Decreasing PSA with antibiotics -- can it still be cancer?

[SG1959]

I am 47 yrs old. 9 months back, while I had an unexpainable low grade fever, I got a routine test done along with PSA. All reports were normal, except PSA, which came to be 18.75. I had no prostatic/urinary symptoms. I got an MRI of prostate and TRUS guided FNAC done. Both revealed signs of BPH (39mmX39mmX56mm) and FNAC revealed signs of chronic prostatitis. DRE (which, incidentally and wrongly was done after FNAC) revealed a  slight firmness (no nodule) on the right side. I took a long course of ofloxacin which dropped the PSA to 12.75 after 3 months.

I continued the ofloxacin hoping for further improvement, but after 6 more weeks the PSA remained the same.

I am an Asian, no family history of PCa, and have no symptoms yet.

What should be my next course of action? Should i get treated for BPH (?dutasteride) and see the results?

Can PSA  reduce only with antibiotics if there is indeed indwelling cancer cells in the prostate?

Is it common for PSA to remain static in chronic prostatitis?

When should I repeat my PSA? (after the last one?)

Many urosurgeons are suggesting repeat biopsy-- I am not too keen to reintroduce infection -- why can't I trust the first FNAC which was done under TRUS guidance and tissues taken from area which looked slightly hypoechoic. It was watched by my wife who is a doctor. The MRI also suggested nothing spcific except BPH? Can i not trust these findings and go on probing till something is found??

Your views will be of great help. It is so difficult to decide and has caused massive depression and anxiety to me.

[Ash Tewari, MD, M.Ch.]

I can understand that your situation causes you anxiety and stress.

PSA can be elevated by a number of reasons other than cancer. Two common non-cancer reasons for elevated PSA are prostatitis and BPH (enlarged prostate).  

Your initial symptoms are consistent with those of prostatitis. If prostatitis was a contributor to your high PSA, we would expect that the PSA would be lower after treatment with a long course of antibiotics.  However, it is not uncommon that men treated with for prostatitis can develop chronic inflammation or recurrences of their prostatitis which can lead to fluctuating or persistently elevated PSA levels despite treatment.  It is common that men in your situation will undergo many repeat biopsies to rule out cancer due to their fluctuating PSA level.

In general, the decision to initiate medication for the enlarged prostate (BPH) is guided by the severity of their symptoms consistent with an enlarged prostate such as frequent urination, difficulty initiating urination, weak stream, and frequent nighttime urination.  Often these are evaluated by a patient’s response to a standardized set of questions that help to establish a threshold of symptoms that warrant treatment with medication.

There is some evidence that supports the use of medications used to treat BPH (such as flomax) to help reduce symptoms of chronic prostatitis, however, this treatment appears to only be effective for a small subset of patients and is not generally recommended.

It is not uncommon for men with prostatitis to develop small calcifications in their prostate which can cause distortions in the ultrasound image and possibly could be felt on rectal exam.  In general, urologists recommend biopsy in men with elevated PSA and irregularities on rectal exam.  For men with more than one negative prostate biopsy and fluctuating PSA suspected to be due to non-cancer causes, some urologists may recommend an extended course of antibiotics and a repeat PSA after treatment before recommending another repeat biopsy, however, ultimately, this should be a decision made between you and your doctor.

The best course of action is to have frequent follow up with your Urologist who will continue to monitor your PSA and may recommend repeat biopsy in the future.

[SG1959]

My sincere thanks --

and regards
SG1959

[SG1959]

I  will be obliged if you can comment on my questions please
regards