Eduovisual
Renal & Urinary
Prostate cancer: USPSTF screening discussion and workup
— Most commonly diagnosed non-skin cancer in US men; 2nd leading cause of male cancer death after lung
— Lifetime risk ~13%; lifetime mortality ~2.5% — most men die with prostate cancer, not from it
— Median age at diagnosis ~67; rare before age 40 outside hereditary syndromes
— Black men: ~70% higher incidence, ~2× mortality vs. White men; consider initiating shared decision-making at age 40–45
— First-degree relative with prostate cancer (especially diagnosed <65): start discussion at 40–45
— BRCA1/BRCA2 carriers, Lynch syndrome: aggressive disease risk; earlier and more intensive screening
— Agent Orange exposure (VA presumptive); some occupational cadmium exposures
— Obstructive LUTS in an older man — but BPH causes the same symptoms; cancer often arises in peripheral zone and is clinically silent
— Hematuria, hematospermia, new erectile dysfunction
— Bone pain (especially axial/lower back), pathologic fracture, unexplained anemia, weight loss → suspect metastatic disease
— Acute urinary retention, lower extremity edema/lymphedema, neurologic deficits from cord compression
— On Step 3, the prostate cancer vignette is almost always a screening/shared decision-making scenario, not a workup of symptoms
— Recognize when to decline screening: life expectancy <10 years, men ≥70, or significant comorbidity
— Know that USPSTF, AUA, and ACS recommendations overlap but are not identical — USPSTF is the test default
Board pearl: A 72-year-old man with CHF EF 25% asking about a PSA test → the correct answer is to counsel against screening because limited life expectancy means harms (biopsy, overtreatment) exceed benefit. Screening is about preventing death from prostate cancer years down the line, not detecting indolent disease in someone unlikely to live long enough to benefit.
— Healthy man 55–69 at routine visit asks "Should I get the PSA test?"
— Or: man brings in an article, family member was diagnosed, or employer wellness program ordered a PSA
— Required next step is shared decision-making, not reflexive ordering or refusal
— LUTS overlapping BPH: hesitancy, weak stream, nocturia, incomplete emptying
— Hematuria or hematospermia — more specific but nonspecific to cancer vs. prostatitis
— New erectile dysfunction in absence of vascular/medication cause
— Obstructive uropathy, hydronephrosis, rising creatinine
— Rectal symptoms from posterior extension (rare)
— Bone pain in axial skeleton, hips, ribs; osteoblastic lesions on imaging
— Pathologic fracture, spinal cord compression (back pain + neuro deficits = emergency)
— Anemia from marrow involvement; elevated alk phos with normal ALT/AST
— Lower extremity edema from pelvic nodal compression
— Age and estimated life expectancy (≥10 years is the threshold)
— Race/ethnicity; family history (number of affected relatives, ages, BRCA status)
— Comorbidity burden (CHF, COPD, dementia, advanced CKD)
— Patient values: tolerance of biopsy, anxiety about indolent disease, willingness to undergo treatment side effects (incontinence, ED)
— Prior PSA values and trajectory
— Medications affecting PSA: 5-alpha-reductase inhibitors (finasteride, dutasteride) roughly halve PSA — double the measured value
— Bone pain, weight loss, neurologic symptoms, gross hematuria, palpable nodule
Key distinction: Screening (asymptomatic) vs. diagnostic workup (symptomatic) — USPSTF guidance applies only to screening. A man with bone pain and a hard prostate nodule gets a PSA as part of diagnostic evaluation; shared decision-making rules do not gate that test.
