Skip to content

MRI PI-RADS scoring

Hi  Can anyone tell me more about PI-Rads scoring after an MRI scan on the prostate.  My husband has been graded a 4 and it waiting for a biopsy the one done under a general anaesthetic.  I have not been able to find out much about it other than 4 means very likely that clinically significant cancer will be found.  We we spoke to the specialist nurse she also said that there was some concern over pelvic lymph nodes.  Not sure if she meant swollen or they thought there was cancer.  Bone scan was negative.  Background on my husband age 71.  Hight psa's since 2002 ranging from starting point of 4 and rising over the years with scores of 7, 14,19,21 and 2016 38.  He was diagnosed with enlarged benign prostate and has had 2 negative biopsies over the years and 2 negative MRI scans.  The only thing found was lot of inflammation noted on biopsies.  Last year when it rose to 38 he had a negative MRI scan which the team looked at and thought it was all down to the inflammation and the prostate size.  We have moved house to a different area where the recent MRI has been done.  I should add that he was given finasteride 2016 to reduce the size of the prostate and his last reading was 26. The consultant says that drugs reduces the psa reading by 50% which means the true reading would be 52.  In the letter sent to our gp which we have a copy of it just says if psa rises 20% above presenting level of 38 to refer back.    I should add that my husband has other health problems namely type 2 diabetes, asthma/copd and is overweight.  Obviously we will have to wait until the biopsy is done.  He is not keen as he had a reaction to the anitbiotics hence the MRI scans.  He also has to have a pre assessment to see if he it fit for general or maybe an epidural.  It is all very worrying and can't seem to read about any patient with a similar story.  All I read is about men with psa under ten being diagnosed with advanced cancer and or those with readings in the 100s or 1000s.  The nurse mentioned if it was cancer and they seem to think it is then maybe radiotherapy or hormone treatment both of which seem to have bad side effects.  Not sure but think that he would not cope very well.  I can't seem to find anything much about inflammation with no symptoms and high psa readings either.  I should add that I have read that the drug finasteride can cause agressive cancers but protect against non agressive ones.  Also he takes a spiriva inhaler for his asthma since Sept 2015 and there are reports of it causing problems with prostate and psa spikes and cancer.  The consultant said it does not.  I have asked the nurse to do some research for me for when we go back.  This is a long and complicated post and unfortunately my husband is not type to want to find out about anything even if he is diagnosed so I try to find out and be prepared.  If anyone could comment I would be grateful  I did post in the Prostate problems forum about 1 year ago and just recently as well which give more details.  Thanks for reading this sorry I have gone on a bit.

94 Replies

  • libralady13

    Wow Libralady. That's a lot to talk about and I'm trying to think about where to start!

    PSA is not a definitive measurement but a useful guide when either rising steeply or when the condition is defined. A lot of things from benign hyperplasia to infections to just having intercourse will raise it.

    PI-RADS scoring is a little complex and involves several things. To quote:

    The score is assessed on prostate MRI. Images are obtained using a multiparametric technique including T2 weighted images, a dynamic contrast study (DCE) and DWI. If DCE or DWI are insufficient for interpretation, the newest guidelines recommend omitting them in the scoring 6.

    A score is given according to each variable. The scale is based on a score from 1 to 5 (which is given for each lesion), with 1 being most probably benign and 5 being highly suspicious of malignancy:

    PI-RADS 1: very low (clinically significant cancer is highly unlikely to be present)

    PI-RADS 2: low (clinically significant cancer is unlikely to be present)

    PI-RADS 3: intermediate (the presence of clinically significant cancer is equivocal)

    PI-RADS 4: high (clinically significant cancer is likely to be present)

    PI-RADS 5: very high (clinically significant cancer is highly likely to be present)

    You have just given the PI-RADS score but perhaps have the other results omitted (eg DCE, DWI - though these are omitted if unclear).

    You are right that clinically significant cancer is likely to be present, but this may be a very slow growing adenocarcinoma entirely within the capsule. Actually the MRI should indicate whether it is likely to have an extra-capsular extension or not.

    The fact that there are indications of lymph node involvement show that there may be some concern regarding the stage. You really do need the biopsy results to get a better indication on this and on the implications regarding the best way to manage this (one form of management may be suppression of testosterone upon which prostate cancer relies).

    I hate to say this to you, but you have to take one step at a time with this or you will always end up making the wrong conclusions. It seems to have been a long story and one that indicates why mpMRI is so superior to conventional MRI.

    Please feel free to PM me if you feel it could be helpful at any time. I feel that this is one of those awful mismanaged cases due mainly to ignorance rather than anything else.


    • romneyj

      Thank you so much for replying,  You have sort of answered one question for me and that is that although it is likely to be be cancer it may be slow growing.  On line I found exactly what you have outlined but not anything abouthow agressive it might be.   We do not have a copy of the MRI scan as yet.  What I can tell you is that the last one in March 2016 showed gross hypertrophy prostate volume approx 210ml.  No suspicious tumour volume within hypertrophied transitional zone.  The peripheral zone compressed to thin rim.  No restriction of diffusion in peripheral zpne.  Patchy restriction in in BPH does not appear suspicious on T2 weighted image.  Patchy enhancement post contrast in transitional zone only.  No extra capsular disease, normal seminel vessels, no lymphapathy,no suspicious skeletal lesion.  No significant change to MRI scan in 2012.  As you say we do have to take one step at a time but I wonder why it would appear to have changed so much in 1 year.  This has been a stressful few years healthwise and in the last 6 months we have had to have colonoscopies, which thankfully turned out fine.  I have had heart scans again negative and he has had loads of blood tests.  Must admit fed up with all things medical.  It does not do my ongoing anxiety much good.  Am due to have some counselling soon.  I will keep you posted on how it goes.  We have been told he will get an appointment in 2 to 4 weeks and that was 1 week ago.  Thanks once again I am gateful for your input.  Ps I wondered why you might think it has been mismanaged.  

