any LUTs symptoms? Did the MRI measure your PSA density? Most of what I have read suggests LUTs is more an indicator of BPH than PC. My PSA density is still considered "normal" due to my prostate size being larger than normal, 0.06 density. I am thinking a threshold of 4 for my PSA is probably when I should consider biopsy.

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    • Posted

      Hi,

      I dont remember PSA density being mentioned. I'm guessing things have changed in the last 7 years.

      I didn't think i had any symptoms but I do remember an occasion when I had held on for hours and when I finally got to go pretty much nothing happened which i thought was very strange but just put down to holding in so much for so long.

      Have you had free PSA measured?

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    • Edited

      No, haven't had free PSA done yet. My Dr. said something about free PSA not being done unless PSA is over 4.0? Maybe it's an insurance thing. I would pay for any of these blood tests to get more clarity and avoid a biopsy. I may need to dig into that more.

      PSA density just divides your PSA by your prostate volume to normalize it. They use the MRI to measure the size and calculate the PSA density.

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    • Posted

      Before your next psa .

      Try the list and see if psa drops.

      1. no ejaculate for three days
      2. take an ibuprofen for the three days to reduce inflammation
      3. no bike riding, caffeine, soda, they can aggravate bladder neck.
      4. alfuzosin or flomax to relax prostate,
      5. make sure the same lab each test.
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