Prostate-Specific Antigen (PSA)#

PSA (prostate-specific antigen) is a protein produced by the prostate gland - a walnut-sized gland in men and trans women on hormone therapy that surrounds the urethra below the bladder. Small amounts of PSA leak into the bloodstream all the time. The level rises with:

• Prostate cancer
• An enlarged prostate (benign prostatic hyperplasia, or BPH)
• Prostate inflammation (prostatitis)
• Recent prostate exam or biopsy
• Recent ejaculation
• Vigorous cycling
• Urinary tract infection

A high PSA does not equal cancer. A normal PSA does not completely rule out cancer.

• Total PSA is the standard measurement, reported in ng/mL.
• Free PSA measures the portion of PSA not bound to other proteins. A low free-to-total PSA ratio (under about 25%) is more typical of cancer; a higher ratio is more typical of a benign enlarged prostate. Free PSA is sometimes used when total PSA is slightly elevated to help decide whether a biopsy is needed.
• PSA velocity is how quickly PSA is rising over repeat tests. A fast rise (over 0.35 ng/mL per year at lower starting levels) raises concern.

• Screening PSA is done in someone with no urinary or prostate symptoms, to look for early disease.
• Diagnostic PSA is done in someone with symptoms (urinary trouble, pelvic pain, blood in urine) - the test is part of working up those specific symptoms, not population screening.

The recommendation against routine screening (see below) applies to screening PSA, not diagnostic PSA in someone with symptoms.

The Canadian Task Force on Preventive Health Care (CTFPHC) recommends against routine PSA screening in men of all age groups. The reasoning:

• PSA screening reduces death from prostate cancer only modestly, if at all
• It leads to a large number of false positives, biopsies, and diagnoses of slow-growing cancers that may never have caused symptoms
• Treatment of these cancers (surgery, radiation, hormone therapy) causes significant harm - including urinary incontinence and erectile dysfunction - in a meaningful number of men

The Canadian Urological Association (CUA) and similar specialty groups support shared decision-making: that men in the right age range should be offered the test and counselled on the benefits and harms, rather than be told not to test. The American Urological Association, European Association of Urology, and many family-medicine groups take similar positions.

So Canadian guidance is split:

• Population-level (CTFPHC, Choosing Wisely): do not routinely screen
• Specialty-level (CUA, urology groups): offer shared decision-making

Most family doctors take a middle path: discuss the test with men ages 50 to 70 (or 45 to 70 if higher risk), explain the trade-offs, and let the patient decide.

• Age (risk rises significantly after age 50, sharply after 65)
• African or Caribbean ancestry
• Family history of prostate cancer in a father or brother, especially before age 65
• Family history of BRCA1 or BRCA2 mutation (raises risk in men and women for several cancers)
• Personal history of certain genetic conditions (Lynch syndrome)

In higher-risk men, some guidelines suggest beginning shared decision-making about PSA at age 45 instead of 50.

Diagnostic PSA is appropriate when you have:

• New urinary symptoms (slow stream, getting up at night, urgency, hesitancy, incomplete emptying)
• Blood in the urine
• Pelvic or perineal pain
• A relative who recently developed prostate cancer at an early age and you have concerns to investigate
• An enlarged prostate detected on physical examination

In these settings, PSA is one piece of information used along with the rest of the workup.

TeleTest can order PSA testing for shared decision-making (after a discussion of the benefits and harms) or for evaluation of urinary symptoms. TeleTest does not:

• Perform digital rectal exams (these require an in-person visit)
• Perform or order prostate biopsies (these require a urologist)
• Order prostate MRI

If your PSA is abnormal or your symptoms suggest the need for a hands-on assessment, you would see your family doctor, a walk-in clinic, or a local urologist for in-person evaluation. TeleTest does not arrange urology referrals - you would arrange that through a local in-person clinician.

For the most accurate result:

• Avoid ejaculation for 48 hours before testing (raises PSA temporarily)
• Avoid vigorous cycling or horseback riding for 48 hours before testing (presses on the prostate)
• Avoid prostate exams or prostate massage for at least 1 week before testing
• Wait at least 6 weeks after a prostate biopsy - PSA stays elevated after a biopsy
• Treat a known urinary tract infection first and wait until it has cleared before testing

No, fasting is not required for PSA.

Probably not. Out of roughly every 1,000 men aged 55 to 69 who are screened over a 13-year period, about 280 will have an elevated PSA at some point. Of those, only about 100 will turn out to have prostate cancer on biopsy - and many of those cancers are slow-growing and may never have caused harm.

Most elevated PSA results turn out to be from a benign enlarged prostate (BPH), prostatitis, recent prostate manipulation, or a urinary tract infection.