    • libralady13

      I believe that the history was sufficiently abnormal to have warrented sending him for mpMRI much earlier. The problem with conventional MRI is lack of sensitivity and difficulty differentiating between inflammation and tumour. Many hospital trusts do not have mpMRI but surely the urologist knows their limitations and where he could receive a more definitive answer. Biopsies are only as good as the guidence they get.

      It would seem that he is likely to have a T2 stage of cancer. (see below for definition):


      The cancer can be felt or seen on scans, but is still contained inside the prostate – localised prostate cancer.

      T2a - the cancer is in half of one side (lobe) of the prostate, or less.

      T2b - the cancer is in more than half of one of the lobes, but not in both lobes of the prostate.

      T2c - the cancer is in both lobes but is still inside the prostate.

      The comment from the nurse, whilst worrying seems to contradict the report you give above that says "no lymphopathy". It would also be very very unlikely that he had a lymph node involvelment from a T2 stage tumour (this might be expected to occurr at T4 stage). It seems that he is also N0 (no lymph node involvement) and M0 - no metastasization to bone.

      The biopsy will be guided by both Ultrasound and the MRI map and will tell you the 'aggressiveness' of the tumour (ie how urgent any treatment might be) and the type of cell involved (which is also a guide to prognosis). Once you have all that information you are in a better position to make decisions on the route you would prefer for treatment.

      I opted for a robotic radical prostatectomy (which resolved well). Others on this site have opted for EBRT (External beam radiotherapy) and feel they made the better choice! Yet others with T2 tumours have been early enough (like your husband) to be able to opt for brachytherapy of different types with great effect and almost no associated problems.

      I realise the waiting game is not only tiring and stressful but has the effect of putting your life on hold. All I can say is hold tight and hopefully the news may not be as bad as you feared.

    • romneyj

      Thank you,  Hope I didn't confuse you the results of the MRI which were March 2016.  We have not had a written copy of the MRi done earlier this month.  They have always said there was inflammation in the biopsies and wondered if this was anything to do with having had a vascectomy when he was 30 which was ok but 6 months afterwards he developed a problem and was in awful pain (  I remember the date because it was our sons birthday) and gp gave him antibiotics and said something about congestion and sperm having no where to go.  As it cleared up  we  did not think anymore about it until all this started a few years back with the first biopsy.  All doctors we have spoken to say there is no connection.  With regard to treatment I think that any treatment will not only be based on the grade and type of cancer but also side effects and that fact that he has other health problems.  I understand that the patient along with the medical profession have to make the best decision for them taking everything into account.    By the way the MRi along with the bone scan was done because of the psa result.  Is the mp MRI relatively new.  The normal ones were done is Greater London and the latest one in North West England.  Will keep you posted.

    • libralady13

      Ah yes. I have clearly crossed over the results of two MRis. My apologies.

      Yes mpMRI is pretty new. Most hospitals do not yet have this and certainly don't have radiologists (imaging specialists) that are trained to interpret their very very comlpex results.

      I do wish you all the best. It is never easy either before you get results or after. Decision making is always going to be a balancing act.

  • libralady13

    Feel for you,  Same here.  My husband had an MRI level 3, equivocal, elevated PSA levels from 11+ up and down and then up again,  An enlarged prostate,  Hospital doctor said 3 is a 50/50 chance of something or nothing and 4 is a higher percentage and 5 is almost definite cancer.  I don't know what PI-RADS means but I am going to look it up.  We are waiting for a template biopsy with general anaesthetic, have had a rectal scan of prostate with dye, and will be  having another MRI before biopsy as my husband has been enrolled in a clinical research trial, otherwise it would have been a TRUS biospy but we decided to delay and pay for a private MP MRI but hospital said they would do this in there clinical research instead when we told them of our intentions.

    My husband just goes along with whatever they say and then I research things and say whether or not I think it is the best approach, but sometimes I wonder if I am just confusing the situation for us both,  Hopefully it is better to be informed than not.

    It's a wild roller coaster ride and sometimes very confusing.  Hopefully for all of us it will be okay please God,  It is an anxious time.

    • anne05147

      Hello Anne  Sorry you are both having to go through all this as well.  I think you are right about us researching and confusing the situation but I need to know what is happening as like your husband mine will just go with what they suggest.  I have learnt from what I have read that this cancer is a lot different to others and there seems to be no one right approach.  As mentioned we are also waiting for an appointment for a template biopsy but first of all he has to be assessed for a general anaesthetic because of his breathing.  If not it will be a epidural which he is not keen on.  He is worried about it making his arthritis worse I think.  If not they have said they would have to do a normal biopsy guided by the MRI scan.  As he has a bad reaction to the anitbiotics they have said they will give him different ones.  We had all this worry last year and they said no cancer and now here we go again.  The high psa levels have been going on since 2002.  Please let me know how your husband gets on.  Please god he will be ok or at least the treatment will be for early cancer and successful.  I will post here again he has had the biopsy and results.At least the bone scan was clear.  Thank you for taking the trouble to post.

    • libralady13

      Yes, I will keep you posted and vice versa.   We're going for another MRI at the end of July and am expecting the biopsy sometime in August as already done the pre anaesthetic assessment.   I understood that enlarged prostate can raise PSA levels. 

      I'm sorry to hear your husband is going through all this again, I hope he will be okay for his anaesthetic. Glad to hear the bone scan was clear.  I have bought books on this and read a lot about it but at the end of the day I think the template biopsy is more accurate especially if they can target a particular area from the MRI.

