High PSA — Assessment & Management

Safety

Red Flags — Metastatic Prostate Cancer, Cord Compression & Sepsis

Done

Very high PSA + bone pain (especially spine, pelvis, ribs) + weight loss or systemic features Metastatic prostate cancer until proved otherwise. → urgently contact urology/oncology. Staging is arranged by the specialist team. ADT is initiated by the specialist team, usually after staging and discussion of goals of care, except where an agreed local emergency pathway specifically authorises initiation — do not independently start leuprorelin, goserelin, bicalutamide, abiraterone, enzalutamide or docetaxel.

High PSA or known prostate cancer + back/radicular pain with any neurological red flag Suspected MSCC is an oncological emergency. Immediately contact the local MSCC coordinator/acute oncology service and arrange emergency hospital assessment. If neurological symptoms or signs are present, give dexamethasone 16 mg orally or an equivalent parenteral dose as soon as possible, with PPI and glucose monitoring, unless local specialist advice indicates otherwise (continued at 16 mg daily while awaiting surgery/radiotherapy; stopped if MSCC is excluded). MRI of the whole spine as soon as possible and always within 24 hours (NICE NG234). Red flags: progressive limb weakness; gait disturbance; sensory change or sensory level; radicular or band-like pain; severe progressive or nocturnal back pain; pain worse on coughing or straining; bladder or bowel dysfunction; saddle anaesthesia. A normal neurological examination does not reliably exclude early MSCC.

Acute urinary retention + inability to void + distended bladder + suprapubic pain + high PSA Acute urinary retention (AUR) — causes include BPH, infection, medication, urethral pathology or prostate cancer; a high PSA alone does not establish malignant obstruction. → Urgent same-day assessment and catheterisation. Use emergency transfer where the patient is severely unwell, has sepsis, renal failure, severe pain, neurological features, suspected traumatic retention or cannot be safely managed in the local service.

PSA rising after previous prostate cancer treatment (radical prostatectomy or radiotherapy) Biochemical recurrence of prostate cancer. → Contact the treating urology/radiotherapy team. Do not independently label biochemical recurrence; consider PSMA PET-CT (prostate-specific membrane antigen PET) only through the urology/oncology pathway where the result will alter management.

High PSA + fever + rigors + perineal pain + exquisitely tender boggy prostate on DRE Suspected acute bacterial prostatitis: obtain MSU before antibiotics without delaying treatment in a systemically unwell patient. If stable and able to take oral treatment, use an appropriate oral antibiotic guided by local resistance and current NICE/MHRA advice (see Step 5). Admit or seek same-day hospital advice if septic, unable to take oral therapy, in acute retention, suspected prostatic abscess, or not improving within 48 hours. Choice of IV antibiotic should be guided by severity, local microbiology, previous cultures and hospital antimicrobial guidance; ceftriaxone is one possible option, but treatment should not be protocolised as ciprofloxacin for all systemically unwell patients. Review antibiotic treatment at 14 days and continue for a further 14 days only if clinically indicated. Avoid prostatic massage.

Raised PSA in a man under 50, or a higher-risk man (Black African/Caribbean ancestry, strong family history, known BRCA2 or other pathogenic variant) Under 40, use clinical judgement; a man aged 40–49 with possible symptoms is referred if PSA >2.5 ng/mL (NG12 threshold, Step 2). Have a lower threshold for urological assessment where PSA is raised in the presence of a suspicious DRE, symptoms, Black ancestry, strong family history or a known pathogenic variant. Black men have increased risk and develop prostate cancer at a younger age; men with a strong family history or a known BRCA2 variant are at higher risk — discuss testing and follow clinical genetics advice where relevant. Do not arrange BRCA1/2 testing solely because a young man has one high PSA — genetic testing follows local genetics/urology criteria.

PSA velocity and PSA density are used mainly in the secondary-care pathway — particularly after mpMRI with Likert 1–2 or after a negative biopsy — to decide whether biopsy or re-referral is appropriate; NICE NG131 gives PSA density >0.15 ng/mL/mL and PSA velocity >0.75 ng/mL/year as examples of strong suspicion in that specific context. Do not use PSA velocity alone as a primary-care suspected-cancer referral threshold (it is not an NG12 criterion). If a patient is discharged after low-risk MRI or negative biopsy, the urology team should provide an explicit PSA/re-referral threshold and follow-up plan. Recording previous PSA values in the GP record still helps interpretation.

