The Prostate: Enlargement, PSA Testing and What the Numbers Mean
The prostate causes two distinct sets of problems that are frequently conflated: benign enlargement, which affects urination and is very common, and prostate cancer, which usually causes no symptoms at all until advanced. Having one does not mean having the other.
Benign prostatic enlargement
The prostate sits below the bladder and surrounds the urethra. It enlarges with age in most men, and when it compresses the urethra it produces lower urinary tract symptoms.
Storage symptoms: urgency, frequency, waking at night to urinate, occasional urge incontinence.
Voiding symptoms: weak or slow stream, hesitancy before starting, straining, intermittent flow, dribbling at the end, a sense of incomplete emptying.
Prostate size correlates poorly with symptom severity. A modestly enlarged prostate in an unhelpful position can cause more trouble than a large one.
Treatments:
- Lifestyle: reduce evening fluid, caffeine and alcohol; double voiding; avoid decongestants and some antihistamines, which worsen retention; treat constipation
- Alpha blockers such as tamsulosin, which relax prostate and bladder neck muscle and work within days. Side effects include dizziness and retrograde ejaculation
- 5-alpha reductase inhibitors such as finasteride and dutasteride, which shrink the gland over months. These roughly halve the PSA value, which matters for interpreting tests
- Combination therapy for larger glands
- Anticholinergics or beta-3 agonists where storage symptoms dominate
- Tadalafil, which helps both urinary symptoms and erectile function
- Procedures: TURP, laser treatments, UroLift, Rezum and others, when medication fails or complications develop
Seek urgent care for: complete inability to pass urine, which is acute retention and is an emergency; blood in urine; fever with urinary symptoms; or symptoms with kidney function decline.
Prostate cancer and PSA
Prostate specific antigen is a protein produced by the prostate. More of it leaks into the blood when the prostate is enlarged, inflamed, infected, irritated, or cancerous. It is prostate-specific, not cancer-specific.
Things that raise PSA besides cancer: benign enlargement, prostatitis, urinary infection, recent ejaculation, vigorous cycling, a recent catheter, and a digital rectal examination immediately beforehand.
Things that lower it: 5-alpha reductase inhibitors, which halve it, and obesity.
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This is why a single raised PSA is a reason to repeat the test after a few weeks, not a diagnosis.
The screening debate, honestly
PSA screening reduces prostate cancer deaths modestly in large trials. It also detects many cancers that would never have caused harm, and investigating and treating those causes real harm: incontinence and erectile dysfunction after treatment are not rare.
This is why most guidelines now recommend shared decision making rather than universal screening: a conversation about benefits and harms, with the decision resting on the individual’s values.
Reasonable framing:
- Discussion from age 50 for average risk
- From 45 for higher risk: a father or brother with prostate cancer, or men of African or Caribbean ancestry
- From 40 where there is a strong family history, or a known BRCA2 mutation
- Generally not recommended where life expectancy is under about ten years, since the benefit takes longer than that to appear
What happens after a raised PSA
Practice has changed significantly, and for the better.
The old pathway went straight from raised PSA to a systematic biopsy, which both missed significant cancers and found many insignificant ones.
The current pathway usually involves multiparametric MRI first. The scan is scored, and a low score may avoid biopsy altogether, while a suspicious area allows a targeted biopsy of the specific region rather than random sampling. This detects more significant cancer and less insignificant cancer.
Active surveillance
Many prostate cancers are low grade and slow growing. For these, active surveillance, meaning monitoring with PSA, MRI and repeat biopsy, with treatment only if the disease progresses, is standard practice and avoids or delays the side effects of treatment.
This matters because the instinct on hearing “cancer” is to treat immediately, and for a low-risk prostate cancer that instinct can cost quality of life without extending it.
Prostatitis, which is different again
Inflammation or infection of the prostate, causing pelvic pain, painful urination, pain with ejaculation and sometimes fever. Acute bacterial prostatitis is an illness needing prompt antibiotics. Chronic pelvic pain syndrome is far more common, often not bacterial, and responds better to a combination of pelvic floor physiotherapy, alpha blockers and pain management than to repeated antibiotic courses.
Practical points
- Avoid ejaculation and vigorous cycling for 48 hours before a PSA test
- Postpone the test for several weeks after a urinary infection
- If you take finasteride or dutasteride, your PSA should be doubled for interpretation
- A rising trend over time matters more than a single value
- Benign enlargement does not turn into cancer
The short version
Urinary symptoms usually mean benign enlargement, not cancer, and are treatable. PSA is a prostate test, not a cancer test, so a single raised value needs repeating rather than panic. If PSA is persistently raised, ask whether MRI comes before biopsy, and if a low-risk cancer is found, ask about active surveillance before agreeing to treatment.