Your PSA Level is High… Now What?

Chances are, you’ve heard the acronym “PSA.” It stands for prostate-specific antigen, a protein produced by cells in the prostate, which is a walnut-sized gland below the bladder that’s involved in semen production.

Normally, only small amounts of PSA enter the bloodstream. But when the prostate is affected by certain health conditions, PSA levels can rise, making it one of the first tools doctors use to monitor prostate health.

There’s a lot of talk about PSA levels and prostate cancer, as well as an association with benign prostatic hyperplasia (BPH), so an elevated PSA in your bloodwork can understandably cause worry. BUT… a high PSA doesn’t always mean cancer. There are several noncancerous reasons for this increase, and understanding them can help you take the appropriate next steps with less anxiety.

A quick note: sometimes there is confusion about the difference between BPH and prostate cancer. Benign prostatic hyperplasia (BPH) is a noncancerous (hence, benign) enlargement of the prostate that commonly occurs with aging and can cause urinary symptoms. Prostate cancer, on the other hand, involves abnormal cell growth that can spread beyond the prostate. We’ll talk at greater length about each as we move along.

What’s “Normal”?

First of all, there isn’t a “normal” across the board. Since PSA levels naturally rise as men get older, doctors now interpret PSA results by also taking into account age, health history, and family history. PSA levels in men aged 40 to 80 generally fall between 0 and 5.5 ng/mL when they’re within a normal range. Levels considered elevated, in general, are as follows:

• >2.5 ng/mL if you’re 40-50 years of age
• >3.5 ng/mL if you’re 50-60 years of age
• >4.5 ng/mL if you’re 60-70 years of age
• >5.5 ng/mL if you’re 70-80 years of age

Again, these numbers are a general guideline. As stated before, other factors are considered.

When PSA levels are elevated, cancer is only one of several possible explanations. When levels spike, other potential causes include:

• Benign Prostatic Hyperplasia (BPH): A noncancerous enlargement of the prostate that often occurs with age. It’s one of the most common reasons for a mild rise in PSA levels.
• Prostatitis (inflammation): Infection or irritation of the prostate can cause temporary spikes.
• Urinary Tract Infections (UTIs): PSA levels can rise during active infection and normalize once it clears.
• Recent sexual activity or ejaculation: Sexual stimulation can cause the prostate to release extra PSA and short-term elevation.
• Medical procedures: Recent prostate surgery, catheterization, or even a prostate biopsy can increase PSA.
• Vigorous exercise: Especially cycling or anything that puts pressure on the prostate area.
  Certain medications or hormone therapy: Some medicines can affect the prostate in such a way that they provoke or inhibit the release of PSA.

PSA levels fluctuate naturally, and one high result doesn’t always signal disease, so doctors often look for a continuous rise over time, rather than reacting to a single reading.

A PSA level over 10 ng/mL raises a stronger suspicion for prostate cancer, and men with PSA levels above 10 have a greater than 50% chance – meaning half of high-PSA results still turn out to be noncancerous.¹

Related But Not Causal

Nearly 70% of men over 70 years of age experience BPH.² It happens when prostate cells proliferate, or multiply, causing the gland to grow and press against the urethra. This can lead to urinary symptoms like:

• A weak or interrupted urine stream
• Frequent urination, especially at night
• Difficulty starting or stopping urination
• A feeling that the bladder isn’t fully emptied

Because BPH increases the volume of prostate tissue, there are simply more cells producing PSA, which naturally pushes the PSA reading higher. So, while PSA is a sensitive test, it isn’t very specific, meaning it doesn’t distinguish between cancer and benign conditions.

Does BPH Lead to Prostate Cancer?

Here’s where the discussion often gets tricky: the short answer is no, BPH doesn’t cause prostate cancer – but they can occur together, and share overlapping risk factors like age and hormonal changes. Both BPH and prostate cancer affect the same gland, but the word “benign” in BPH means it’s not cancer. You can have both at the same time, but one doesn’t turn into the other.

However, having BPH can be an influential risk factor for developing cancer. One study found that men with BPH had a 2.9-fold higher incidence of prostate cancer and a 1.7-fold higher incidence of bladder cancer. That doesn’t mean BPH causes cancer – instead, the study pointed out that the two may share biological mechanisms like hormonal imbalance, inflammation, and metabolic changes that spur less-than-optimal cellular changes in the prostate.²

Inflammation, in particular, is a bad actor. Chronic inflammation in the prostate can disrupt the balance of cell growth and death (apoptosis), creating conditions where both BPH and cancer are more likely to develop. So, while the two conditions are distinct, they may coexist or stem from similar underlying processes.

What Happens Next?

If your PSA level comes back elevated, your provider won’t jump straight to conclusions. Instead, they’ll look at the whole picture: your age, history, symptoms, and trending PSA levels over time.
Here’s what often happens next:

• Repeat PSA Test: Sometimes, PSA levels return to normal when retested after a few weeks, especially if infection or temporary factors caused the spike.
• Digital Rectal Exam (DRE): A quick manual exam where your doctor feels the prostate for lumps, firmness, or irregularities.
• Imaging Tests: If needed, you may have a prostate MRI or transrectal ultrasound to visualize the gland.
• Biopsy: If suspicion remains high, a small tissue sample may be taken and examined under a microscope for the presence of cancer cells.

Each of these steps helps your provider rule out noncancerous causes before considering a cancer diagnosis. Again, PSA alone can’t diagnose cancer. It can be a signal, but it’s not a verdict.

A Number Worth Knowing, Not Fearing

Screening recommendations can vary slightly, but most experts suggest beginning around age 50. PSA screening might start as early as age 40-45 if you have risk factors such as:

• A family history of prostate cancer, especially a brother or father
• African American ethnicity, which carries a higher risk
• Symptoms of urinary changes, pain, or blood in the urine

If you have any of these risk factors or are experiencing urinary difficulties, consider seeing a urologist.

Proactive prostate care is the best tactic. Partner with a urology specialist at Georgia Urology to catch any concerning changes before they become serious, and avoid unnecessary stress or invasive procedures.

Bottom line: don’t panic. Even if your PSA is elevated, most men don’t have cancer, and many causes are easily managed or monitored. If it does turn out to be cancer, catching it early means it’s more treatable.

References:

1. American Cancer Society. (2023, November 22). Prostate cancer screening tests. Www.cancer.org. https://www.cancer.org/cancer/types/prostate-cancer/detection-diagnosis-staging/tests.html.
2. Dai, X., Fang, X., Ma, Y., & Xianyu, J. (2016). Benign Prostatic Hyperplasia and the Risk of Prostate Cancer and Bladder Cancer: A Meta-Analysis of Observational Studies. Medicine, 95(18), e3493. https://doi.org/10.1097/MD.0000000000003493.