Diagnose

PSA — Interpretation & Non-Malignant Causes

Done

What PSA measures

PSA (prostate-specific antigen) is a serine protease produced by prostate epithelial cells — it is organ-specific (prostate) but NOT cancer-specific. PSA is elevated by: prostate cancer (but also all benign causes below). In cancer: PSA is elevated due to disruption of normal prostate tissue architecture and loss of the basal cell layer that prevents PSA from entering the bloodstream. Limitations: approximately 15-25% of prostate cancers (especially low-grade) have PSA in the normal range (false negatives); many benign conditions elevate PSA (false positives). PSA density cannot be calculated reliably in primary care without a validated prostate-volume measurement (usually MRI or ultrasound), and free:total PSA is not part of the NICE primary-care referral pathway — do not routinely request free:total PSA or PSA density in primary care unless specifically supported by the local urology pathway.

Non-malignant causes of PSA elevation

Benign prostatic hyperplasia (BPH) (most common cause of PSA 4-10 ng/mL in older men — enlarged gland produces more PSA proportionally to size). Acute prostatitis (can raise PSA markedly — 10-100x normal). Chronic prostatitis / CPPS (chronic pelvic pain syndrome — modest PSA elevation). Urinary tract infection (UTI — PSA can be elevated; repeat after treating UTI). Ejaculation (raises PSA transiently — abstain for 48h before testing). Vigorous prostate massage / DRE (small transient rise — DRE within 48h of PSA test may elevate minimally but is not a clinically significant confounder at standard timing). Prostatic biopsy (large PSA elevation for 4-6 weeks). Catheterisation, cystoscopy, instrumentation or urinary retention (can raise PSA — interpret with caution). TURP/surgery (PSA drops post-TURP — remaining prostate produces less PSA).

NICE NG12 age-specific thresholds (people with possible symptoms)

Under 40: use clinical judgement. Age 40-49: >2.5 ng/mL (micrograms/L). Age 50-59: >3.5 ng/mL. Age 60-69: >4.5 ng/mL. Age 70-79: >6.5 ng/mL. Over 79: use clinical judgement. NICE NG12 (updated April 2026) says to consider PSA and DRE in people with lower urinary tract symptoms, erectile dysfunction or visible haematuria. For symptomatic patients with PSA above the NICE age-specific threshold, refer using a suspected cancer pathway referral (NICE NG12), discussing his preferences and comorbidities. These thresholds should not be presented as a universal screening rule for asymptomatic men: for asymptomatic men who ask about testing, offer an informed discussion; a man aged 50 or over who still wants a PSA test after counselling may have it (Prostate Cancer Risk Management Programme, PCRMP), and for men aged 50–69 the PCRMP threshold is PSA ≥3.0 ng/mL rather than the symptomatic NG12 thresholds.

The age-adjusted PSA thresholds for suspected cancer pathway referral have been part of NICE NG12 since 2015, when the guideline adopted the age-specific reference range from the Prostate Cancer Risk Management Programme (the April 2026 update did not change the prostate recommendations) — a single threshold of PSA >4 ng/mL for all ages misclassified both young men (where PSA >2.5 is already elevated) and elderly men (where PSA of 5-6 is common from BPH alone). The current NICE NG12 (updated April 2026) approach uses age-specific thresholds. Important practical considerations: the NG12 thresholds apply to men with possible symptoms (LUTS, erectile dysfunction, visible haematuria) — refer using a suspected cancer pathway referral above the threshold, discussing preferences and comorbidities. They are not a universal screening rule for asymptomatic men: offer an informed discussion; a man aged 50 or over who still wants a PSA test after counselling may have it (PCRMP). Below the threshold, clinical judgement still applies — a suspicious DRE, symptoms, Black ancestry, strong family history or a known pathogenic variant lower the threshold for urological assessment. PSA velocity alone should not trigger referral.

Diagnose

Assessment — History, Examination & Investigations

Done

History

Lower urinary tract symptoms (LUTS): storage symptoms (frequency, urgency, nocturia, urgency incontinence) vs voiding symptoms (hesitancy, poor stream, intermittency, terminal dribbling, incomplete emptying). International Prostate Symptom Score (IPSS): validated 7-question symptom score (0-35): 0-7 = mild; 8-19 = moderate; 20-35 = severe. Haematuria (aged 45 or over with unexplained visible haematuria without UTI, or visible haematuria that persists or recurs after successful UTI treatment → urology suspected cancer pathway referral). Bone pain (metastatic). Sexual function (erectile dysfunction). Family history: prostate cancer (first-degree relative age <65 — doubles lifetime risk). BRCA2 mutation (significantly increases risk of aggressive prostate cancer). Ethnicity: Black African or Caribbean ancestry (increased risk, younger onset). Previous PSA results and any prostate treatment. Medications affecting PSA: 5-alpha reductase inhibitors (finasteride, dutasteride) — reduce PSA by approximately 50% after 6 months (double the PSA reading as a rough guide when interpreting on 5-ARI; any confirmed rise from the lowest PSA achieved on a 5-ARI requires clinical assessment — simply doubling the value is not sufficient).