— Cachexia, pallor (anemia of marrow infiltration), lymphadenopathy
— Spine tenderness over thoracolumbar vertebrae → consider metastasis
— Lower extremity edema (pelvic nodal obstruction), focal neurologic deficits (cord compression)
— Normal prostate: smooth, rubbery, symmetric, walnut-sized (~20 g), with palpable median sulcus
— BPH: symmetrically enlarged, smooth, rubbery, sulcus preserved
— Prostatitis: tender, boggy, warm; in acute bacterial prostatitis, avoid vigorous massage (bacteremia risk)
— Cancer suspicion: hard, irregular, nodular, asymmetric; loss of median sulcus; fixed to surrounding tissue if locally advanced
— USPSTF does not recommend DRE as a stand-alone screening test
— AUA notes DRE may be considered alongside PSA in shared decision-making, but sensitivity is poor (~50%) and most cancers arise in posterior peripheral zone — many are missed
— A palpable nodule in an asymptomatic man → proceed to PSA and urology referral even if PSA is "normal"
— Describe size (small/normal/enlarged), consistency (rubbery/firm/hard), symmetry, nodules, tenderness, sulcus
— Note sphincter tone and rectal masses; check stool guaiac if indicated for other reasons
— Cannot rule out cancer (poor sensitivity)
— Cannot reliably distinguish BPH-only from BPH+cancer
— Does not meaningfully elevate PSA in clinically significant ways — PSA can be drawn same visit before or after DRE
Step 3 management: Asymptomatic 60-year-old man, PSA 2.1, but DRE reveals a firm posterior nodule → next step is referral to urology for prostate MRI and/or biopsy, not repeat PSA. A suspicious DRE finding alone is an indication for further evaluation regardless of PSA level. Do not be falsely reassured by a "normal" PSA when the exam is abnormal.
— Serum glycoprotein produced by prostate epithelium; not cancer-specific
— Elevated in BPH, prostatitis, recent ejaculation (24–48 h), recent instrumentation, vigorous cycling, UTI, acute urinary retention
— Not significantly elevated by routine DRE in clinically relevant fashion
— 5-ARIs (finasteride/dutasteride) halve PSA after ~6–12 months; double the value for interpretation
— Traditional: PSA >4.0 ng/mL triggers further evaluation
— Age-adjusted cutoffs sometimes used (lower threshold for younger men)
— Persistent rise on repeat test is more meaningful than a single elevated value
— Free PSA ratio: lower free/total ratio (<10%) suggests cancer; >25% suggests benign
— PSA density: PSA/prostate volume; >0.15 raises concern
— PSA velocity: rate of rise (>0.75 ng/mL/year); controversial but used
— 4Kscore, PHI (Prostate Health Index), SelectMDx, ExoDx: secondary biomarkers used between PSA elevation and biopsy decision
— Every 2 years preferred over annual per USPSTF/AUA — reduces overdiagnosis while preserving mortality benefit
— Stop screening at age 70 (USPSTF) or when life expectancy <10–15 years
— Urinalysis (rule out UTI as PSA confounder)
— CBC, BMP, alkaline phosphatase (bone metastasis screen), LFTs
— Testosterone if hypogonadal symptoms (relevant for later therapy)
Board pearl: Before re-checking an elevated PSA, address reversible causes — treat any UTI, defer for 48 hours after ejaculation, and wait 6 weeks after prostate instrumentation or prostatitis. Repeating the PSA after addressing confounders avoids unnecessary biopsy in 20–30% of men with mildly elevated initial values. A single elevated PSA is rarely an emergency.
— Increasingly the next step after persistently elevated PSA, before biopsy
— Uses PI-RADS v2.1 scoring (1–5); PI-RADS 3+ generally warrants targeted biopsy
— Improves detection of clinically significant cancer (Gleason ≥7) and reduces detection of indolent disease
— Negative MRI in low-risk men may permit surveillance instead of biopsy
— Transrectal ultrasound (TRUS)-guided or increasingly transperineal (lower infection risk)
— Typically 12 systematic cores ± MRI-targeted cores at suspicious lesions
— Prophylactic antibiotics (fluoroquinolone or per local resistance) before TRUS biopsy
— Complications: hematuria, hematospermia, urinary retention, sepsis (1–3% — main reason transperineal is rising)
— Gleason score: sum of two most common patterns (e.g., 3+4=7)
— Grade Group 1–5 system (modern reporting):
— Grade Group 1 = Gleason 6 (3+3) — often indolent
— Grade Group 2 = 3+4=7
— Grade Group 3 = 4+3=7 (worse than 3+4)
— Grade Group 4 = Gleason 8
— Grade Group 5 = Gleason 9–10
— Bone scan (technetium-99m) for PSA >20, Gleason ≥8, or symptoms
— CT abdomen/pelvis or MRI for nodal disease
— PSMA-PET (Ga-68 or F-18 piflufolastat): increasingly used for staging high-risk and biochemical recurrence — superior sensitivity for nodal/bone mets
— Consider in metastatic, high-risk localized, or strong family history (BRCA1/2, ATM, CHEK2, Lynch genes)
Step 3 management: Persistently elevated PSA + no UTI/recent ejaculation/instrumentation → refer to urology; modern pathway is mpMRI first, then targeted biopsy if PI-RADS 3+. Do not order bone scan in low-risk localized disease — it has near-zero yield and risks workup of incidental findings.
