Elevated psa

What a High PSA Level Means if It’s Not Prostate Cancer

A high PSA level can be the first sign of prostate cancer, but it can also be a sign of a less-serious condition. Find out why else you may have an abnormal PSA reading.

By Chris Iliades, MD

Medically Reviewed by Justin Laube, MD

PSA tests measure a protein in your blood called prostate specific antigen. Prostate cancer makes PSA levels go higher, but a high PSA test result doesn’t always mean a man has prostate cancer.

Sometimes PSA readings are elevated because of something benign, such as ejaculating within 24 hours of the test, or because of a problem that needs treatment, such as a urinary tract infection, but that isn’t cancer.

Because the test can’t distinguish between serious causes of elevated PSA and other causes, the United States Preventive Services Task Force (USPSTF) has historically recommended against prostate specific antigen (PSA) testing in healthy men — that is, men who have no family history, known risk factors, or symptoms of prostate cancer.

But in 2017 the USPSTF released new draft guidelines that encourage doctors to discuss the potential benefits and harms of using the PSA test to screen for cancer in men ages 55 to 69. The final recommendation statement is now being developed.

In the meantime, here are seven reasons, besides prostate cancer, your PSA level could be above normal.

1. Aging Affects PSA Levels

Even without any prostate problems, your PSA level can go up gradually as you age. “At age 40, a PSA of 2.5 is the normal limit,” says John Milner, MD, a urologist in the Chicago area. “By age 60, the limit is up to 4.5; by age 70, a PSA of 6.5 could be considered normal.”

2. Prostatitis: A Common Problem in Men Under 50

“The PSA test is a good screening tool for prostate cancer, but it is not very specific,” says Erik P. Castle, MD, a urologist and researcher at the Mayo Clinic in Phoenix, Arizona. “Common causes of inflammation in the gland, called prostatitis, can cause high PSA levels.”

Prostatitis is the most common prostate problem for men younger than 50.

Prostatitis caused by bacteria can be treated with antibiotics. Another, more common type of prostatitis, called nonbacterial prostatitis, can be harder to treat and may last a long time.

3. Medical Procedures Can Cause PSA to Rise

“Anything that traumatically interferes with the architecture around the prostate gland can make PSA go up,” says Dr. Milner. “One of the most common causes of significantly high PSA from this type of trauma is the placing of a catheter into the bladder.”

Another cause is a prostate or bladder exam that involves passing a scope or taking a biopsy.

“Since it takes about two to three days for PSA to go down by half, you should wait two to three weeks after this type of trauma to do a PSA test,” Milner says.

4. In Men Over 50: BPH May Be the Cause of High PSA

Benign prostatic hyperplasia (BPH) is an enlargement of the prostate gland, but it’s not prostate cancer. “BPH means more cells, so that means more cells making PSA,” explains Dr. Castle.

BPH is the most common prostate problem in men over age 50. It may not need to be treated unless it’s causing frequent or difficult urination.

Your primary care doctor may be able to tell the difference between BPH and prostate cancer by doing a digital rectal exam, but commonly this will require evaluation by a urologist and further testing, such as a biopsy or imaging studies.

5. High PSA Levels From a Urinary Tract Infection

“Any infection near the prostate gland, including a urinary tract infection, can irritate and inflame prostate cells and cause PSA to go up,” says Milner.

If you’ve been diagnosed with a urinary tract infection, be sure to wait until after the infection has cleared up before you get a PSA test. In men, most urinary tract infections are caused by bacteria and respond well to antibiotics.

Having BPH increases your risk for a urinary tract infection.

6. Ejaculation Is a Potential Cause of Mildly Elevated PSA

“Ejaculation can cause a mild elevation of your PSA level, and so can having a digital rectal exam,” says Milner. “These types of PSA elevations are usually not enough to make a significant difference unless your PSA is borderline. PSA should return to normal in two to three days.”

To avoid this type of elevation, doctors will usually draw blood for a person’s PSA level before doing a rectal exam. Ask your doctor if you should avoid ejaculation for a few days before a PSA test.

7. Can Riding Your Bike Raise Your PSA Level?

There have been occasional studies that link prolonged bike riding to an increase in PSA levels, but others haven’t found this connection. “You would probably have to be a Lance Armstrong–type bike rider to worry about bike riding and a significant rise in your PSA,” says Castle.

The Takeaway on the PSA

“The most important thing to know about PSA is that it is still a really important screening test for prostate cancer,” Castle says.