Examination

Digital rectal examination (DRE): assess prostate size, consistency, symmetry. Normal: smooth, rubbery, bilobed (median sulcus palpable), uniform consistency, mobile, non-tender. Suspicious features: hard nodule, irregular surface, loss of median sulcus, asymmetry, fixed (invasion). Perform DRE where clinically appropriate and where the clinician is trained and confident. Refer using a suspected cancer pathway referral if the prostate feels malignant, regardless of PSA. A DRE is not a prerequisite for referral after a raised PSA, and should not delay the suspected-cancer pathway. A normal DRE does not exclude cancer. Abdominal: bladder palpation (distended = retention). Neurological lower limb (cord compression screen). Lymph node assessment.

Investigations

PSA (no fasting needed; same laboratory where possible; avoid ejaculation and vigorous exercise/cycling for 48h; exclude or treat UTI before interpreting; defer 4-6 weeks after prostatitis; recent catheterisation, biopsy, cystoscopy, urinary retention and instrumentation affect interpretation; do not repeat routinely unless a probable transient cause, and do not delay urgent referral for PSA >20 or concerning symptoms) · MSU (exclude UTI before PSA interpretation) · Multiparametric MRI prostate (mpMRI) (via the suspected cancer pathway — NICE NG131 2019: mpMRI before biopsy pathway, PI-RADS score) · TRUS-guided biopsy or template biopsy (via urology — after mpMRI) · Bone scan + CT chest/abdomen/pelvis (metastatic staging — arranged by the specialist team, not routinely from primary care) · PSMA PET-CT (selected biochemical recurrence — only through the urology/oncology pathway where the result will alter management). Do not routinely request free:total PSA or PSA density in primary care unless specifically supported by the local urology pathway.

The multiparametric MRI (mpMRI) pathway before prostate biopsy has transformed prostate cancer diagnosis since its adoption in NICE NG131 (2019) — mpMRI uses T2-weighted imaging (morphology), diffusion-weighted imaging (DWI — tissue cellularity), and dynamic contrast enhancement (DCE) to detect and characterise suspicious prostate lesions, graded using the PI-RADS v2.1 scoring system (1-5: 1 = very unlikely malignant; 3 = indeterminate; 4-5 = likely malignant). The clinical benefit: mpMRI before biopsy reduces the number of unnecessary biopsies (mpMRI PI-RADS 1-2: approximately 50% of men can safely avoid biopsy), reduces the detection of insignificant low-grade cancers (Gleason 3+3 — which would never cause harm and lead to overtreatment), and increases the detection of clinically significant high-grade cancers (Gleason ≥3+4). The PRECISE trial and PRECISION trial both confirmed that mpMRI-guided biopsy is significantly superior to standard systematic biopsy for detecting clinically significant cancer.

Diagnose

BPH, Active Surveillance & Risk Stratification

Done

BPH assessment and LUTS management

LUTS/BPH is a separate pathway — a benign diagnosis does not replace PSA interpretation and cancer referral decisions above. IPSS + quality of life question (1-6 scale). Flow rate (uroflowmetry): normal peak flow >15 mL/s; obstructed <10 mL/s. Post-void residual (PVR): bladder USS — significant if >300 mL. Urinary diary (frequency-volume chart): 72h, distinguishes OAB from polyuria. Prostate volume on TRUS or USS: prostate estimated >30 g or PSA >1.4 ng/mL with high risk of progression — add 5-ARI (NICE CG97). Consider specialist referral if: IPSS severe, recurrent UTIs, haematuria, post-void residual >300 mL, upper tract dilatation, or failed medical treatment.

Prostate cancer risk stratification (traditional low/intermediate/high groups — NICE NG131 now uses the five Cambridge Prognostic Groups, CPG 1–5)

Low risk: PSA <10 + Gleason ≤6 + stage T1/T2a → active surveillance (AS) preferred. Intermediate risk: PSA 10-20 OR Gleason 7 (3+4 or 4+3) OR stage T2b → radical treatment or AS. High risk: PSA >20 OR Gleason ≥8 OR stage T3/T4 → radical treatment + consider ADT. Locally advanced/metastatic: ADT + docetaxel or abiraterone (STAMPEDE regimen — specialist-initiated). Gleason score: primary + secondary grade. Gleason 3+3=6 (indolent). Gleason 3+4=7a (significant but potentially curable). Gleason 4+3=7b (higher grade — more aggressive). Gleason 8-10 (high grade).

