Reasoning GP · Algorithm · 1-page summary
High PSA in primary care
For: adult men with a raised PSA, or deciding whether to test (with symptoms, or an informed request). Not for: LUTS treatment detail (male LUTS protocol), acute prostatitis management (prostatitis protocol), or known prostate cancer — follow the treating team's plan.
Core rule: a malignant-feeling prostate at any PSA, or a PSA above the NG12 age-specific threshold in a man with possible symptoms → suspected cancer pathway referral. A DRE is not a prerequisite, and do not repeat the PSA first unless there is a probable transient cause.
0Act now — emergencies with a raised PSA
- Back or radicular pain + any neurological red flag (limb weakness, gait change, sensory level, bladder/bowel dysfunction, saddle anaesthesia) → Immediately MSCC coordinator / acute oncology, emergency hospital assessment; MRI whole spine always ≤24 h. Neurological signs: dexamethasone 16 mg orally with PPI, unless specialist advice differs.
- Acute urinary retention → Same-day assessment and catheterisation; emergency transfer if severely unwell, sepsis, renal failure, severe pain or neurological features.
- Fever, rigors, perineal pain, tender boggy prostate (acute prostatitis) → MSU without delaying antibiotics; Same-day hospital if septic, unable to take oral, retention, suspected abscess or no better by 48 h. No prostatic massage.
- Very high PSA + bone pain, weight loss or systemic features → Urgent urology / oncology contact; staging and ADT are specialist-led — do not start them.
1Triage — what is the context?
| Context | Route |
|---|---|
| Possible symptoms | LUTS, erectile dysfunction, visible haematuria → NG12 thresholds (block 2) |
| No symptoms, asking | Offer an informed discussion; 50+ who still wants a test after counselling may have it (PCRMP: 50–69 ≥3.0 ng/mL) |
| On a 5-ARI | PSA roughly halves by 6 months; any confirmed rise from the lowest on-treatment value → clinical assessment |
| Transient cause | UTI, prostatitis, recent catheter, biopsy or instrumentation → treat, repeat after 4–6 weeks |
| After radical treatment | Rising PSA → contact the treating team |
2Screen — suspected cancer routes
- Malignant-feeling prostate (hard, nodular, asymmetric), any PSA → Suspected cancer urology.
- Possible symptoms + PSA above threshold (40–49 >2.5; 50–59 >3.5; 60–69 >4.5; 70–79 >6.5 ng/mL; <40 or >79 judgement) → Suspected cancer referral, discussing preferences and comorbidities.
- PSA >20 → Urgent urology assessment.
- Aged 45+, unexplained visible haematuria (no UTI, or persisting after UTI treatment) → Suspected cancer urology.
- Black ancestry, strong family history, known BRCA2 or other variant → lower threshold for urological assessment.
3Assess
☐ DRE if appropriate and trained — never delay referral for it ☐ Bladder, lower-limb neurology ☐ MSU ☐ Previous PSAs, same laboratory, 5-ARI use ☐ No ejaculation or vigorous exercise for 48 h before testing
Not in primary care: free:total PSA, PSA density, PSA velocity as a referral trigger, staging scans, PSMA PET-CT.
4Classify — only if blocks 0–2 are negative
- BPH — commonest cause of PSA 4–10 in older men; a benign diagnosis does not replace the NG12 decision.
- Infection or instrumentation — treat or wait, repeat after 4–6 weeks; still above threshold → suspected cancer referral.
- Within range, no concern — explain the limits of PSA; a normal PSA does not exclude cancer.
- Active surveillance — specialist protocol; report rising PSA, new symptoms or anxiety to the team.
- Uncertain — say so; discuss with urology and record who reviews and when.
5Treat today — only these
- Acute prostatitis, stable: oral antibiotic per local resistance and NG110; fluoroquinolone only if others inappropriate (MHRA); trimethoprim 200 mg BD otherwise. Review at 14 days.
- LUTS / BPH: tamsulosin 400 mcg OD ± finasteride 5 mg OD if prostate >30 g or PSA >1.4 ng/mL with high progression risk; PSA before a 5-ARI; ask about depression (MHRA). Doses: NICE/SPC, BNF, local formulary.
- Counsel: false positives and negatives, overdiagnosis; Prostate Cancer UK decision tool.
6Refer routinely
- BPH with IPSS ≥20 or failing medical treatment, recurrent UTIs with raised PSA, post-void residual >300 mL → urology.
- Discharged after low-risk MRI or negative biopsy → follow urology's PSA re-referral threshold; re-refer if PSA keeps rising.
- BRCA2, strong family history, Black men → discuss testing; follow clinical genetics advice where relevant. No genetic test for one high PSA alone.
7Never reassure by
- A normal PSA when the prostate feels malignant.
- A normal DRE — it does not exclude cancer.
- A benign BPH diagnosis when PSA is above threshold.
- Doubling a 5-ARI PSA while ignoring a rise from its lowest value.
- A repeat PSA with no transient cause — it delays referral.
- A normal neurological examination in suspected MSCC.
8Safety-net — say it, then document it
999 / Same-day “Before your appointment, call 999 or contact us the same day for new weakness or numbness in the legs, trouble walking, loss of bladder or bowel control, being unable to pass urine, or new bone pain. Fever or shivering with pain between the legs — contact us today.”
Referral: confirm it was accepted and the appointment arrived; if not, resubmit or contact urology directly.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Symptoms, age band, risk factors and confounders recorded
Benign cause named, or uncertainty stated
Informed discussion and repeat or review date recorded
Safety-net given and documented
Summary of the full Reasoning GP high PSA algorithm, which holds interpretation, BPH, active surveillance, ADT and post-treatment detail. Sources: NICE NG12 (updated April 2026), NG131, NG234, NG110; GIRFT/BAUS prostate pathway (2024); MHRA fluoroquinolones (2024) and 5-ARI (2026); Prostate Cancer Risk Management Programme. Clinical reference — follow local pathways and check doses: NICE/SPC, BNF.