      You say this has been going on since 2002, that's a long time.  Our GP said when this all started that if they look hard enough they will find prostate cancer in most men and that it is a very slow growing cancer and the doctor at the hospital said that it is more likely that old age will kill you before prostate cancer does.  Obviously there are those who have a serious aggressive type and I got the impression from the doctor that he thought having the psa test caused more problems than it helped. when he asked 'why did you have the test done?'  It was my idea because I  had heard about it and suggested it to my husband who rarely visits the GP.

      Did you husband have a biopsy last year.?  Was it a TRUS biopsy?Keep in touch and let me know how you are.

      Best wishes  -  Anne


    • anne05147

      Thank you for your kind words.  No he did not have a biopsy last year as they were satisfied with the MRI results.  If you read my posts to Romneyj you will see the results of the MRI just the normal type. I was ill on the day he got his results and could not go but out daughter went with him.  The consultant said that the cancer team had looked at the results and discussed the case and the history and came to the inclusion no cancer and that he should have regular psa testing and only be referred back to the urology dept if his psa rose 20% above the latest presenting level of 38 ( he did have another test whilst all this was going on and it came back at 30)  we have learnt since that while he is on finasteride to reduce size of prostate and helo with urinary symptoms you should double the psa result which is now 26 so that would be 52 worrying I know but others have said that it is not possible to know how well the drug works so the percentage might vary.  Doctors don't always agree on things do they.  I was not aware of the new MRI until he had the latest one but I did know there were 2 types of biopsy.  I will keep in touch and let you know what happens.  Good luck for your husband too.

      All the best 


    • libralady13

      I cannot add any more value that what Romeny has written. He knows this stuff. All I will say is that make sure that PSA tests are all carried out by the same lab as different labs have subtle differences in how they measure. Ensure that MRI scans are ideally using a 3T MRI scanner and that reports are written by radiologists that specialise in prostate reporting.

      Before rushing to a biopsy, which is an invasive procedure don't forget, discuss with the urologist and GP if your husband's other medical issues will greatly affects him before he'll suffer the effects of the cancer.

      I am 51 and last year was diagnosed with a PIRADS 4 before having a biospy. The PIRADS 4 prognosis was pot on!

    • barney34567

      Thank you for your reply.  He is not keen on having any type of biospy but they have insisted he needs this one done after the MRI results PIRADS 4.  He has to have a preop assessment so that will take into account his breathing and diabetes.  They have said if he is not suitable for a general then possibly an epidural.  They gave the impression that if does not go ahead with the biospy they would still want to treat it and then it is possible that he would have treatment he did not need together with all the side effects.  I don't think he has much option this time round.  What treatment did you have although I realise you are 20 years younger than my husband so this may limit his choice.

    • Meant to say you mention the PIRADS 4 was spot on after biospy.  Can I ask what stage cancer you were diagnosed with.  When it says PIRADS 4 a high chance of clinically significant cancer  found does this also refer to the agressiveness of the cancer.  Not really sure what significant cancer actaully means.

    • libralady13

      I interpreted "clinically significant" as most likely to be cancer than not. And a cancer that should be acted upon. My biopsy showed a 4+5, which is pretty darn bad.

      The biopsy indicated a T2 which meant that the PCa did not as far as could be seen, extend beyond the prostate. But this really doesn't men an much as I am proof that while mine was not the really bad T3 or T4, the surgery did not cure me.

    • libralady13

      Two key points come to mind:

      1. If he has a biopsy, he should get the best there is, that is an ultrasound guided transperineal biopsy. This method has a proven record of far lower risks of infection than the commonly used transrectal method, and

      2. Has he had any lower back or admininal surgeries in the past?

    • barney34567

      Thank you so much for your replies.  Sorry you have been going though all this how are you doing now?

      He is going for a pre op on Saturday morning to make sure he is fit for a general.  I am a bit concerned about this but will leave to the experts.  He has as you know a PIRADS 4 after the MRI and as I understood it he will have a guided biopsy under the general.  We did not see the consultant after the first consultation but the specialist cancer nurse said that would enable them to take more samples from the targeted place and being out of it would mean he is more comfortable.  Do you think this means the usual biopsy but under a general or the transperineal one.  I assumed it would be the latter now I am not so sure so I will get him to ask that on Saturday.  If all goes well the biospy is planned for Wednesday of next week.  They know he has a problem with ciprofloxin so are going to give him an alternative.  He has not had any abdominal surgeries in the past but he does have hip arthritis.  Earlier this year he has a colonscopy which although they found several polyps they were benign.  He is now on yearly followup.  As well as the Diabetes and the asthma/copd the thing that worrys me is that he is very overweight mostly abdomen sure you know what I mean.  I don't know how long it will be after the biospy when he gets the results hoping it will be before our daughter goes on holiday next month.  I don't want to spoil her holiday if she contacts us.  Will have to try and be patient very hard as you know.

    • libralady13

      Just to clarify, one biospy, the trans rectal, approaches the prostate from the rear which is why there is a good chance of infection. While the transperennial approaches the prostate from below the prostate, near the scrotum. This is what I had.

      The benefit of a MRI ultra sounded guided (in my case, transperennial) biopsy is that the urologist can maximise the number of supsicous cores that are sampled. If a unguided biopsy takes place then the samples gained are hit and miss and not that definitive, because they are not targeting the PIRADS region of suspicion.

      As far as I know both transperennial and trans rectal require a general anaesthetic. My query as to whether your husband and has had earlier lower back or abdominal surgery is because he may not want a second anaesthetic in that region, if he ends up with surgery. It is common in surgery to receive a general anaesthetic but sometimes, especially in robotic surgery but, not as far as I know in biopsies, the urologist may want to immobilise the lower part of the patient which requires a second anaesthetic. As I had lower back surgery, I declined the second anaesthetic which would be given smack bang in the middle of my earlier lower back surgery.