Active surveillance (AS) protocol

For low-risk and selected intermediate-risk prostate cancer. Avoids or delays treatment (and treatment-associated side effects — ED, incontinence). Active surveillance is specialist-led — use the agreed urology protocol. NICE suggests PSA every 3–4 months during year 1, DRE at 12 months, mpMRI at 12–18 months, then PSA every 6 months and annual DRE thereafter. Repeat biopsy is triggered by the specialist protocol, MRI/PSA concern or discordance; it is not automatically required at 12–18 months for every patient. PSA kinetics (including a short doubling time) prompt specialist reassessment, usually mpMRI and/or biopsy, rather than automatic radical treatment; patient preference also matters. AS is appropriate management — not inadequate treatment — for carefully selected low-risk cancers (PROTECT trial: no difference in 10-year survival between AS, surgery, and radiotherapy for low-risk prostate cancer).

Active surveillance (AS) for low-risk prostate cancer is one of the most important patient communication challenges in primary care — many men (and their partners) instinctively find it difficult to accept 'watch and wait' when a cancer diagnosis has been made. The evidence base: the PROTECT trial (New England Journal of Medicine 2016, 10-year follow-up) showed that for men with low-risk localised prostate cancer (which accounts for approximately 50% of all diagnoses), 10-year prostate cancer-specific survival was approximately 99% whether treated with surgery, radiotherapy, or active monitoring. Metastasis-free survival was slightly lower in the AS group but overall mortality was identical. The GP's role in the AS conversation: reinforce the shared-decision making rationale, normalise the concept of monitoring a slow-growing cancer without immediate treatment, and ensure the monitoring programme is adhered to — PSA non-attendance is the most common reason for delayed detection of progression.

Refer

Referral Pathways

Done

Emergency / Same-day

Acute urinary retention — urgent same-day assessment and catheterisation (emergency transfer if severely unwell, sepsis, renal failure, severe pain, neurological features or suspected traumatic retention) · Suspected MSCC — contact the MSCC coordinator immediately for any neurological red flag (see Step 1) · Acute prostatitis with sepsis, acute retention, suspected prostatic abscess, inability to take oral antibiotics or no improvement within 48 hours

Suspected cancer · urology

Symptomatic man (LUTS, erectile dysfunction, visible haematuria) with PSA above the NG12 age-specific threshold (see Step 2), discussing preferences and comorbidities · Malignant-feeling prostate (hard nodule or asymmetry) on DRE regardless of PSA level · PSA >20 — urgent urology assessment (NHS England/GIRFT) · Very high PSA with bone symptoms/systemic features — urgent urology/oncology assessment · Haematuria + elevated PSA · Man under 40 — clinical judgement (40–49 with possible symptoms: NG12 threshold >2.5 ng/mL); lower threshold with suspicious DRE, symptoms, Black ancestry, strong family history or known pathogenic variant · Post-treatment PSA rise — contact the treating urology/radiotherapy team · Do not use PSA velocity alone to trigger referral

Urology (routine)

BPH with IPSS ≥20 or bothersome symptoms failing medical treatment · Recurrent UTIs with elevated PSA · Post-void residual >300 mL

GP management

BPH with mild-moderate LUTS (IPSS <20): alpha-blocker (tamsulosin 400 mcg OD) ± 5-ARI (finasteride 5 mg OD if prostate estimated >30 g or PSA >1.4 ng/mL, at high risk of progression). Acute bacterial prostatitis (stable and able to take oral treatment): MSU before antibiotics, without delaying treatment if unwell. Oral antibiotic guided by local resistance, previous cultures and current NICE NG110/MHRA advice — NICE lists ciprofloxacin 500 mg BD or ofloxacin (prostatic penetration), but MHRA (January 2024) restricts systemic fluoroquinolones to when other commonly recommended antibiotics are inappropriate; trimethoprim 200 mg BD if a fluoroquinolone is not appropriate. If a fluoroquinolone is used: avoid concomitant corticosteroids where possible; prescribe with particular caution in people over 60, with renal impairment or transplant; avoid after a previous serious quinolone/fluoroquinolone reaction; advise stopping immediately and seeking review for tendon pain, neuropathy, severe mood change or other serious adverse effects (risk of long-lasting or irreversible disability). Review at 14 days and either stop or continue for a further 14 days if clinically indicated. Avoid prostatic massage. Hospital referral if septic, unable to take oral therapy, in acute retention, suspected abscess, or not improving within 48 hours. Chronic prostatitis/CPPS: management is complex — analgesia, alpha-blocker, physiotherapy, CBT.