— Ages 55–69: Grade C — individualized shared decision-making; do not screen routinely without discussion
— Age ≥70: Grade D — recommend against PSA screening
— <55: No formal recommendation; consider in high-risk groups via shared decision-making
— Patient's age, life expectancy, comorbidities
— Family history, race, prior PSAs
— Benefits: modest reduction in prostate cancer-specific mortality (ERSPC: ~1 death prevented per 1000 men screened over 13 years)
— Harms: false positives (~75% of biopsies negative), overdiagnosis of indolent cancer (20–50% of detected), treatment complications (incontinence ~5–20%, ED 30–60%), biopsy complications
— Patient values, willingness to act on results
— Very low/low risk: PSA <10, Grade Group 1, cT1c-T2a → often active surveillance
— Favorable intermediate: GG 2, PSA <20
— Unfavorable intermediate: GG 3, or multiple intermediate features
— High risk: PSA >20, GG 4–5, or cT3+
— Very high/metastatic: nodal or distant disease
— PSA every 6 months, DRE annually, repeat MRI/biopsy every 1–3 years
— Convert to treatment if grade progression or significant PSA rise
— Avoids overtreatment of indolent disease while preserving curative window
Board pearl: When the stem describes a 58-year-old man asking about PSA, the correct answer is almost never "order the PSA" or "do not order the PSA" — it is "engage in shared decision-making about benefits and harms" or "discuss the risks and benefits of PSA screening." This phrasing reflects USPSTF Grade C and is the right Step 3 answer.
— Androgen deprivation therapy (ADT) added to radiation for intermediate/high-risk localized disease
— GnRH agonists: leuprolide, goserelin — initial testosterone flare for 1–2 weeks; cover with antiandrogen
— GnRH antagonists: degarelix, relugolix (oral) — no flare; faster castration
— First-generation: bicalutamide, flutamide, nilutamide — used short-term to block flare or in combination
— Second-generation (novel hormonal agents): enzalutamide, apalutamide, darolutamide — used in metastatic hormone-sensitive (mHSPC), nonmetastatic CRPC, mCRPC
— Abiraterone + prednisone — blocks adrenal androgen synthesis; used in mHSPC and mCRPC
— Monitor LFTs, K+, BP (mineralocorticoid excess)
— Docetaxel — taxane; first-line cytotoxic in mHSPC (with ADT) and mCRPC; neuropathy, neutropenia, fluid retention
— Cabazitaxel — after docetaxel progression
— PARP inhibitors (olaparib, rucaparib): BRCA1/2 or HRR-mutated mCRPC
— Sipuleucel-T: autologous immunotherapy for asymptomatic/minimally symptomatic mCRPC
— Pembrolizumab: MSI-high or TMB-high tumors
— Denosumab or zoledronic acid: reduce skeletal-related events in bone metastases — supplement calcium/vitamin D, dental clearance for osteonecrosis of jaw
— Radium-223: alpha-emitter for symptomatic bone mets without visceral disease
— Hot flashes, fatigue, decreased libido, ED, osteoporosis, sarcopenia, metabolic syndrome, increased CV events, depression, gynecomastia, anemia
Step 3 management: Before starting any GnRH agonist, give an antiandrogen (e.g., bicalutamide) for 1–2 weeks before and 2–4 weeks after to prevent testosterone flare — critical in patients with bone metastases or impending cord compression where a flare could precipitate catastrophe.