The typical next steps are:

1. Confirm with a repeat PSA in 4 to 12 weeks (eliminating recent ejaculation, biking, infection, biopsy)
2. Rule out a urinary tract infection with a urine test
3. Add a free PSA if total PSA is between about 4 and 10 - a low ratio raises concern for cancer
4. In-person assessment with a family doctor, walk-in clinic, or urologist - usually including a digital rectal exam
5. See a urologist for advanced imaging (multiparametric prostate MRI) and a discussion of biopsy

TeleTest can help with steps 1, 2, and 3 (total and free PSA). Steps 4 and 5 require in-person assessment, which you would arrange through a local in-person clinician. TeleTest does not arrange urology referrals.

The main harms include:

• False positives - an elevated PSA that turns out not to be cancer. This causes anxiety, repeat testing, and sometimes biopsies that turn out to be unnecessary.
• Biopsy complications - about 1 to 3 out of 100 men who have a prostate biopsy experience an infection or bleeding that requires medical care, and a smaller number need hospitalization.
• Overdiagnosis and overtreatment - finding slow-growing prostate cancers that may never have caused harm. Treatment can cause urinary incontinence (around 5 to 15 out of 100) and erectile problems (around 30 to 70 out of 100, depending on age and treatment) that may be permanent.

Some men view these trade-offs as acceptable; others do not. This is why the decision to screen is shared, not automatic.

Urinary symptoms are most common with benign prostate enlargement, but can also occur in prostate cancer:

• Getting up at night to urinate (nocturia)
• Slow urinary stream
• Hesitancy (taking time to start)
• Starting and stopping mid-stream
• Urgency (sudden strong urge to urinate)
• Frequent daytime urination
• Feeling of incomplete emptying

Less common but more concerning symptoms include:

• Blood in the urine or semen
• New severe pelvic or back pain
• Unexplained weight loss
• Inability to urinate (urgent - see below)

BPH is the gradual enlargement of the prostate that occurs in nearly all men as they age. The enlarged prostate presses on the urethra, causing the urinary symptoms above. BPH is very common (more than half of men over 60) and is not cancer. PSA is often mildly elevated in BPH.

BPH is usually managed by a family doctor and includes lifestyle measures, prescription medications that relax the prostate or shrink it, and - in more severe cases - urology procedures.

Acute urinary retention is when you cannot pass urine at all despite a full bladder. It is most commonly caused by sudden worsening of BPH but can also occur with infection, certain medications, or after surgery. It is a medical emergency because urine backs up into the kidneys and can cause permanent kidney damage.

If you cannot urinate, go to an emergency department or urgent-care centre immediately.

The IPSS is a 7-question questionnaire that scores the severity of urinary symptoms from 0 to 35. It is widely used to track symptom severity over time and decide on treatment.

• 0 to 7: Mild symptoms
• 8 to 19: Moderate symptoms
• 20 to 35: Severe symptoms

You can complete the IPSS yourself online (search "IPSS calculator"). It is a useful tool to share with your clinician.

A prostate biopsy is performed by a urologist, usually in a hospital or outpatient clinic. Modern practice often includes a prostate MRI first, then a targeted biopsy of any suspicious areas seen on imaging. This approach reduces unnecessary biopsies and improves accuracy.

Biopsy is uncomfortable but usually well-tolerated. The main risks are infection (1 to 3 out of 100) and bleeding. You will typically receive antibiotics around the procedure.

Treatment depends on how aggressive the cancer is, your age, and your overall health. Options include:

• Active surveillance - regular monitoring with PSA, MRI, and repeat biopsies, used for slow-growing low-risk cancers. Many men with low-risk prostate cancer never need any active treatment.
• Surgery (prostatectomy) - removing the prostate
• Radiation therapy - external beam or seeds placed inside the prostate (brachytherapy)
• Hormone-blocking medications - usually combined with radiation for more advanced disease

Treatment decisions are made with a urologist or oncologist, not a primary-care clinician. They involve significant trade-offs between cancer control and side effects.

If you and your clinician decide PSA screening is appropriate:

• PSA below 1.0 ng/mL: every 2 to 4 years is reasonable
• PSA between 1.0 and 2.5 ng/mL: every 1 to 2 years
• PSA between 2.5 and 4.0 ng/mL: repeat in a few months to confirm, then yearly with close monitoring
• PSA above 4.0 ng/mL: in-person assessment, likely with a urologist (arranged through your local in-person clinician, not TeleTest)

There is little benefit to PSA testing in men with less than 10 years of expected life remaining, because slow-growing prostate cancers are unlikely to cause harm in that timeframe.

Coverage varies. PSA is generally covered when there is a clinical reason - urinary symptoms, family history with an in-person discussion, or follow-up of a previously elevated result. Some provinces cover PSA screening more broadly than others.

For pure screening with no symptoms or risk factors, PSA may be billed as an uninsured test. TeleTest will order PSA as an insured test when there is a documented clinical reason; otherwise, you can pay an uninsured fee at the lab.

Costs vary by lab. Contact your local lab for current pricing, or see your TeleTest booking confirmation.