The DRE (digital rectal examination) remains useful where clinically appropriate — a hard, irregular, or asymmetric prostate on DRE indicates clinical T3 or T4 disease and should trigger a suspected cancer pathway referral regardless of the PSA level. PSA can be low in poorly differentiated (high-grade) prostate cancer because dedifferentiated prostate cancer cells lose the ability to produce PSA — the 'PSA leak' is paradoxically reduced in some high-grade cancers. A man with a rock-hard, nodular prostate and a PSA of only 3 ng/mL should still be referred on the suspected cancer pathway. Perform DRE where clinically appropriate and where the clinician is trained and confident. A DRE is not a prerequisite for referral after a raised PSA — NHS England/GIRFT states that no DRE is needed if the PSA is raised and that men fit for radical treatment can proceed directly to mpMRI in secondary care — and it should not delay the suspected-cancer pathway. A normal DRE does not exclude cancer.

Treat

BPH Medical Management & ADT for Prostate Cancer

Done

Mild-moderate BPH (IPSS 8-19) — first-lineAlpha-1 adrenoceptor blocker: tamsulosin 400 mcg modified-release OD (most commonly used; selective for urinary tract alpha-1a and alpha-1d receptors). Alternative: alfuzosin 10 mg MR OD; silodosin 8 mg OD. Onset of action: days-2 weeks. Check postural symptoms and blood pressure. Counsel about dizziness/postural hypotension (especially in elderly — first dose) and ejaculatory dysfunction (particularly tamsulosin and silodosin). Ask about cataract surgery history or plans (intraoperative floppy iris syndrome). Avoid if significant hypotension. Review response (symptoms, IPSS) rather than promising specific improvements in peak flow or IPSS.

Moderate-severe BPH, prostate estimated >30 g or PSA >1.4 ng/mL, high progression risk — add 5-ARI5-alpha reductase inhibitor: finasteride 5 mg OD or dutasteride 500 mcg OD. Mechanism: inhibits conversion of testosterone to DHT (the primary prostatic androgen), reducing prostate volume by 20-30% over 6 months. PSA EFFECT: 5-ARI reduces PSA by approximately 50% at 6 months — double the PSA reading as a rough guide when monitoring cancer risk on a 5-ARI, but any confirmed rise from the lowest PSA achieved while taking a 5-ARI requires clinical assessment — simply doubling the value is not sufficient. Response: takes 6-12 months for maximum effect. Side effects: erectile dysfunction (5-10%), reduced ejaculate volume, reduced libido (sexual dysfunction may persist after stopping), rare gynaecomastia; depression/suicidal ideation (finasteride; precautionary for dutasteride) — ask about prior depression and advise reporting mood changes (MHRA 2026). Combination therapy (alpha-blocker + 5-ARI): superior to either alone for moderate-severe BPH (MTOPS trial).

Severe LUTS or OAB component — add antimuscarinic or beta-3If storage symptoms (urgency, frequency) predominate alongside voiding: add mirabegron 50 mg OD (beta-3 adrenoceptor agonist — relaxes detrusor, fewer side effects than antimuscarinics, safe with alpha-blocker, check blood pressure before and during treatment; contraindicated in severe uncontrolled hypertension) or solifenacin 5 mg OD (antimuscarinic — caution where there is significant residual urine or retention risk). No single post-void residual threshold applies universally — decide on symptoms, flow, PVR, obstruction risk and local urology guidance. Bladder training: scheduled voiding + urgency suppression techniques.

Advanced/metastatic prostate cancer — ADT (specialist-initiated)Androgen deprivation therapy (ADT) is initiated by the urology/oncology team, usually after staging and discussion of goals of care, except where an agreed local emergency pathway specifically authorises initiation. Options include an LHRH agonist (e.g. leuprorelin, goserelin) or a GnRH antagonist (degarelix, relugolix). An LHRH agonist can cause an initial testosterone flare: specialist teams may use short-term anti-androgen cover in selected patients at high risk of symptomatic flare, particularly extensive spinal metastases, impending cord compression or significant bladder outlet obstruction. This is not required for GnRH antagonists and should not be initiated routinely in primary care. Docetaxel or abiraterone/enzalutamide for metastatic disease (STAMPEDE regimen) are oncology-led. Bone health: see Step 8 — zoledronic acid for skeletal-related events in hormone-relapsed metastatic disease is an oncology-led regimen, not generic bone protection.