      You ask how soon the biopsy results are available. I can tell you this seems to be s function of how much "weight" the urologist carries. If he is a "big" name then he can tell the pathologist to get a move on and the result can be ready in a day or two. Before the biopsy, you could tell the urologist that you would like to the results ASAP. Ask him if you could see him on his first consulting day after the biopsy, assuming a biopsy is performed. 

      Did you bring the matter of diabetes and asthma/cold to the urologist's attention? Also mention any meds he is on or was on.


    • barney34567

      Hello Sorry for delay in replying.  My husband has had his pre op on Saturday morning.  Biospy scheduled for 13th July.  There has been some sort of mix up and when we looked at the letter it said a different hospital and I remembered that the specialist nurse said that it was only done at another one.  This morning I have spoked to the nurse and she confirmed it has to be done at the hospital she said rather than the one in the letter.

      We are waiting to hear back from her which won't be until tomorrow.  So now we don't quite know what day it will be.  A bit annoyed as he was hoping to get it done before my daughter does on holiday as he will reply on her or her husband for transport as I don't drive.  I did find out that he is to have a saturation biopsy and that could be transrectal or transperineal.  It will be up to the doctor who does the procedure.  He will only find out if it will be a general or epidural on the day after he sees the Anaesthetist.  Yes they do know about his diabetes and he has been given instructions on medication etc.  When he had the pre op his blood pressure and ecg were fine.  They also took blood.  The trouble is with my husband that when he sees a doctor or nurse he tends to play down asthma/copd symptoms and it probably seems if he is not too bad especially if he happens to be ok during the length of the appointment.  It is me and family who hear him coughing and choking and having trouble breathing.  Personally I am worried about him having a general and so is our daughter.  I did say this to the nurse.  I suppose we have to leave it up to the anaesthetist on the day.  Will let you know when we know when the date of the biopsy.

    • barney34567

      Have just had confirmation my husbands biopsy will be done on 13th July at the hospital on the letter so obviously wasn't a mistake.  As mentioned it will be a saturation biopsy either rectal or perineal depending on what the doctor thinks after viewing the MRI scan.  It will be done either under general or epidural.  He has a morning appointment because of his Diabetes so that is good.  This is the NHS so I don't think you can pick and choose what type of biopsy you want.   Will report again afterwards.

    • libralady13

      You say you I'll leave it up to the anaesthetist.

      I disagree.

      Before any surgery or biopsy you must tell the anaesthetist your husband's full medical history and every concern you have must be brought to the anaesthetist's attention.

      Question as much as you want.

      As mentioned earlier, I had spinal surgery a year before my prostatectomy. I was recommended a general and a spinal anaesthetic, because urolologicsl surgeons prefer both when using a robot in surgery. I impressed on the anaesthetist my understanding from the literature that sometimes very adverse reactions can take place if the site where ten spinal surgery is disturbed by a needle and that if the price of not having that second anaesthetic is more pain post op then so be it.

      After some badgering from me, the anaesthetist finally  agreed to my request and was genuinely surprised by my concern.

      The bottom line is that a patient needs to be hyper vigilant about his/ her concerns and that concern must not be outsourced to a physician.

    • libralady13

      I hear when you say you can't pick and choose a biopsy given you're going via the NHS.

      I assume that there are urologists who work for the NHS that prefer transrectal biopsies and other urologists that work for the NHS that prefer transperineal.

      Is the urologist your husband is seeing specialising in prostate cancer or is he a general urologist who does much more than just prostate cancer?

    • barney34567

      Thanks for your reply.  I agree with you, but I am unable to go with him as I don't drive, you are unable unable to wait with the patient anyway.  My son in law will be driving him there and collecting him later on.  They have all the history, but I could perhaps get him to take the copies of the paper work and discharge when he was in hospital in 2015 for his breathing.  if I mention anything about the whole subject he just tells me off.  I suppose he is not handling it well and is worried but it is hard for me too.  At the moment I am not feeling my best, a  cold and stomach problems.  I have been trying to think ahead and prepare us for any bad news treatment,  but clearly until he knows the biopsy results he will not speak about it.  From what I have read about treatment mainly radiotherapy and hormone treatment (because that is what the nurse thought any treatment might be) it seems the side effects are many and with his history of enlarged prostate urinary symptoms, breathing problems, being overweight and having Diabetes it seems that he might not be a good candiate for either treatment, also  I'm not sure how he would cope.  You may think I am jumping the gun a bit, but only trying to be prepared and after nearly 48 years of marriage, I think I know him well enough to know how he might react, although I could be wrong.  Will let you know how it all goes and thank you for showing an interest, much appreciated.

    • barney34567

      Sorry I missed this post.  All we know is the name of the consultant urologist who he is under the care of and who we saw in clinic.  Whether he will be doing the prodecure I don't know.  The consultant specialises in urology.  To give you an example when he had a colonoscopy earlier this year although he was under the care of a consultant colorectal surgeon another endoscopist did the procedure.  When I too had a colonoscopy earlier this year I was under the care of the Consultant in general and colorectal surgery and it was him to did the procedure.  It was at different hospital.  

    • libralady13

      I admire your proactivity. You ask if you're jumping the gun? Maybe, but that's a good thing. There are no prizes for asking questions after the event.

      You mention you want to give the anaesthetist or urologist your husband's earlier surgical reports. This is good but on a separate sheet I would summarise his surgical and medical history.

      This is because most physicians have no time to wade through countless sheets of papers a patient delivers. By all means have those papers ready to show the physician, but add them to a summary sheet as  listed above.

      Assuming the urologist and anaesthetist are prepared to go ahead with the biopsy given your husband's weight and medical  history the question to ask is: does he have serious medical issues that may imperil his life say in the next decade? The reason for this question is that a biopsy is an invasive procedure which should confirm the PIRADS 4 MRI diagnosis. The point of a biopsy is not only to determine if there is cancer, but to lead into a discussion as to how best to treat it.