Prostate cancer is the third leading cause of cancer death in American men, behind lung and colon cancer, according to the American Cancer Society.

Prostate-Specific Antigen (PSA) Blood Test

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Prostate-specific antigen (PSA) is a substance produced by the prostate gland. Elevated PSA levels may indicate prostate cancer, a noncancerous condition such as prostatitis, or an enlarged prostate.

Most men have PSA levels under four (ng/mL) and this has traditionally been used as the cutoff for concern about the risk of prostate cancer. Men with prostate cancer often have PSA levels higher than four, although cancer is a possibility at any PSA level. According to published reports, men who have a prostate gland that feels normal on examination and a PSA less than four have a 15% chance of having prostate cancer. Those with a PSA between four and 10 have a 25% chance of having prostate cancer and if the PSA is higher than 10, the risk increases and can be as high as 67%.

In the past, most experts viewed PSA levels less than 4 ng/mL as normal. Due to the findings from more recent studies, some recommend lowering the cutoff levels that determine if a PSA value is normal or elevated. Some researchers encourage using less than 2.5 or 3 ng/mL as a cutoff for normal values, particularly in younger patients. Younger patients tend to have smaller prostates and lower PSA values, so any elevation of the PSA in younger men above 2.5 ng/mL is a cause for concern.

Just as important as the PSA number is the trend of that number (whether it is going up, how quickly, and over what period of time). It is important to understand that the PSA test is not perfect. Most men with elevated PSA levels have noncancerous prostate enlargement, which is a normal part of aging. Conversely, low levels of PSA in the bloodstream do not rule out the possibility of prostate cancer. However, most cases of early prostate cancer are found by a PSA blood test.

How Is The PSA Screening Test Done?

The test involves drawing blood, usually from the arm. The results are usually sent to a lab and most often come back within several days.

When Should I Have My PSA Levels Tested?

The American Cancer Society says men should talk to their doctors about the benefits, risks, and limitations of prostate cancer screening before deciding whether to be tested. The group’s guidelines make it clear that prostate-specific antigen (PSA) blood testing should not occur unless this discussion happens. They recommend that most men at average risk for prostate cancer start the discussion at age 50 and those with higher risk for prostate cancer should start the discussion earlier.

The American Urological Association recommends that men ages 55 to 69 who are considering screening should talk with their doctors about the risks and benefits of testing and proceed based on their personal values and preferences. The group also adds:

• PSA screening in men under age 40 is not recommended.
• Routine screening in men between ages 40 and 54 at average risk is not recommended.
• To reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have decided on screening after a discussion with their doctor. As compared to annual screening, it is expected that screening intervals of two years preserve the majority of the benefits and reduce over diagnosis and false positives.
• Routine PSA screening is not recommended in men over age 70 or any man with less than a 10-15 year life expectancy.

The U.S. Preventive Services Task Force, however, doesn’t recommend routine PSA screening for men in the general population, regardless of age. They say the tests may find cancers that are so slow-growing that medical treatments — which can have serious side effects — would offer no benefit.

If your doctor is concerned that you might have prostate cancer based on either a PSA level or a rectal exam, a biopsy (a lab testing of a small amount of tissue from the prostate) will be the next step. This is the only way to positively identify the presence of cancer.

What Does an Elevated PSA Level Mean?

Elevated PSA levels may indicate prostate cancer or a noncancerous condition such as prostatitis or an enlarged prostate.

Your PSA level can also be affected by other factors:

• Age. Your PSA will normally go up slowly as you age, even if you have no prostate problems.
• Medications. Some drugs may affect blood PSA levels. Tell your health care provider if you are taking finasteride (Proscar or Propecia) or dutasteride (Avodart). These drugs may falsely lower PSA levels typically by half of what it would normally be.

If your PSA level is high, your doctor may recommend that you get a prostate biopsy to test for cancer.

Alternative PSA Testing

There are some new PSA tests that may help you and your health care provider determine if you need a biopsy. You should know that doctors do not always agree on how to use or analyze the results of these additional tests.

• Percent-free PSA. PSA takes two major forms in the blood. One is attached, or bound, to blood proteins and the other circulates freely. The percent-free PSA test indicates how much PSA circulates free compared to the total PSA level. The percentage of free PSA is lower in men who have prostate cancer than in men who do not. Studies show that if your PSA results are in the borderline range (4 to 10), a low percent-free PSA (less than 10%) means that the likelihood of having prostate cancer is about 50% and that you should probably have a biopsy.