The testosterone flare with LHRH agonist initiation is a specialist prescribing consideration for prostate cancer ADT — LHRH agonists (leuprorelin, goserelin, triptorelin) cause an initial surge of LH and testosterone in the first 1-2 weeks before receptor desensitisation produces testosterone suppression. In patients with bone metastases or obstructing locally advanced cancer, this testosterone surge can cause disease flare: worsening bone pain (and risk of pathological fractures), urinary retention, spinal cord compression, and hypercalcaemia. Specialist teams may therefore use short-term anti-androgen cover in selected patients at high risk of symptomatic flare; the need, duration and agent depend on the drug, indication and specialist protocol, and current evidence questions the need for anti-androgen cover in all patients. It is not required for GnRH antagonists such as degarelix or relugolix. ADT and flare cover should not be initiated in primary care; continuing GP prescribing requires specialist initiation, baseline monitoring and an explicit shared-care agreement.

Treat

Prostate Cancer Treatment Options & Side Effect Management

Done

Radical prostatectomy vs radiotherapy — patient discussion

Radical prostatectomy (open or robotic-assisted laparoscopic): urinary incontinence (approximately 10-20% at 1 year, most improve), erectile dysfunction (approximately 40-70% at 1 year — varies by nerve-sparing technique), no risk of radiation effects. Radiotherapy (EBRT ± brachytherapy): urinary frequency + urgency + rectal side effects during treatment, late bowel effects (approximately 5-10%), erectile dysfunction (approximately 40-60%). Both achieve equivalent cancer-specific survival for low-intermediate risk. Choice: patient-specific based on age, comorbidity, sexual function priorities, preference (PROTECT trial).

ADT side effects — GP management

Hot flushes (approximately 70% of men on ADT): medroxyprogesterone acetate (NICE NG131: offer medroxyprogesterone for troublesome hot flushes, usually 20 mg daily initially for 10 weeks; consider cyproterone acetate if ineffective), venlafaxine 37.5-75 mg OD, gabapentin 300 mg TDS. Bone loss (ADT reduces testosterone → accelerated osteoporosis): assess fracture risk and consider baseline DEXA per local protocol; do not routinely offer bisphosphonates solely to prevent osteoporosis; offer a bisphosphonate where osteoporosis is present, and consider denosumab if bisphosphonates are contraindicated or not tolerated (NICE NG131) — see Step 8. Metabolic syndrome (weight gain, dyslipidaemia, insulin resistance, cardiovascular risk): lifestyle advice + statin consideration, annual HbA1c + lipid profile. Fatigue: aerobic exercise (30 min/day). Gynaecomastia: bicalutamide-induced — tamoxifen 20 mg weekly (off-label) prevents gynaecomastia.

Erectile dysfunction after prostate cancer treatment

Early penile rehabilitation (from 4-6 weeks post-surgery): PDE5 inhibitor (sildenafil 50-100 mg PRN or tadalafil 5 mg OD — improves oxygenation of erectile tissue, may promote nerve recovery). Vacuum erection device (VED). Intracavernosal alprostadil. Penile prosthesis (last resort). Psychosexual counselling: for both patient and partner — essential component of rehabilitation.

Next steps: see Benign prostate enlargement · Male LUTS · Prostatitis · Metastatic spinal cord compression

The cardiovascular risk associated with long-term ADT is a clinically important GP responsibility to monitor — ADT (androgen deprivation therapy) significantly increases cardiovascular risk in prostate cancer patients: retrospective cohort studies show approximately 15-30% increased risk of myocardial infarction, stroke, and cardiovascular mortality in men on long-term ADT. The mechanisms: testosterone suppression causes: increased body fat (visceral adiposity), reduced lean muscle mass, insulin resistance (approximately 44% increased risk of diabetes), dyslipidaemia (increased triglycerides, LDL), and direct vascular effects. Where a specialist has formally transferred monitoring under shared care, metabolic screening (HbA1c or fasting glucose, lipid profile, blood pressure, weight and BMI) at approximately 3–6-month intervals is supported, with exact frequency per treatment combination and local protocol, plus exercise prescription (150 min moderate aerobic exercise per week reduces metabolic side effects).