      The next question is what treatment would your husband consider undergoing after the biopsy, given confirmation of a cancer? This must be answered taking into account any other serious medical conditions he may have, which may prove to be bigger issues than the possible prostate cancer he may have.

      Correct me if I am wrong but I sense you are leading your husband towards a definitive diagnosis and biopsy and that he is reluctant or indifferent to move this way.

      I willingly went through the stages of MRI, biopsy and treatment. But, if I sensed that inwas reluctant, I would preempt telling others that I don't appreciate being shoehorned into diagnosis and treatment by first seeking help from say a psychologist.


    • barney34567

      Hello again, In many ways I am on the same page as you been proactive and thinking about any treatment taking into account his medical problems. No one has ever said much about how his condition might change over the years.  The only thing in his favour is a history of longevity on his dads side who lived to be 84 and all of his brothers and sister except one have lived well into 80' and 90's one even made 100.  My husband had 2 brothers one coming upto 70 and another 75 both as far as I know in good health.  

      With regard to whether I am leading him into diagnosis and biopsy I may have mislead you.  That is not the case I think it may my health anxiety you are picking up.  I am awaiting some counselling for general anxiety.  My husband would rather not have any biopsy and agreed to this one reluctantly as he was told if you don't go ahead we would probably want to treat you and then you could suffer side effects which maybe you might not have needed to do.  I think this is what made him agree.  When we lived in The London area he was under the urology dept at our local hospital from 2002 until 2016 when we moved up here.  He had a biospy in 2005 and one in 2010 after the second one he had a reaction to the antibiotic used and said he would never have another biopsy again.  When they wanted to do a biopsy in 2012 following a psa rise he was reluctant but agreed to an MRI and regular psa testing.  He had another MRI in 2016 and was started on the finasteride for the prostate enlargement and once again regular psa testing.  This brings us up to the latest MP MRI scan which I understand is much more accurate with the PIRADS scoring.  

      I will do as you suggest and get him to take his notes and i will add some things myself plus get him to really ask about the biopsy risks in his particular case bearing in mind his other problems.  At the end of the day it must be his decision but as you say he does need to know all the facts and the medical profession need to know about his health history and his feelings on the subject.  Do you know when the PIRADS score is a 4 which means clinically significant cancer likely does this mean that cancer is present or that the cancer is agressive.  I think I will get him to ask this.  All the nurse as nice as she is says is we can't force him to have a biopsy but he does need it.  I do realise that they are dealing just with the likelyhood of prostate cancer and really not the whole person.  Myself I am worried about the affects of the biopsy, the outcome if he does not have it and if there is cancer  any treatment.  Quaility of life is very important during the latter years of your life.  We both have things we cannot do but are trying to make the best of it.  I myself have joined a choir and looking for suitable exercise classes and my husband is waiting for a course of pulmonary rehabilitation classes which include diet and exercise etc.  Sorry this post is long and involved.  Once again I do appreciate your interest and advice.

    • libralady13

      You raise two issues:

      1. Whether PIRADS 4 means an aggressive cancer. I am no expert, but having a PIRADS 4 diagnosis I was told that the money's on me having cancer which will be confirmed by a biopsy.

      As to how aggressive it is, the biopsy will sample with needles parts of the prostate. This is called "cores". Pathologists will look at the cores and determine how close to "cancer" the cores appear. It is reasonable to expect a PIRADS 4 MRI conclusion to be repeated with a high risk cancer diagnosis at biopsy.

      2. You are right to try to minimise all the risks inherent in a biopsy. One major risk is a bad infection called "sepsis". As mentioned earlier, this risk is greatly reduced with a transperennial rather than a transrectal biospy, but many patients defer to their urologist's preferred biopsy. I for one urge patients, if reasonably possible, to put their health ahead of placating any physician with his preferred procedure. After all, it is the patient's well being that must trump all else.

    • barney34567

      Thanks for your reply.  We were told that pirads4 score meant that the biopsy would probably just confirm what they already knew.  This was of course before I had a chance to look up on line about this scoring system. I did ask as he had a long history of prostate inflammation (with no symptoms) which had been identified on both earlier biopsies I asked what was the chance that it would be inflammation only.  The nurse said a very small chance but unlikely.  

      With regard to the chance of sepsis.  I have told him to find out which biopsy they want to do and explained that the rectal one carries a bigger chance of infection campared with the transperineal.  However I have also read that the transperineal one causes more swelling and can cause urine retention needing catherisation.  Once again he said leave it until the day and see what they say.  So you can see I am not getting anywhere so will not mention it again.  

      The other thing I wonder if why if it is cancer why has it progressed so quickly in one year or is it that the MP MRI scan is so much better than the normal MRI scan in finding problems.

    • libralady13

      The advantage (before a biopsy) of a multiparametric mri over other imaging modalities is that it allows for better anatomical and functional pictures that explain what is going on in the prostate gland better than any other tool.

      As to your concern about what risks one biopsy has over another, two things should be paramount: the number of procedures performed by a urologist is a proxy for his experience and swelling or urine retention are two side effects I did not suffer, but think even if I did, they are not as worrisome as sepsis. I believe you have done very well attempting to correctly steer your man, but he remains uncooperative. You can do no more, short of engaging in a major argument or shouting contest, neither of which would prove fruitful.

    • barney34567

      Hello reply for barney34567 and others who were kind enough to reply to my original post.  

