Understanding an elevated prostate-specific antigen (PSA) level and what happens next
A raised PSA is a common finding in men, particularly as they get older. PSA (prostate-specific antigen) is a protein produced by the prostate gland and measured using a blood test.
An elevated PSA does not necessarily mean prostate cancer. PSA levels can rise for several reasons, including benign enlargement of the prostate, inflammation or infection of the prostate, and recent urinary or prostate procedures.
However, a raised or rising PSA can sometimes be an early sign of prostate cancer. The important question is therefore not simply whether the PSA is above a particular number, but why it is raised and whether further investigation is appropriate.
Mr Gidon Ellis is a Consultant Urological Surgeon specialising in the assessment of men with raised PSA and suspected prostate cancer. He provides specialist assessment to understand the significance of an elevated PSA and, where appropriate, arranges further investigation including prostate MRI and referral for biopsy.
What is PSA?
PSA stands for prostate-specific antigen. It is a protein produced by cells within the prostate gland and is normally present in small amounts in the bloodstream.
PSA levels tend to increase as men get older, partly because the prostate commonly becomes larger with age. A PSA blood test can therefore provide useful information about prostate health, but it is not a cancer-specific test.
A raised PSA can occur with:
- Benign prostatic hyperplasia (BPH)
- Prostate cancer
- Prostatitis or inflammation of the prostate
- Urinary tract infection
- Recent urinary or prostate procedures
- Urinary retention
This is why PSA results need to be interpreted alongside your age, symptoms, prostate size, examination findings and other clinical information.
What is a normal PSA level?
There is no single PSA level that can be considered normal for every man. PSA generally increases with age, which is why age-specific thresholds are used when assessing men with possible prostate cancer.
NICE currently recommends the following age-specific PSA thresholds for men with possible symptoms of prostate cancer:
| Age | PSA threshold |
|---|---|
| 40–49 years | More than 2.5 µg/L |
| 50–59 years | More than 3.5 µg/L |
| 60–69 years | More than 4.5 µg/L |
| 70–79 years | More than 6.5 µg/L |
| Under 40 or over 79 | Clinical judgement |
These figures are thresholds rather than absolute normal/abnormal boundaries. A PSA below the age-specific threshold does not completely exclude prostate cancer, while a PSA above it does not mean that cancer is present. The significance of an individual PSA result depends on the overall clinical picture.
What can cause a raised PSA?
There are several possible causes of an elevated PSA.
Benign prostate enlargement (BPH)
As men get older, the prostate commonly becomes larger. A larger prostate contains more prostate tissue and can therefore produce more PSA. Benign prostate enlargement is one of the most common reasons for a raised PSA.
Prostate cancer
Prostate cancer can cause PSA levels to rise. However, the PSA level alone cannot diagnose prostate cancer. Further assessment is required to determine whether a raised PSA is likely to be related to cancer.
Prostatitis and inflammation
Inflammation of the prostate can cause a significant temporary increase in PSA.
This may occur with:
- Pelvic or perineal discomfort
- Burning when passing urine
- Urinary frequency or urgency
- Difficulty passing urine
- Pain associated with ejaculation
- Fever or feeling unwell in acute cases
If infection or inflammation is suspected, PSA may need to be repeated after the condition has settled.
Urinary infection
A urinary tract infection can sometimes cause PSA to rise, particularly when there is associated prostate inflammation.
Urinary retention
A significant episode of urinary retention can result in a temporary rise in PSA.
Recent procedures
PSA may be affected by recent instrumentation or procedures involving the urinary tract or prostate. Your doctor will take the timing of any recent procedures into account when interpreting the result.
Does a rising PSA always mean prostate cancer?
No. PSA levels can fluctuate and may rise for reasons unrelated to cancer. However, a persistently rising PSA can be important, particularly when considered alongside prostate size, age, family history, symptoms and previous PSA measurements. The pattern over time can therefore provide useful information, rather than looking at a single PSA result in isolation.
What happens if my PSA is raised?
The next step depends on the degree of elevation and the circumstances in which the test was performed.
Your assessment may include:
Reviewing the PSA result
Mr Ellis will consider:
- Your age
- Your current PSA level
- Previous PSA measurements
- The rate and pattern of change over time
- Your symptoms
- Family history
- Your prostate size
- Any recent infection, inflammation or urinary procedures
Prostate examination
A digital rectal examination (DRE) may be appropriate as part of the assessment. This allows the prostate to be assessed for enlargement or areas that feel abnormal.
Repeat PSA
If there is a possible temporary reason for the elevation, such as infection or inflammation, repeating the PSA after an appropriate interval may be appropriate. The timing depends on the individual circumstances.