Lifestyle

Prostate Health, Screening & ADT Wellbeing

Done

PSA testing and informed consent There is no NHS population screening programme for prostate cancer (unlike breast and cervical screening) — PSA testing in asymptomatic men is an individual informed choice. Men who request PSA testing should receive a balanced discussion: benefits (early detection of potentially curable cancer), harms (false positives leading to unnecessary biopsy, overdetection of clinically insignificant cancers, anxiety, treatment side effects). Prostate Cancer UK (prostatecanceruk.org) has a validated PSA decision tool. The UK National Screening Committee does not recommend population PSA screening; offer an informed discussion; a man aged 50 or over who still wants a PSA test after counselling may have it (Prostate Cancer Risk Management Programme, PCRMP). For asymptomatic men aged 50–69, the PCRMP threshold is PSA ≥3.0 ng/mL rather than the symptomatic NG12 age-specific thresholds. Black men and men with a strong family history or known pathogenic variant (e.g. BRCA2) are at higher risk — discuss testing and follow clinical genetics advice where relevant.

Diet and lifestyle Advise a balanced diet, healthy weight, physical activity, smoking cessation and moderation of alcohol. Avoid presenting individual foods or supplements as proven methods of preventing or treating prostate cancer.

Exercise during prostate cancer treatment Exercise is one of the most evidence-based supportive interventions for prostate cancer — systematic-review evidence supports structured exercise during and after treatment. Benefits: reduces ADT-related fatigue, preserves muscle mass and bone density, reduces depression and anxiety, improves cardiovascular risk markers. Prescription: 150 min moderate aerobic exercise + 2x resistance training per week. NHS Exercise Referral Scheme: GP referral for supervised programme. Prostate Cancer UK exercise resources: menshealth.prostatecanceruk.org.

ADT and bone health ADT accelerates bone loss and increases fracture risk. At ADT initiation, assess fracture risk and consider baseline DEXA according to local protocol. Advise weight-bearing and resistance exercise, smoking cessation, moderation of alcohol, adequate dietary calcium and vitamin D sufficiency. Do not routinely offer bisphosphonates solely to prevent osteoporosis; use a bisphosphonate or denosumab only where osteoporosis/fracture-risk criteria are met (denosumab if bisphosphonates are contraindicated or not tolerated) or where indicated by the oncology pathway. Before treatment check renal function (bisphosphonate), dental assessment/oral health and calcium/vitamin D status; denosumab carries a hypocalcaemia risk and needs a planned discontinuation strategy because rebound vertebral-fracture risk requires specialist management. Do not use zoledronic acid 4 mg every 3 weeks as generic "bone protection" — that is an oncology-led regimen for skeletal-related events in hormone-relapsed metastatic disease.

Sexual health and relationships after prostate cancer Erectile dysfunction (ED) affects approximately 40-70% of men after radical prostatectomy and approximately 40-60% after radiotherapy — even without treatment, ADT suppresses testosterone and causes ED in virtually all men. Prostate Cancer UK Specialist Nurse service (0800 074 8383). Relate (relate.org.uk): couples therapy for sexual and relationship impact of prostate cancer. Ask about mood, fatigue, cognition, sexual function, relationship impact and urinary/bowel symptoms, and refer to the specialist nurse, psychosexual service or primary-care mental-health pathway where required. PDE5 inhibitors (sildenafil, tadalafil): prescribable on NHS for erectile dysfunction caused by prostate cancer treatment.

Urinary symptoms after prostate cancer treatment Post-surgical incontinence: pelvic floor exercises (supervised — GP referral to pelvic floor physiotherapist). Continence pads: OT/nurse assessment for correct product. Urinary urgency/frequency post-radiotherapy: bladder training + mirabegron. New or significant haematuria after prostate radiotherapy requires urgent urological assessment according to severity (recurrent/new urothelial malignancy, infection, clot retention, radiation cystitis, upper-tract pathology). Manage clot retention, infection and bleeding with urology advice; do not prescribe tranexamic acid routinely in primary care. Obstructive symptoms post-brachytherapy: alpha-blocker. Urethral stricture post-treatment: urology.

Family history and hereditary prostate cancer First-degree relative with prostate cancer diagnosed under age 65: approximately 2x lifetime risk. BRCA2 mutation: lifetime prostate cancer risk approximately 20-25% (vs 11% population risk) and significantly higher risk of high-grade aggressive cancer. BRCA1 carriers: modest increased risk. Lynch syndrome: increased risk of prostate and other cancers. Men with a strong family history, Black African/Caribbean ancestry or a known pathogenic variant are at higher risk — discuss PSA testing and follow clinical genetics advice where relevant. Genetic testing (e.g. BRCA2) follows local genetics/urology criteria — do not arrange it solely because of one high PSA.