— Open, laparoscopic, or robotic-assisted (most common in US)
— Indication: localized disease, life expectancy >10 years, patient preference
— Nerve-sparing technique preserves erectile function when oncologically safe
— Complications: urinary incontinence (stress type, ~5–20% long-term), erectile dysfunction (30–70%), anastomotic stricture, lymphocele, rare rectal injury
— Pelvic lymph node dissection for intermediate/high risk
— External beam (EBRT) — IMRT, SBRT, proton: 4–8 weeks of fractions
— Brachytherapy — low-dose-rate (permanent seeds) or high-dose-rate (temporary catheters); option for low/intermediate-risk
— Combined with ADT (4–6 months for intermediate-risk; 18–36 months for high-risk)
— Complications: radiation proctitis, cystitis, urethral stricture, secondary malignancy (bladder, rectal — rare), ED (delayed onset)
— Preferred for low-risk (GG 1) and select favorable intermediate-risk
— PSA q6mo, DRE annually, mpMRI and/or biopsy every 1–3 years
— Trigger for treatment: pathologic upgrading, significant PSA kinetics, patient preference
— Distinct from active surveillance — for men with life expectancy <10 years; treat only symptoms (e.g., palliative ADT, palliative XRT for bone pain), no curative intent
— HIFU (high-intensity focused ultrasound), cryotherapy, irreversible electroporation — investigational/select use
— TURP for obstructive symptoms from local disease
— External beam XRT for painful bone metastases (single-fraction 8 Gy effective)
— Spinal decompression + XRT for cord compression
— Bilateral orchiectomy — fast, definitive castration; cost-effective alternative to lifelong GnRH agonists
CCS pearl: For a man presenting with back pain, leg weakness, and known prostate cancer, immediately order MRI of the entire spine, start IV dexamethasone 10 mg, consult radiation oncology and neurosurgery, and admit. Cord compression is time-critical — every hour of delay worsens neurologic recovery.
— USPSTF Grade D — recommend against PSA screening at ≥70 regardless of health status
— Exception: rare highly functional 70-year-old with life expectancy >15 years and high-risk family history may pursue with informed shared decision-making
— Use validated life expectancy tools (e.g., ePrognosis, Lee Index) rather than chronologic age alone
— Frailty assessment before treatment decisions: Clinical Frailty Scale, gait speed, comorbidity index
— Active surveillance or watchful waiting strongly favored for low/intermediate-risk
— Surgery has higher morbidity (incontinence, cardiopulmonary complications)
— Radiation generally well tolerated but ADT toxicity worsens with age (falls, osteoporosis, cognition)
— Hypofractionated radiation reduces treatment burden
— PSA itself is not renally cleared in problematic way
— Bisphosphonates (zoledronic acid): adjust or avoid if CrCl <30; denosumab is renally safer (but watch hypocalcemia)
— Contrast for staging CT: balance risk in CKD; consider non-contrast MRI or PSMA-PET
— Cabazitaxel and docetaxel: minimal renal adjustment but monitor closely
— Abiraterone: avoid in Child-Pugh C; monitor LFTs monthly during first 3 months
— Enzalutamide, apalutamide: hepatic metabolism; use cautiously in severe impairment
— Docetaxel: dose-reduce or avoid in significant LFT elevations
— Baseline DXA before or shortly after starting ADT
— Calcium 1000–1200 mg/day, vitamin D 800–1000 IU/day
— Bisphosphonate or denosumab if T-score ≤ –2.5 or FRAX threshold met
Board pearl: A 78-year-old healthy man asks for a PSA test because his neighbor was just diagnosed. The correct response is to explain that screening is not recommended at his age because the time-to-benefit (~10 years) exceeds his expected life benefit; do not order the test even if he insists without first thoroughly discussing the harms.