Prostate MRI
If there is ongoing concern about prostate cancer, a multiparametric MRI (mpMRI) of the prostate is commonly used to assess the prostate in greater detail. MRI can identify areas that may require further investigation and can help determine whether a biopsy is appropriate.
Additional prostate cancer risk assessment
In selected men with a raised or borderline PSA, additional biomarkers may sometimes provide further information about the likelihood of clinically significant prostate cancer.
Stockholm3 is a blood test that combines PSA measurements with other protein and genetic markers to estimate the risk of clinically significant prostate cancer. It may be considered in selected circumstances where additional risk assessment could help inform the decision about whether further investigation, such as prostate biopsy, is appropriate.
Stockholm3 is not a replacement for prostate MRI or biopsy, and its availability and role vary between healthcare settings. Mr Ellis can discuss whether additional biomarker testing is appropriate based on your individual circumstances.
Prostate biopsy
If MRI or other clinical findings suggest that cancer may be present, a prostate biopsy may be recommended. If a biopsy is required, Mr Ellis will refer you to an experienced specialist colleague who performs prostate biopsy, ensuring that the biopsy is undertaken by an appropriate expert.
Biopsy involves taking small tissue samples from the prostate which are then examined under a microscope. Not every man with a raised PSA will require a biopsy.
PSA and prostate screening
PSA testing can be used in men who do not have symptoms, but it is important to understand the benefits and limitations of testing. There is no national NHS prostate cancer screening programme in the UK. Instead, men without symptoms can discuss whether PSA testing is appropriate for them.
The decision depends on factors including age, family history, ethnicity, previous PSA results and individual preferences. A PSA test can sometimes identify prostate cancer at an earlier stage, but it can also lead to false alarms, further investigations and treatment of cancers that might never have caused problems.
This means PSA testing is best approached as an individual decision after discussion of the potential benefits and limitations, rather than as a routine screening test for every man. A more detailed discussion of PSA screening, including who should consider testing and how often it should be repeated, can be explored in a dedicated guide to PSA screening and prostate cancer risk.
When should I seek medical advice?
You should arrange an assessment if:
- Your PSA is above the age-specific reference threshold
- Your PSA has risen significantly compared with previous results
- You have a strong family history of prostate cancer
- You have urinary symptoms together with a raised PSA
- You have been advised that your PSA requires further investigation
You should seek more urgent medical advice if urinary symptoms are accompanied by:
- Fever or feeling significantly unwell
- Severe pelvic or lower abdominal pain
- Sudden inability to pass urine
Why choose Mr Ellis?
A raised PSA does not automatically mean prostate cancer, but it should be interpreted carefully. Mr Ellis takes a structured approach to understanding why the PSA is elevated, considering benign prostate enlargement, infection, inflammation and prostate cancer rather than assuming that an abnormal result represents cancer.
Where further investigation is appropriate, assessment can include prostate examination, repeat PSA testing and prostate MRI. If a biopsy is indicated, Mr Ellis works with experienced specialist colleagues and will arrange referral for the biopsy and subsequent management as appropriate. The aim is to avoid unnecessary investigations while ensuring that clinically important prostate cancer is not missed.
Frequently asked questions
Does a raised PSA mean I have prostate cancer?
No. PSA can be raised by several benign conditions, particularly prostate enlargement and inflammation. Further assessment is needed to understand the reason for the elevation.
What PSA level is considered high?
There is no single threshold that applies to every man. PSA normally increases with age, which is why age-specific thresholds are used. NICE currently uses thresholds of 2.5 µg/L for men aged 40–49, 3.5 for 50–59, 4.5 for 60–69 and 6.5 for 70–79 when assessing men with possible symptoms of prostate cancer.
Can an infection raise PSA?
Yes. Urinary infection and inflammation of the prostate can cause PSA to rise, sometimes substantially. In this situation, the PSA may need to be repeated after the infection or inflammation has settled.
Should I repeat my PSA?
Sometimes. If there is a possible temporary reason for the elevation, repeating the PSA can be useful. The appropriate timing depends on the circumstances and should be discussed with your doctor.
Does a raised PSA mean I need an MRI?
Not necessarily, but prostate MRI is an important next investigation when there is ongoing concern about prostate cancer. Whether MRI is appropriate depends on the PSA level, clinical assessment and other risk factors.
Will I need a prostate biopsy?
Not necessarily. MRI and the overall clinical assessment help determine whether a biopsy is appropriate. Some men with a raised PSA will have a reassuring MRI and may be monitored without immediate biopsy.
Arrange a consultation
If you have been told that your PSA is raised, rising or requires further investigation, Mr Gidon Ellis offers specialist assessment in London. A consultation provides an opportunity to review your PSA history, assess your prostate cancer risk and decide whether repeat testing, MRI, additional risk assessment, biopsy or monitoring is the most appropriate next step.