Post-treatment monitoring Follow the specialist post-treatment surveillance plan. NICE: PSA no earlier than 6 weeks after radical treatment, at least every 6 months for the first 2 years, then at least annually. Document the post-treatment PSA (nadir). After radical prostatectomy a detectable or rising PSA is concerning — biochemical recurrence is commonly PSA ≥0.2 ng/mL confirmed by a second test. After radiotherapy PSA can decline slowly and may show a benign bounce; the Phoenix definition is PSA nadir +2 ng/mL. Management depends on PSA trend, pathology, imaging, prior treatment and specialist review. Do not independently label biochemical recurrence or arrange PSMA PET-CT without urological/oncological discussion — contact the treating team.

The PDE5 inhibitor (sildenafil, tadalafil) prescribing on the NHS for prostate cancer treatment-related ED is a quality standard — NHS England guidance confirms that erectile dysfunction caused by prostate cancer treatment (surgery, radiotherapy, or ADT) is a specific indication for NHS prescription of PDE5 inhibitors, distinct from the Selected List Scheme restriction that still applies to branded PDE5 inhibitors (generic sildenafil, and more recently generic tadalafil and vardenafil, no longer need an SLS endorsement). GPs should not decline to prescribe sildenafil or tadalafil for prostate cancer treatment-related ED on grounds of cost or non-urgent status — this represents a failure to provide evidence-based care for a significant treatment-related morbidity. Where a branded product is prescribed, endorse the FP10 "SLS" (prostate cancer and prostatectomy are qualifying conditions).

Safety

Follow-Up, PSA Monitoring & Treatment Review

Done

PSA monitoring after a suspected cancer referral

Confirm the referral was accepted and appointment received. If not: resubmit or contact urology direct. If rapid deterioration before appointment (new bone pain, urinary retention, neurological symptoms): 999/same-day reassessment.

BPH treatment monitoring

Alpha-blocker: first review at 4–6 weeks. 5-ARI: review at 6 months (PSA baseline before starting; any confirmed rise from the lowest PSA on treatment needs clinical assessment). IPSS + flow rate at 12 months. Annual review thereafter: IPSS score, post-void residual, PSA (on a 5-ARI, interpret against the lowest on-treatment value).

Active surveillance monitoring

Specialist-led — follow the agreed urology protocol (NICE: PSA every 3–4 months in year 1, DRE at 12 months, mpMRI at 12–18 months, then PSA every 6 months and annual DRE; repeat biopsy only if triggered by the protocol or MRI/PSA concern). Report to the team: rising PSA, new symptoms, patient anxiety about AS — PSA kinetics prompt specialist reassessment, not automatic radical treatment.

ADT monitoring in shared care

Only once a specialist has formally transferred responsibility under a shared-care agreement; frequency per treatment combination and local protocol (often approximately 3–6-monthly). Monitor: PSA and testosterone (castrate level <1.7 nmol/L); symptoms and clinical progression; weight, BMI and blood pressure; HbA1c or fasting glucose; lipid profile; renal function and LFTs where indicated by the systemic regimen; bone health/DEXA; falls risk; mood, cognition, fatigue and sexual function; hot flushes and anaemia.

Emergency / Same-day

Acute urinary retention (same-day catheterisation; emergency transfer if severely unwell) · Suspected MSCC — any neurological red flag; contact the MSCC coordinator, MRI whole spine within 24 h · Acute prostatitis with sepsis, retention, suspected abscess or no improvement within 48 h

Suspected cancer

Symptomatic man with PSA above the NG12 age-specific threshold · Malignant-feeling DRE regardless of PSA · PSA >20 · Haematuria + elevated PSA · Post-treatment PSA rise → treating team (PSA velocity alone is not a referral criterion)

The nadir PSA after radical prostatectomy should be undetectable (below the assay detection limit, typically <0.01-0.1 ng/mL depending on the assay used) within 4-6 weeks of surgery — because all PSA-producing prostate tissue should have been removed. A detectable PSA after radical prostatectomy (above the assay threshold) suggests either residual prostate tissue or persistent/recurrent disease. GPs monitoring post-prostatectomy patients must use an ultrasensitive PSA assay (detection limit <0.01-0.05 ng/mL) — a standard PSA assay with a detection limit of 0.1 ng/mL is inadequate for post-prostatectomy monitoring. Biochemical recurrence after prostatectomy is commonly defined as PSA ≥0.2 ng/mL confirmed by a second test (first PSA no earlier than 6 weeks after surgery); follow the specialist surveillance plan and discuss any detectable or rising PSA with the treating team rather than labelling recurrence independently.