A 64-year-old man comes to the physician for follow-up of an abnormal test. He was hospitalized a week earlier for an episode of acute urinary retention provoked by amitriptyline. His other medical problems include post-herpetic neuralgia, hypertension, hyperlipidemia, and a stable abdominal aortic aneurysm. He is a former smoker and his father had prostate cancer. Physical examination during the admission showed a moderately enlarged, nontender prostate with no nodularity. The obstruction was relieved by a Foley catheter, and amitriptyline was stopped. The patient has had no voiding difficulties or other urinary symptoms since being discharged. Blood tests at the time of hospital admission showed a white blood cell count of 12,000/µL, creatinine of 1.4 mg/dL, and serum prostate-specific antigen of 7.5 ng/mL (normal

Question

A 64-year-old man comes to the physician for follow-up of an abnormal test.  He was hospitalized a week earlier for an episode of acute urinary retention provoked by amitriptyline.  His other medical problems include post-herpetic neuralgia, hypertension, hyperlipidemia, and a stable abdominal aortic aneurysm.  He is a former smoker and his father had prostate cancer.  Physical examination during the admission showed a moderately enlarged, nontender prostate with no nodularity.  The obstruction was relieved by a Foley catheter, and amitriptyline was stopped.  The patient has had no voiding difficulties or other urinary symptoms since being discharged.  Blood tests at the time of hospital admission showed a white blood cell count of 12,000/µL, creatinine of 1.4 mg/dL, and serum prostate-specific antigen of 7.5 ng/mL (normal <4 ng/mL).  No prior prostate-specific antigen levels are available for comparison.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_bfd3_c568_8f63_6374a08cd143_MD0005_00 Prostate-specific antigen (PSA) is a glycoprotein expressed by both normal prostate tissue and prostate cancer. Persistently elevated PSA can be due to benign prostatic hyperplasia (BPH), prostate cancer, and prostatic inflammation or infection (prostatitis). BPH is highly prevalent in healthy men age >50, and PSA can be mildly elevated (up to 6.5 ng/mL) without any associated malignancy. In addition, mild-to-moderate PSA elevation can occur transiently due to urine retention, subclinical inflammation, cystoscopy, or ejaculation. This patient's elevated PSA is most likely due to recent hospitalization for amitriptyline-induced urinary retention. Acute urinary retention can lead to prostatic inflammation and swelling and transiently elevate serum PSA. However, the elevation is generally mild and normalizes over the following 2-6 weeks. In addition, a digital rectal examination during inpatient admission can also mildly elevate PSA. This patient's urinary symptoms have resolved, and he needs no further intervention except a repeat PSA test to document improvement. A persistently elevated or rising PSA level may warrant further investigation. Recent guidelines have questioned the validity of PSA for prostate cancer screening. However, PSA can be very useful as a diagnostic test in ill patients with symptoms of possible prostatic disease (eg, hematuria, urine retention, unexplained pelvic pain). It can also be used to follow the course of established prostate cancer. (Choice A) Transurethral resection of the prostate (TURP) and related procedures (eg, microwave thermotherapy, laser prostatectomy) may relieve symptoms of bladder outlet obstruction but are indicated only for chronically persistent obstructive symptoms. TURP is usually considered only if the patient first fails a trial of medication to relieve the symptoms. (Choice B) Computed tomography scan of the genitourinary system is useful in evaluating disease of the upper tract (eg, kidney stones, renal cell carcinoma). However, it has poor sensitivity for diagnosing prostate cancer. (Choice C) Cystoscopy is indicated for evaluating symptoms related to the bladder and urethra (eg, hematuria to rule out bladder cancer). It is also performed during TURP and similar procedures in patients with symptomatic BPH. However, it is not necessary in this patient whose symptoms have resolved. (Choice E) Transrectal biopsy of the prostate is indicated for patients with evidence of prostate malignancy (eg, prostate nodules, asymmetric prostate enlargement) or persistently elevated PSA. This patient had a benign prostate examination, and transrectal biopsy is not recommended at this time unless the PSA remains elevated or rises further. Educational objective: Transient elevations of prostate-specific antigen (PSA) can occur due to a variety of benign causes (eg, urinary retention) and usually decrease within 4-6 weeks. Further investigation is needed if the PSA level remains elevated or prostate examination shows suspicious findings. References: A systematic review of the diagnostic accuracy of prostate specific antigen. (http://www.ncbi.nlm.nih.gov/pubmed/19744336) Management of elevated prostate-specific antigen in men with nonbacterial chronic prostatitis. (http://www.ncbi.nlm.nih.gov/pubmed/19570492)

A 64-Year-Old Man Comes to the Physician for Follow-Up of an Abnormal