When you visit a Urologist for urinary or prostate-related issues, a comprehensive evaluation starts with a detailed history taking prior to any invasive or uncomfortable investigations. This will include questions about urinary symptoms and risk factors for prostate disease.
Your doctor will then examine you, including doing a digital rectal examination (DRE). A gloved, lubricated finger will be inserted into the rectum to feel for any abnormalities in the consistency or shape of the prostate.
Depending on the findings, your doctor will then determine what tests need to be done to further evaluate your prostate. This can be broadly divided into the following:
1. Blood tests
PSA or prostate-specific antigen is the most common blood test performed.
It is considered a tumor marker for prostate cancer. However, a raised PSA level does not always mean you have prostate cancer. An enlarged, benign prostate or a urinary tract infection can also cause raised PSA levels. Its interpretation must be taken in context with other clinical information gathered by your doctor.
Other blood tests are usually performed as a supplement to the initial PSA if it turns out to be abnormal. They may help your Urologist decide if an invasive prostate biopsy is necessary. These include PHI (prostate health index) and CTC (circulating tumor cells).
2. Imaging
The simplest form of imaging performed is an ultrasound scan, which can help determine the size and shape of your prostate. This is usually performed through your abdomen in the clinic. Another form of ultrasound is performed through the rectum, usually during the time of a prostate biopsy.
An MRI scan gives the best details and is able to detect abnormalities in the prostate, ranging from benign enlargement, inflammation to cancerous nodules. MRIs are commonly performed when you have an abnormal PSA level or suspicious nodule on DRE.
As prostate cancer commonly spreads to the bones, a bone scan (a form of radionuclide scan), may be performed.
CT scans or PET-CTs are more often done in the setting of confirmed prostate cancer, and usually when there is a suspicion for prostate cancer spread to other organs. These may guide treatment in later stages of prostate cancer.
3. Prostate biopsy
A biopsy means obtaining tissue samples from your prostate for examination under a microscope to confirm the diagnosis of cancer.
This is done through 2 methods:
- transrectal: through the wall of the rectum
- or transperineal: through the skin between the scrotum and the anus
An ultrasound and/or your MRI images are used to guide your Urologist as he decides which areas of your prostate to sample.
If the biopsy confirms the presence of cancer, it is usually reported with a Gleason score and grade group (which tells how aggressive the cancer cells look under the microscope).
Based on the results of all your tests, your Urologist will advise you on the best course of management for your prostate problem.