— Higher incidence, earlier onset, more aggressive biology, 2× mortality
— Consider starting shared decision-making at age 40–45
— Underrepresented in screening trials — actual benefit may be greater than population estimates suggest
— USPSTF acknowledges insufficient evidence for separate recommendation but encourages clinician judgment
— One first-degree relative with prostate cancer: ~2× risk
— Two or more affected first-degree relatives, or diagnosis <55: significantly higher
— Start discussion at age 40–45
— BRCA2 > BRCA1: aggressive, earlier-onset disease; screen annually starting age 40
— Lynch syndrome (MMR mutations): elevated risk; screen per genetic counseling guidance
— HOXB13, ATM, CHEK2, PALB2: emerging high-risk genes
— Refer for genetic counseling if: metastatic disease at any age, high-risk localized + family history, Ashkenazi Jewish ancestry, known familial mutation
— Prostate is not removed during gender-affirming surgery
— Estrogen + anti-androgen lowers but does not eliminate risk
— Continue individualized screening discussion; PSA interpretation altered (suppressed levels)
— DRE may be acceptable per patient comfort
— Persistent PSA elevation: consider mpMRI, biomarker panels (4K, PHI), repeat biopsy with template/saturation
— VA presumes service connection; screening conversations often initiated earlier
Step 3 management: A 42-year-old Black man whose father died of metastatic prostate cancer at 58 asks about screening. Engage in shared decision-making now rather than waiting until age 55, document the conversation, and offer baseline PSA + DRE if he chooses to proceed. Earlier start is appropriate given race + family history; ages are guidance, not rigid cutoffs.
— Bone metastases: pain, pathologic fracture, hypercalcemia (less common than in breast/lung), marrow failure with anemia/thrombocytopenia
— Spinal cord compression — oncologic emergency
— Obstructive uropathy: bladder outlet obstruction, ureteral obstruction → hydronephrosis, AKI
— Lymphedema of lower extremities from pelvic nodal disease
— Disseminated intravascular coagulation: rare paraneoplastic phenomenon
— False-positive PSA → anxiety, unnecessary biopsy
— Biopsy: sepsis (1–3%), hematuria, hematospermia (weeks–months), urinary retention, vasovagal events
— Overdiagnosis: identifying cancers that would never have caused harm
— Urinary incontinence (stress, often improves over 12 months; ~5–20% persistent)
— Erectile dysfunction (30–70%, varies with nerve-sparing and baseline function)
— Anastomotic stricture, lymphocele, bladder neck contracture
— Inguinal hernia (increased post-prostatectomy)
— Perioperative: DVT/PE, MI, bleeding
— Acute: cystitis, proctitis, fatigue
— Late: radiation proctitis with bleeding, urethral stricture, ED (delayed), bladder fibrosis
— Small increased risk of secondary bladder/rectal malignancy
— Osteoporosis and fractures — screen with DXA, supplement Ca/vit D
— Cardiovascular: increased MI, stroke, possibly QT prolongation
— Metabolic syndrome: weight gain, insulin resistance, dyslipidemia
— Cognitive effects, depression
— Hot flashes (SSRIs, gabapentin, venlafaxine help), gynecomastia, sarcopenia, anemia
Board pearl: A man on long-term leuprolide presents with a vertebral compression fracture from minor trauma. Workup must include DXA and assessment of calcium/vitamin D — ADT-induced osteoporosis is common and underdiagnosed. Start bisphosphonate or denosumab and ensure dental clearance before initiation.
— PSA persistently elevated after addressing reversible causes
— Suspicious DRE finding regardless of PSA
— Significant PSA velocity (>0.75 ng/mL/year) or PSA density >0.15
— Persistent hematuria or hematospermia
— Patient choosing biopsy or active surveillance
— Newly diagnosed metastatic disease
— Biochemical recurrence after definitive therapy
— Castration-resistant prostate cancer (rising PSA despite castrate testosterone)
— Consideration of systemic therapy (ADT, chemotherapy, novel agents)
— Treatment decision for localized disease (offer alongside surgical option)
— Palliative radiation for bone pain, spinal lesions
— Salvage radiation post-prostatectomy
— Metastatic disease at any age
— Family history of BRCA, Lynch, or multiple cancers
— Ashkenazi Jewish ancestry with prostate cancer
— Malignant spinal cord compression — admit, dexamethasone 10 mg IV, urgent MRI whole spine, radiation oncology + neurosurgery
— Obstructive uropathy with AKI — Foley catheter; bilateral hydronephrosis may require percutaneous nephrostomy or ureteral stents
— DIC with active bleeding — hematology, supportive transfusion
— Hypercalcemia of malignancy — IV fluids, calcitonin, zoledronic acid or denosumab
— Febrile neutropenia post-chemotherapy — broad-spectrum antibiotics within 1 hour, admit
— Post-biopsy sepsis — emergent admission, broad-spectrum antibiotics covering gram-negatives including resistant E. coli
CCS pearl: In CCS-style management, a patient with prostate cancer presenting with back pain and leg weakness: order MRI of the spine, give IV dexamethasone, place a Foley catheter (assess for retention), consult radiation oncology and neurosurgery, admit to inpatient ward, and order bone scan and PSMA-PET if not already done. Sequence matters — dexamethasone before imaging is appropriate when cord compression is clinically obvious.