Some doctors recommend biopsies for men whose percent-free PSA is 20 or less.

Using the PSA Blood Test After Prostate Cancer Diagnosis

Although the PSA test is used mainly to screen for prostate cancer, it is valuable in other situations:

• To guide treatment. Along with a doctor’s exam and tumor stage, the PSA test can help determine how advanced a prostate cancer is. This may affect treatment options.
• To determine treatment success. After surgery or radiation, the PSA level can be monitored to help determine if treatment was successful. PSA levels normally fall to very low levels if the treatment removed or destroyed all of the cancer cells. A rising PSA level can mean that prostate cancer cells are present and your cancer has come back.

If you choose a “watchful waiting” approach to treatment, the PSA level can help determine if the disease is progressing and if active treatment should be considered.

During hormonal therapy, the PSA level can help indicate how well the treatment is working or when it may be time to try another treatment.

Common Reasons For Elevated PSA Levels Besides Prostate Cancer

Prostate specific antigen (PSA) is a protein produced by cells of the prostate gland in men. A man may have a PSA blood test measuring the level of PSA in a man’s blood with the results reported as nanograms of PSA per milliliter (ng/ml) of blood. A normal PSA level is considered to be between 1.0 and 4.0 ng/ml. If the number is above 4.0, the level is considered abnormal or elevated.

Typically when a man’s PSA blood level is elevated it is associated with prostate cancer. But there can be additional reasons besides prostate cancer influencing a man’s PSA level to rise.

Listed below are some of the more common reasons why a man’s PSA may be elevated that is not due to prostate cancer:

• A man’s age

A man can have an elevated PSA level without having any prostate problems – often due to the PSA levels gradually increasing with a man’s age. For instance, at age 40, a PSA of 2.5 is within the normal limit but by age 60, the limit can go up to 4.5 and by age 70, up to 6.5. These higher levels of PSA can be normal for an older man but a doctor will most likely want to do some other testing just to be sure there is nothing more serious developing.

• Benign prostatic hyperplasia (BPH)

BPH is an enlargement of the prostate gland but is not cancerous or considered to be prostate cancer. More cells are producing PSA making the number increase. Depending on whether a man is having symptoms such as frequent or difficulty urinating, BPH may not need to be treated. For men after the age of 50, BPH is considered to be the most common prostate problem in men.

• Urinary tract infection

An infection such as a urinary tract infection can irritate and inflame prostate cells causing PSA to rise. It is best to wait to have a PSA test until after an infection has cleared up to get a more accurate reading.

• Sex

A man should refrain from sex or ejaculation for at least 24-48 hours before a PSA test as ejaculation can cause a mild increase in the PSA number.

• Digital rectal exam

Having a digital rectal exam can increase PSA levels – a doctor will should always draw blood for a PSA test before doing a rectal exam.

• Prostatitis

Prostatitis is an infection of the prostate causing inflammation of the prostate gland. A man who has this condition should wait until after it is cleared up before having his PSA levels checked.

• Bicycling

A few studies have linked prolonged bike rides to increasing PSA levels. In order to make that happen, most doctors believe that a man would have to be training at the level of Lance Armstrong to be concerned with bicycling raising PSA. Most doctors agree that any man who rides a bike for prolonged periods of time should refrain from this at least 24 to 48 hours and to refrain from ejaculation before having the PSA test done.

What happens if the PSA level is elevated?

Due to the fact there are numerous things that can raise a man’s PSA level besides prostate cancer, it is important to treat each man individually. A biopsy of the prostate gland is not always necessary when a man has an elevated PSA. A man with an elevated PSA however does warrant further investigation into a potential problem.

Whether a man has a biopsy or not, depends on how high the PSA is and how much it has changed from previous readings. When a urologist reviews a man’s health history and physical, then is when he may be able to identify the cause of an elevated PSA. It is at this point when a physician can recommend a biopsy to rule out cancer. Otherwise, if an elevated PSA is high due to an infection, then antibiotics will be given or a scope procedure may be done to evaluate the size of the prostate.

In summary

The most important message for men is to have regular yearly checkups with their physician along with a PSA blood test and DRE starting at age 40. Do not assume right away that a high PSA is automatically prostate cancer. There are many different causes for an elevated PSA. Sorting out what exactly is the cause needs to be determined before assuming it is prostate cancer. Even if it is, when a man receives regular medical care and follows healthy lifestyle habits, he will be in a better position to beat back the cancer and get on with his life.