📝 PSA Testing – A Complete High-Yield Guide for PLAB 2

Ann Augustin
Jul 7
2 min read

Updated: Jul 8

🔬 What is PSA?

Prostate Specific Antigen (PSA) is a glycoprotein enzyme produced by prostate epithelial cells.
Used as a tumour marker for prostate cancer, but not cancer-specific as levels can rise in benign conditions too.

📈 Causes of Elevated PSA

Condition	Key Exam Clues
Prostate Cancer	Persistent elevation, especially >10 ng/mL. Hard, irregular prostate on DRE.
Benign Prostatic Hyperplasia (BPH)	Mild to moderate elevation due to prostate enlargement.
Prostatitis	Often marked transient elevation due to inflammation.
Urinary retention	Bladder distension can elevate PSA.
Ejaculation	Elevates PSA for up to 48 hours.
DRE	Causes minimal, clinically insignificant rise.
Catheterisation or cystoscopy	Can transiently raise PSA.

🔢 Normal Age-Specific PSA Ranges (UK Guidelines)

50–59 years: up to 3.0 ng/mL
60–69 years: up to 4.0 ng/mL
70+ years: up to 5.0 ng/mL

(Exact cutoffs vary slightly by region, but these are standard for UK GP/PLAB 2 exams.)

⚠️ Pre-Test Advice

Avoid:
- Ejaculation (48 hours prior)
- Vigorous exercise/cycling (48 hours prior)
- Testing during UTI or prostatitis – treat first, then repeat after resolution.

🩺 When to Refer (2WW)

PSA above age-specific range
Abnormal DRE (hard, nodular, irregular prostate)

📝 Prostate Cancer Risk Management Programme (PCRMP)

UK guidance to GPs for PSA testing in asymptomatic men.
No national screening programme, but:
- Men ≥50 years can request PSA testing.
- Counselling is mandatory before testing to explain benefits and risks.
- DRE should be performed prior to PSA.

🔑 Benefits of PSA Testing

May detect prostate cancer early, before symptoms.
Early treatment could prevent spread or complications.
Provides peace of mind if normal.

⚠️ Risks of PSA Testing

False positives → unnecessary anxiety, investigations, biopsies.
False negatives → cancer may still be present despite normal PSA.
Overdiagnosis → detecting harmless (indolent) cancers that would never cause harm.
Overtreatment → treating these indolent cancers leads to side effects:
- Urinary incontinence
- Erectile dysfunction
- Bowel problems (if radiotherapy used)
Complications of biopsy: infection, bleeding, pain.

👨‍⚕️ Explaining Overdiagnosis and Overtreatment to Patients

🗣️ “PSA testing can find cancers that grow so slowly they would never cause you problems in your life. But once we find them, treatment can cause side effects like leaking urine or problems with erections, even though the cancer may never have harmed you. That’s why it’s important to weigh the pros and cons before having the test.”

❓ If a Patient Requests PSA Over the Phone

Do NOT arrange PSA testing directly.
Book a face-to-face consultation for:
1. Counselling on risks and benefits.
2. Digital Rectal Examination (DRE) to assess the prostate.

✅ Does DRE Raise PSA?

Minimal, clinically insignificant rise.
No need to delay PSA testing after DRE.

🧠 PLAB 2 Key Exam Triggers

✔️ Asymptomatic man requesting PSA → Counsel + DRE + PSA if appropriate.

✔️ PSA mildly raised with UTI symptoms → Treat UTI and repeat PSA after resolution.

✔️ Abnormal DRE regardless of PSA → Urgent referral.

✔️ Screening not recommended nationally due to overdiagnosis and overtreatment risks.

📌 Summary

✅ Always counsel before PSA testing.

✅ Perform DRE first – abnormal findings warrant urgent referral regardless of PSA.

✅ Understand benefits vs. risks (false positives, false negatives, overdiagnosis, overtreatment) for safe practice and exams.

📚 References