— Symmetrically enlarged, smooth, rubbery on DRE
— LUTS (storage and voiding); IPSS score >7
— PSA can be elevated (correlates with gland volume) but usually modestly
— Treatment: alpha-blockers (tamsulosin), 5-ARIs (finasteride), TURP for refractory; 5-ARI halves PSA — interpret accordingly
— Key distinction: BPH does not cause hard nodules or markedly elevated PSA out of proportion to gland size
— Fever, dysuria, pelvic/perineal pain, exquisitely tender boggy prostate
— UA with pyuria, often positive urine culture (E. coli most common)
— PSA can be dramatically elevated; defer screening PSA for 6 weeks after resolution
— Treatment: fluoroquinolone or TMP-SMX 2–4 weeks (longer if chronic)
— Avoid prostate massage in acute bacterial prostatitis (bacteremia risk)
— Persistent pelvic pain ≥3 months, variable LUTS, often negative cultures
— Can mildly elevate PSA
— Multimodal therapy: alpha-blockers, NSAIDs, pelvic floor PT, sometimes antibiotic trial
— Failure to improve on prostatitis therapy; transrectal US or CT confirms; drainage required
— LUTS, weak stream, post-void dribbling; history of instrumentation, STI, or trauma
— Diagnose with uroflowmetry, retrograde urethrogram, cystoscopy
— Painless gross hematuria — workup with cystoscopy and CT urogram
— Risk factors: smoking, occupational dye exposure
— Urgency, frequency without obstruction; treat with antimuscarinics or beta-3 agonists
Key distinction: Acute prostatitis can elevate PSA into the hundreds; do not biopsy or interpret a screening PSA during or shortly after prostatitis. Treat the infection, wait 6 weeks, then recheck PSA before deciding on workup.
— Prostate cancer bone metastases: osteoblastic, axial skeleton, elderly man
— Paget disease of bone: isolated alk phos elevation, characteristic radiographic findings (cortical thickening, bone enlargement), often asymptomatic; nuclear medicine bone scan shows uptake but no PSA elevation
— Multiple myeloma: lytic lesions (not blastic), anemia, hypercalcemia, renal failure, M-spike on SPEP/UPEP
— Vertebral osteomyelitis: fever, elevated ESR/CRP, MRI findings; PSA normal
— Osteoporotic compression fracture: no PSA elevation, low bone density, lower-impact mechanism
— Bladder cancer, renal cell carcinoma, nephrolithiasis, glomerulonephritis, anticoagulation, UTI, BPH
— Workup: CT urogram + cystoscopy for adults with unexplained gross hematuria
— Pelvic mass (prostate, bladder, lymphoma), CHF, venous insufficiency, DVT, hypoalbuminemia
— Retroperitoneal fibrosis, retroperitoneal lymphadenopathy (lymphoma, testicular cancer), ureteral stones, cervical cancer (in women)
— Prostate, lung, breast, kidney, thyroid cancers all metastasize to bone
— Multiple myeloma
— Tuberculosis (Pott disease)
— BPH, prostatitis, recent ejaculation, prostate manipulation, urinary retention, UTI, perineal trauma (cycling)
— Drug-induced (spironolactone, digoxin, cimetidine, finasteride), hypogonadism, cirrhosis, hyperthyroidism, hCG-secreting tumors (testicular, lung), antiandrogen therapy
Board pearl: An older man with back pain and elevated alkaline phosphatase but normal calcium and normal PSA — think Paget disease, not prostate cancer. The classic prostate cancer bone pattern is osteoblastic with markedly elevated alk phos and elevated PSA. Order a PSA early in workup of bone pain in any older man.