      My husband had a Saturation TRUSS biopsy this morning it was done under local anaesthetic.  We thought it was going to be a general or spinal. The anaesthetist said that he did not think his gullet was wide enough for the tube to go down with the general and wanted to do a spinal.  The surgeon said he could do it under a local and this is what was done.  We now have 2 to 3 weeks wait for the results.  This was what is said on the discharge letter.    PSA 53.4  (I don't know if this is a new one as they did take some blood at the preop or the last one which was 26.7 and apparently if you take finasteride you need to double it for a correct result but not sure as they say it reduces the psa by 50% but I have also read that it can be anywhere from 20 to 70&wink.  MRI T2 NI M1? LEFT PZ and LEFT TZ  3rd truss biopsy.  

      Procedure  Saturation Truss biopsy under LA Lidocaine 1% 20ml.  

      24 cores taken

      Prosate volume 149cm3.  Huge BPH appearance.

      Biopsies on left side concentrated in PZ at 5 oclock.

      Normal capsule and seminal vessels.

      Not sure what all this means but will do some googling.  

      He is back home now very uncomfortable and has taken some paracetamol and is having a nap.

      He is pleased that it is over but now we have the long wwait until we return to the clinic.

    • libralady13

      Hi Carol, thanks for the update.  Wishing your husband a speedy recovery and all best wishes to you both.  My husband is due to have his in August, just waiting for confirmed date.  Will be a transperineal with general anaesthetic.  Please God all will go well for you and us. Take care of yourselves.  Anne xx

    • libralady13

      I too had a MRI before a  biopsy and I was told (and agree) that the MRI is a good guide for what the biopsy will prove, but the MRI is not 100% definitive. Just like images on PET scans, they are not always as they seem.

      You mention N1 M1 which means something that resembles a cancer was seen in the lymph node and on a bone beyond the lymph glands. If nothing was seen the conclusion would be N0 M0.

      That said, let's wait for the biopsy pathology and consider all the options at that time.

    • anne05147

      I had the same biopsy and do my best to convince others to go that way, assuming they have that option, I know not everyone has every option available.

      I was told and read to confirm that the transperennial biopsy has a very low risk of sepsis and other infections.

      I was offered a general and a spinal anaesthetic but rejected the latter given recent spinal surgery, thinking an injection at the spine tumor site could be monumentally damaging to my health. The anaesthetist FINALLY relented and shelved the spinal aneaesthetic. 

    • barney34567

      Thanks for your reply.  It was recorded as M1 ? which I took to mean metastasis?  The bone scan which was done after the MRI scan was clear.  The nurse did mention that the MRI had picked somethng in the pelvic lymph nodes hence the N1 although she did not specifically say cancer.  As you say we will wait for biopsy results and then consider all options before making any decisions.  Not sure about my husband but I have accepted that there is a good chance of cancer but I am just trying to get on with life until we know what we are dealing with.  

    • barney34567

      Thanks Barney, we were originally offered the TRUS biopsy but then asked our GP to refer us to another hospital who gave a choice.  We then said we were going to pay for our own MP MRI before biopsy as the previous MRI was done over a year ago and we wanted a more uptodate one.  The consultant then said there's no need if you enrol on our research programme we will do a transrectal ultra sound and another MP MRI prior to perineal biopsy with general anaesthesia.  We were very relieved that we would actually get what we wanted and not be told this is your only option.  It's good to have a choice and thankfully we got one.  Hope you are well and it's all good with you now.


    • libralady13

      To clarify: N1 means cancer is thought to involve a lymph node. There is no guaranty this is so based on anything other than a pathology. I have such a diagnosis following some scans but even the folk reporting on it are not certain what looks like cancer  involving a node is indeed cancer.

      M1 indicates that in a scan an area on a nine was found to most likely be cancer. The questions to ask a radiologist is "how many spots were found to be cancerous"? And "what is their size"? The less spots found and the smaller they are the more amenable they are to radiation.

      Your husband is very lucky that he has a very clear eyes woman like you looking out for him.

      Please note, even if a cancer is diagnosed the worse thing to do is to rush to any treatment. You must carefully  consider and weigh up all options including the option of doing nothing.

    • barney34567

      Thank you so much for that information.  Just one thing I did not quite understand The M1 indicates that in a scan an area on a nine was found to be most likely cancer.  What do you mean by nine?  The M1 had a question mark after it and the bone scan was clear.

    • barney34567

      Thank you for the information.  Just one thing that I do not understand you say M1 indicates that in a scan an area on a a nine was found to most likely be cancer.  What do you mean by nine?  The M1 had a question mark after it and the bone scan was clear.

    • libralady13

      Sorry about the lack of clarity in my response. My autocorrect program misspelled a word.

      I meant to say that on my scan ("mine" not "nine"wink I had a dubious mark on a bone that the radiologist called M1 but he isn't confident it is a metastastis.

    • anne05147

      Hello Anne  Just wondering if your husband has had his transperineal biopsy yet.  I do hope so. You will see from my recent post that my husbands recent biopsy found no cancer.  This is good news but worrying as his psa is rising.  Please let me know how he gets on.  Fingers crossed for both of you that it will be good news.


    • libralady13

      Hi Carol

      Fantastic news that no cancer was found.  So pleased for you both.

      What do they think is causing his psa to continue rising?

      we were all booked up for the biopsy but in between my husband need his appendix removed in an emergency op.  We weren't expecting that.  Everything has been postponed as can't have the MRI done until six weeks post op and then rebook for the biopsy, so looking at September now.

    • libralady13

      Hi Carol, he has been delayed as need an emergency op to have his appendix out in July.  Still waiting to get a date for another biopsy but wants to discuss the MRI he had done last week, which was also delayed as you can't have an MRI before 6 weeks after an operation apparently. I'm spending most of my time going with him for hospital appointments and then last week my mum broke her hip so is also in hospital.  It's been a bit full on.  How's your husband doing?  Well I hope.

