Management of Suspected Prostate Cancer and Upper Urinary Tract Pathology

Initial Assessment and Diagnostic Approach

The American Urological Association suggests that the combination of elevated PSA, prostate lesion, flank pain, and hematuria represents a concerning clinical picture requiring prompt evaluation, with a strength of evidence level of high 1
The presence of flank pain with hematuria raises concern for upper urinary tract pathology, such as pyelonephritis or urolithiasis, which requires imaging, according to the European Association of Urology, with a strength of evidence level of moderate 2, 3
The European Urology guidelines recommend complete urinalysis and urine culture to confirm infection and assess antibiotic sensitivity, with a strength of evidence level of high 1
Renal function tests are indicated to evaluate for possible renal impairment, as suggested by the European Urology guidelines, with a strength of evidence level of moderate 1

Upper urinary tract imaging (ultrasound or CT) is indicated due to the presence of hematuria, flank pain, and history of urolithiasis, according to the American Urological Association, with a strength of evidence level of high 2, 4
Transrectal ultrasound (TRUS) of the prostate is recommended to assess prostate size and shape, and to guide biopsy of the suspicious lesion, as suggested by the European Urology guidelines, with a strength of evidence level of moderate 2, 5
Prostate biopsy is indicated due to elevated PSA, presence of a lesion on prostate, and need to rule out prostate cancer, according to the European Urology guidelines, with a strength of evidence level of high 5, 6
If prostate cancer is diagnosed, staging and treatment will depend on Gleason score, clinical stage, PSA level, and patient's overall health status, as recommended by the American Urological Association, with a strength of evidence level of high 7

Close monitoring of symptoms, particularly resolution of flank pain, clearance of hematuria, and normalization of urinalysis, is recommended, as suggested by the European Urology guidelines, with a strength of evidence level of moderate 3, 1
Repeat PSA testing after resolution of infection is indicated, as infection can falsely elevate PSA, according to the American Urological Association, with a strength of evidence level of high 8
Urological follow-up based on findings from initial evaluation is necessary, as recommended by the European Urology guidelines, with a strength of evidence level of moderate 9
The combination of elevated PSA and a prostate lesion raises significant concern for prostate cancer, which requires definitive diagnosis, according to the European Urology guidelines, with a strength of evidence level of high 6, 5

Inflammatory processes in the prostate associated with UTIs can lead to release of PSA into the bloodstream, resulting in elevated serum PSA values 10

When evaluating an elevated PSA, urinalysis should be performed to rule out UTI before proceeding with further diagnostic workup 11
Urinalysis is a recommended component of the basic evaluation for men presenting with lower urinary tract symptoms and should be used to detect pyuria or other signs of infection 12

If UTI is present, appropriate antibiotic therapy should be initiated based on culture and sensitivity results 13
The elevation of PSA in UTI can be substantial enough to potentially lead to unnecessary prostate biopsies if the infection is not identified and treated first, with studies showing significant PSA elevation 10, 11