— Mediterranean-style diet, reduced red/processed meat
— Regular aerobic exercise — reduces all-cause and possibly prostate cancer-specific mortality
— Maintain healthy weight; obesity associated with more aggressive disease
— Smoking cessation; tobacco linked to higher-grade disease and recurrence
— No clear benefit (and some harm) from selenium, vitamin E supplementation (SELECT trial)
— Post-prostatectomy: PSA should be undetectable within 6–8 weeks; check every 3–6 months × 5 years, then annually
— Biochemical recurrence = PSA ≥0.2 ng/mL confirmed on repeat
— Post-radiation: PSA nadir within 18 months; biochemical recurrence = nadir + 2 ng/mL (Phoenix definition)
— DRE annually
— Imaging only for clinical or biochemical recurrence
— Incontinence: pelvic floor PT (Kegels), absorbent products; refractory → urethral sling or artificial urinary sphincter
— ED: PDE5 inhibitors first-line; vacuum devices, intracavernosal injections, penile prosthesis
— Hot flashes: venlafaxine, gabapentin, SSRIs; avoid estrogens
— ADT-related: DXA every 1–2 years, lipid panel, A1c annually; address fall risk
— Annual BP, lipids, fasting glucose/A1c, weight
— Statin if indicated; aggressive ASCVD risk factor management
— Calcium 1000–1200 mg/day, vitamin D 800–1000 IU/day
— DXA at baseline and every 1–2 years on ADT
— Bisphosphonate or denosumab if osteoporosis or high fracture risk
— Continue age-appropriate cancer screening (colorectal, lung if eligible)
— Influenza annually, pneumococcal, RSV (≥60), shingles, COVID-19, Tdap
Step 3 management: A 65-year-old man 2 years out from prostatectomy with PSA rising from undetectable to 0.3 ng/mL on two occasions → this meets biochemical recurrence. Order PSMA-PET to localize disease and refer to radiation oncology for consideration of salvage radiation ± ADT.
— Biennial PSA preferred; some patients/clinicians elect annual
— Stop at age 70 or life expectancy <10–15 years
— Document conversations clearly each cycle — preferences may change
— PSA every 6 months
— DRE every 12 months
— mpMRI every 1–3 years
— Confirmatory biopsy within 6–12 months of diagnosis; surveillance biopsies every 2–5 years or as clinically indicated
— Trigger for treatment: grade progression, significant PSA kinetics, MRI progression, patient preference
— Realistic expectations: most prostate cancers detected by PSA screening are indolent
— Treatment side effects, especially urinary incontinence and erectile dysfunction
— Lifestyle modifications (diet, exercise, smoking cessation)
— Mental health: depression and anxiety common after diagnosis
— Sexual health discussion — partners, intimacy alternatives, prosthetic options
— Survivorship resources, support groups
— Primary care continues to manage cardiovascular risk, diabetes, and other comorbidities
— Survivorship care plan: treatments received, late effects to monitor, surveillance schedule, who is responsible for each test
— Communicate among urology, oncology, radiation oncology, primary care to avoid gaps
— Avoid PSA screening in men ≥70 (Choosing Wisely)
— Avoid imaging for staging in low-risk localized disease (Choosing Wisely — overuse measure)
— Document shared decision-making to meet quality benchmarks
— Decision aids (USPSTF, AHRQ, AUA) improve informed choice and reduce decisional conflict
— Provide written materials reflecting numeric outcomes (benefits per 1000 screened, harms per 1000 screened)
Board pearl: When a patient declines screening after a thorough shared decision-making discussion, document the conversation and respect the decision; do not re-raise PSA each visit unless circumstances change. Repeated pressure undermines autonomy and trust. Revisit when life circumstances or family history changes.