    • anne05147

      Hello Anne,  Sorry to hear about your Mum.  It does seem that everything comes at once.  I hope she is ok although I expect her recovery will take time.  You did mention about your Husbands appendix surgery and I hope he is fully recovered.  How did his MRI scan go?  I hope he does not have to wait long for the biopsy.  

      My husband is ok apart from his other health problems.  He see will see the consultant Urologist around December/January to discuss whether he has the transperineal biopsy or just monitoing  and regular PSA tests.  I probably mentioned that he does not want to have any more biopsies and he seems adamant  about that.  I have been trying to get him to lose weight (he needs really to lose about 3/4 stone) but he is not interested as he thinks he should not go without anything he likes.  It would really help with his breathing, his arthritis and especially his Diabetes which could be controlled better.  I know it is not easy dieting but I managed to lose 2 stone although I need to lose more.  If only he would just try.  It just ends up in an argument.  I have my own health problems to cope with but it would be me who has to deal with any problems he has so I feel a bit resentful.   He also is having trouble with his hearing aids and has been saying for years there is something wrong with his left ear and they are only now referring him to hospital at least when we get an appointment. On a good note I will be 70 next month and my daughters are arranging a party for me.  Hopefully it will also mean I get to see our son who we have not seen in over a year since we moved up here.   Hang on in there and hope to hear from you soon.  Fingers crossed everything will be ok for him.


    • libralady13

      Thanks Carol.  My mum has dementia but is always mostly bright and cheerful. although yesterday was a bit tearful.  She is in a care home since 2014 and will be glad to get back to it.  She is 85 and always been a strong independent woman.

      Well done losing 2 stone, it is the same amount I need to lose.

      ​My husband wants to discuss his latest MRI before biopsy, but it seems they want to do the biopsy anyway as part of a clinical research trial.  We are holding out for a discussion on the latest findings first.

      Take care, stay strong.  xxAnne.

    • anne05147

      Hello again Anne,  Sorry I did not realise your Mum had dementia and is in a care home.  Good age though at 85.  My Dad had Alzheimers and was in a care home for the last 8 months of his life he died just before his 80th Birthday in 1997.  

      I don't blame you wanting to find out exactly what the MRI reveals even if they want to do the biopsy as part of the clinical research.

      Do let me know how you get on.

      Take care.


    • libralady13

      The fact that you lost the weight you did and your husband cannot or will not is evidence to your strong willpower and clear decision making process.

      I understand the problems you have in trying to get him to lose weight, exercise and his non prostatic health issues. But the fact is, we are all adults. Don't beat your head against a wall trying to convince him to do what you would do in his place.

      We are all adults.

      Either he is unwilling or unable to do what he needs to do. Possibly his behaviour has a psychological foundation. You could do worse than have him see a psychologist to assist him in dealing with his health issues.

      If he refuses to get the help he needs to make him better able to deal with his issues, I think you have done all that is expected of a spouse, short of dragging him into treatment.

    • libralady13

      Will do Carol.   You take care of yourselves too.  Mum was discharged today and back at the care home today.  I took her myself in the end as we waited 5 hours for transport yesterday and by the time they arrived she wouldn't go as she was really confused.   She was bright again this morning and I thought we're not going through all that again today so asked if I could take her in my car and the physio's helped me make this happen.  Please God she won't have another fall, she has always been really active and this has knocked her sideways and she can barely walk now.  She has been talking about being ready to die but hoping her mood will lift once she gets some strength back.

      ​Onwards and upwards though. smile

    • libralady13

      Dear Carol  just an update.  The new MRI came back showing nothing suspicious, my husband opted not to have a biopsy and he is going to have his PSA monitored every 6 months instead,  any increases and then review again.  He had a colonoscopy yesterday due to him having acute appendicitis and appendectomy in July,  it is another investigation due being the wrong age to have acute appendicitis, it is usually very young and older people but not as a 60 year old.  It was all clear, thank God, relieved.  We're both hoping there will be a long pause before we have any further investigations for anything else.   

      ​Hope you are both well. Take care.  Anne.

    • anne05147

      Hello Ann,  That is really good news.  I am not surprised he opted not to have the biopsy and just do psa monitoring.  As you say he can think again if he gets further psa rises.  As you know my husband has said that he will not have another biopsy.  He is due to see the consultant around December for another psa and urine flow test.  I am hoping there will be no increase in the psa.  I am trying to get him to eat more healthily although good news he has been taken off one of his Diabetic tablets as his latest results were much better.  I have just bought a soup maker and so experimenting with soups.  A good way to get more veg into us both.  Glad his colonoscopy was clear.  We have both had them.  The prep is not nice.  As you say hope there will be a long pause before anything else.  At the moment is is my turn for tests have had awful upper back ache and slight indigestion am being referred for camera down the throat.  I had my 70th Birthday and there were some family problems which upset me and increased my anxiety.  I had a lovely party though even though I was in some pain.  Have stated counselling for the anxiety.  Will keep in touch and let you know how it goes.  So pleased your husband has had good news for both tests.  

    • libralady13

      Happy birthday Carol.  I've had one this month too and my husband's is on Tuesday.

      Steve managed well with the prep and fine with the colonoscopy.  I wouldn't though as would get myself in a right fluster. smile

    • anne05147

      Hello Just wondered how you and your husband are doing, also your mum.

