The traditional investigation for suspected prostate cancer was a transrectal ultrasound-guided (TRUS) biopsy. However, recent guidelines from NICE have now advocated the increasing use of multiparametric MRI as a first-line investigation.

Complications of TRUS biopsy:

• sepsis: 1% of cases
• pain: lasting >= 2 weeks in 15% and severe in 7%
• fever: 5%
• haematuria and rectal bleeding

Multiparametric MRI is now the first-line investigation for people with suspected clinically localised prostate cancer.

• the results are reported using a 5-point Likert scale

If the Likert scale is >=3 a multiparametric MRI-influenced prostate biopsy is offered

If the Likert scale is 1-2 then NICE recommend discussing with the patient the pros and cons of having a biopsy.

PSA Testing

Prostate specific antigen (PSA) is a serine protease enzyme produced by normal and malignant prostate epithelial cells. It has become an important tumour marker but much controversy still exists regarding its usefulness as a screening tool.

PSA testing should be:

• considered in men with suspected prostate cancer
• offered to men older than 50 years of age who request a PSA test

Age-specific PSA thresholds for people with possible symptoms of prostate cancer are shown below. Patients who have a PSA above this level should be referred on the suspected cancer pathway referral (for an appointment within 2 weeks) if their PSA level is above the threshold for their age.