— PSA screening is the prototypical Step 3 informed-consent encounter — there is no right answer, only an aligned one
— Document: risks, benefits, alternatives, patient values, decision reached
— A signed consent form is not required for the test, but documented discussion is the standard of care
— A PSA drawn without discussion (bundled labs, hospital admission, employer wellness) can trigger a cascade — biopsy, sepsis, overtreatment — for a result the patient never wanted
— Best practice: do not order PSA without prior conversation
— If a PSA arrives unexpectedly elevated, the next step is discussion, not automatic biopsy referral
— Patient with limited life expectancy who insists on screening: explore the source of concern, document discussion, generally honor refusal of intervention but avoid ordering tests not aligned with goals
— Cognitively impaired patient: involve surrogate decision-maker, weigh against likely net harm
— Post-biopsy patients discharged with prophylactic antibiotics need clear instructions on fever return precautions — sepsis from TRUS biopsy can present 24–72 hours later
— Active surveillance patients can be lost to follow-up — establish recall systems
— Hand-offs between urology and primary care for surveillance must specify who orders which test and when
— Black men experience worse outcomes — under-screening compounds disparities; over-screening can also harm
— Access barriers: insurance, transportation, distrust of medical system
— Tailor shared decision-making to literacy, language, cultural context
— BRCA testing has implications for family members — discuss cascade testing
— GINA protects against health insurance and employment discrimination but not life or disability insurance
— Both over-screening (causing harm from cascade) and under-screening (missed cancer) carry liability
— Strong documentation of shared decision-making is the best protection
Step 3 management: A 68-year-old man returns to clinic distraught after an unexplained PSA of 6.5 was drawn during a hospitalization for pneumonia. The correct next step is to acknowledge the test was inappropriately bundled, address infection-related confounding (repeat PSA in 6 weeks), and re-engage shared decision-making — not immediate urology referral and biopsy.
Board pearl: When you see "elevated PSA + recent UTI" — the answer is treat the UTI and recheck PSA in 6 weeks, not urology referral. Always remove confounders before initiating the cancer workup cascade.
— 58-year-old man at annual visit asks about "the prostate test"
— Correct answer: "Discuss the risks and benefits of PSA screening" / "Engage in shared decision-making"
— Distractor: ordering PSA outright or refusing to discuss
— 73-year-old healthy man asks for PSA
— Correct answer: counsel against screening (USPSTF Grade D ≥70)
— Distractor: order PSA, order DRE, refer to urology
— 60-year-old with PSA 6.0, recent UTI treated 2 weeks ago / cycling 50 miles last weekend / prostatitis last month
— Correct answer: repeat PSA in 6 weeks after confounder resolved
— Distractor: immediate biopsy, prostate MRI, urology referral
— Man on finasteride for 2 years for BPH, PSA 3.2
— Correct answer: effective PSA is ~6.4 — refer for evaluation
— Distractor: reassure, repeat in 1 year
— Man with known metastatic prostate cancer, back pain, leg weakness
— Correct answer: IV dexamethasone + MRI whole spine immediately, radiation oncology consult
— Distractor: oral steroids, outpatient MRI, opioids alone
— Asymptomatic man, normal PSA, but hard nodule on DRE
— Correct answer: urology referral for biopsy — DRE finding alone warrants evaluation
— Distractor: reassure because PSA normal
— Older man with back pain, alk phos 400, normal calcium, normal LFTs
— Differentiate: prostate cancer mets (check PSA), Paget disease, myeloma
— Man starting leuprolide for metastatic disease with extensive bone mets
— Correct answer: pretreat with bicalutamide to prevent testosterone flare
— Distractor: start leuprolide alone, use degarelix (acceptable alternative but flare prevention with antiandrogen is the classic answer)
— Post-prostatectomy PSA rising from undetectable to 0.3 confirmed
— Correct answer: PSMA-PET imaging and refer for salvage radiation
Board pearl: When in doubt on a Step 3 prostate cancer stem, ask: "Is this a screening question or a management question?" Screening questions almost always answer to shared decision-making or age-based refusal; management questions answer to address confounders, refer appropriately, or treat the emergency.
Prostate cancer screening is a shared decision-making conversation about PSA testing — offered to men ages 55–69 (and earlier in Black men, BRCA carriers, or strong family history) and recommended against in men ≥70 or with <10-year life expectancy — with workup of elevated PSA proceeding only after addressing reversible confounders, ideally via mpMRI before targeted biopsy.
Board pearl: Master four phrases for Step 3 prostate cancer questions — "shared decision-making," "double the PSA on a 5-ARI," "repeat PSA after addressing confounders," and "dexamethasone before MRI in suspected cord compression" — and you will get virtually every vignette right.