      My husband had a scare in December the hospital thought he may have had a TIA or mini stroke.  He saw the stoke consultant the next day and had a doppla scan on the carotid artery the result was fine and now from listening to what happened the consultant thinks it might have been a migraine.  We still have to wait for the result of the head MRI which he will get next week.  The appointment for a prostate followup was in December but we decided to cancel it until after Christmas especially as my husband was not allowed to drive for a month and as you know I don't drive.  It was a pain but better to be safe than sorry even though it was probably a migraine.  This morning he went for his prostate check and has told them he does not want any further biopsies. The psa is now 21 andthey said last time it was 42.  This is totally different from what the doctor told us last time when they said is was  70/80? which needed to be doubled because he takes finasteride.  Something not right there and anyway he had a psa of 21 years ago.  When we lived in London after years of seeing the consultant psa tests and biopsies the last one in 2016 was 38 and they said they would only need to see him if it increased.  I tried to ask him this morning about why it kept going up and down and he said it does that with an enlarged prostate.  The only think I can think of is that often he would have the psa test after having a couple of pints the night before.  This time he has mostly stopped drinking due to the scare and had not had alcohol for a week or so.  I remember you saying about researching why psa rises.  Not sure if this helps just a thought.  So he will now have a followup appointment in 6 months and another psa test.  I just hope the MRI will be negative although the consultant said he would be surprised if anything showed up and he would have contacted us rather than waiting 6 weeks for the clinic appointment.  My anxiety of course has soared and I have also had to have the camera down and have been diagnosed with mild gastritis no ulcers hiatus hernia or god forbid cancer.  I just hope 2018 will be quieter on the medical front.  I wish you and your husband well for 2018 and trust you had a good Christmas



    • libralady13

      Dear Carol

      ​Happy New Year.  Sorry to hear you've had another scare.  Likewise we're hoping 2018 will be less of a roller coaster ride.  I'm just over the flu which my mum also had despite having the flu vaccine.

      ​Steve is having another psa test next week and we are only going to return to the prostate clinic if it rises dramatically over a short space of time which was our agreement last time we went for a check up.  I'll let you know what the result of the psa test is once we get it back.  Steve has already been told he has a large prostate which showed in an ultrasound and MRI.  He's recovered well from having his appendix out in July and my mum broke her hip in September but is doing quite well considering all she's been through but her dementia has worsened but she remains cheerful despite everything bless her.

      ​I developed 'silent migraines' in 2013 after initially having BPPV  which affected my balance and just fell to the floor one day when I got out of bed as had completely lost my balance.  I crawled around on the floor for a while until I felt able to stand up again.  It can be quite a shocker when it happens but I still have balance/dizzy days but never as bad as that particular one and was treated for the migraines with Nortriptyline.  Any colds/flu or nasal congestion now makes my balance worse now.

      ​Sorry to hear your anxiety soared but quite understandable.  Good news that everything is okay. Hope everything is quiet for us all this year.

      ​All best wishes  Anne.xx


    • anne05147

      Hi Anne,  Sorry to hear you have not been well.  I believe this vertigo BPPV is common as you get older.  Silent migraines does that mean you get no symptoms or does it mean you get auras.  A friend of mine gets that type.  I suffered really bad with migraines during the menopause I now only get auras plus a mild headache but not that often.  It must have been so frightening for you falling to the ground.  I do hope that the medication works for you.  I can understand how any congestion can make it worse.  Have you tried salt water spray for your nose it does help a bit.  It is good that your Mum is cheerful despite her dementia.  Yes do let me know how your Steve gets on with his psa.  Take care and as you say let's hope this year will be better for us all.

    • libralady13

      Hi Carol

      ​I didn't know I was having migraines as no headache but thumping in my left ear,  the only symptoms were balance problems  and visual disturbances and feeling exhausted so more aura than headache.  The consultant said not to get the BPPV mixed up with the migraine symptoms as I thought it was all due to BPPV.  It took a couple of years to get a diagnosis as in the end I saw a neuro otologist who said I had wasted my time with ENT basically and had I been diagnosed sooner then less damage would have been done to my brain but it would take longer to recover at it had taken so long to diagnose.  He said he thought it was all due to the menopause and particular foods triggering it like chocolate, cheese, caffeine.  I go easy on these now.  I was hopeful it would go away in the beginning but after 4 years of it I think it is ongoing with some days better than others and have come to accept it might always be there to a greater or lesser degree.  At first I was all over the place like the drunken sailor,  but now my body/brain has adjusted/compensated and I try not to overdo things now as anxiety/tiredness makes it worse.  The consultant prescribed me Nortriptyline which I took for a while and it seemed to help but took myself off it when I started feeling better as not inclined to take meds if I can do without.  I take hrt now which also helps as I was having a lot of stiffness due to arthritis.

      ​I've tried everything up my nose and it doesn't appear to make the slightest difference but I drink more water now to keep hydrated as I never that much before.  I have also just got myself a humidifier for the bedroom, it arrived today, so will use it tonight as hoping it will help with nasal congestion.  My GP suggested I try Sudofed nasal spray instead of my usual steroid nasal spray.   I tried Sudofed nasal spray, it really helped me breathe much more easily but also caused nose bleeds, headaches and made me feel quite shakey.  What a messsmile  He has now given me the steroid nasal spray back, which was what I initially wanted which has worked well for me past couple of years.  I only use it sparingly when needed and mostly in the winter months when the heating kicks in and blocks my nose.  I think he suggested Sudofed because you can buy it over the counter without prescription, now he says never use it again because it doesn't agree with me, plus you can't use it long term as it can cause rebound congestion. I'd rather not take anything but also need to be able to breathesmile  I do seem to have turned into a bit of wuss since the menopause with all these ENT problems but that's just how it has affected me.

      ​Onwards and upwards.  Love anne.



Report as inappropriate

Thanks for your help!

We want the forums to be a useful resource for our users but it is important to remember that the forums are not moderated or reviewed by doctors and so you should not rely on opinions or advice given by other users in respect of any healthcare matters. Always speak to your doctor before acting and in cases of emergency seek appropriate medical assistance immediately. Use of the forums is subject to our Terms of Use and Privacy Policy and steps will be taken to remove posts identified as being in breach of those terms.