This patient with a raised PSA of 16 ng/ml with few LUTS, I would take full history, in luding !

/" #isi$le hematuria, urgen y, perennial pain,%ia$etes, medi ations, e#aluate fre&uen y #olume hart and IPSS, with a flow test and P'S, on arri#al to out patient lini on an urgent $asis(US)*+ I would perform a %,-, will note, si.e, nature of prostate,$enign feeling, or tender $oggy Prostate suggesting Prostatitis, raggy, hard et , nodularity, if there is e/tent(T0/T1 et *,keeping in mind that 2345 of a$normal %,-s are asso iated with prostate an er, the remainder $eing $enign hyperplasia, prostati al uli, hroni prostatitis, or post6radiotherapy hange+ "nly 745 of an ers diagnosed $y %,will $e organ6 onfined+ The a ura y of %,- alone in men with palpa$le lesions appro/imates 345 and of those indi#iduals diagnosed $y this modality alone more than 845 will $e upstaged at the time of pathologi al e/amination+ %,- alone dete ts less than 1+85 of all diagnosed prostate an ers e#en when there is a high inde/ of suspi ion of glandular a$normalities+ I would perform a full neurologi al e/amination with regard to $a k pain+ !is symptoms of fre&uen y ould $e due to lower tra t infe tions, in this ase, to e/ lude Prostatitis+, 9"", $enign enlargement of prostate, urethral stri ture: detrusor o#er6a ti#ity !is no turia ould $e due to e/ essi#e fluid intake, no turnal polyuria (;145 of daily urine produ tion o urs at night time hours*+ I would like to see !$, inflammatory markers, renal fun tion, reatinine, -S,, Alkaline phospahate+ I would he k Urine dips, to rule out infe tion, (if there is would treat it* or see presen e of ,9)s, in the later ase, I would re&uest a <le/i$le )ystos opy to e/plain the non #isi$le hematuria+ =ith regard to patient>s raised PSA, ;345 of patients ha#e e/tra 6 prostati disease if PSA ;14ng/ml+ ?35 of patients ha#e lymph node metastases and only 15 ha#e $one metastases if PSA ?04ng/ml+ PSA is prostate6spe ifi , $ut not prostate an er6spe ifi + @o parti ular LUTS are spe ifi for prostate an er+ Patient>s symptoms might $e due to oe/istent 9P! or some other LUT pathology+ The presen e of LUTS, a low flow rate, an enlarged prostate, and old age are asso iated with an in reased risk of urinary retention+ The serum PSA le#el alone annot $e used to relia$ly predi t the pathologi al stage of disease+ Appro/imately 845 to A45 of patients with lo ally ad#an ed prostate an er ha#e a serum PSA le#els >14 ng/mL+ I would perform an urgent T,US $iopsy in this ase after informed onsent, in a$sen e of Prostatitis+ As patients with a Bleason s ore of 6 or higher are likely to progress to ad#an ed an er (if they ha#e not already done so*, as are patients with a prostate6spe ifi antigen (PSA* #alue of 14ng/mL or higher+ The Bleason $iopsy s ore may ha#e more predi ti#e #alue in predi ting the e/tent of disease+ Although a higher per entage of an ers are hypoe hoi , prostate an er an also $e hypere hoi or isoe hoi on transre tal ultrasound imaging+

T,US $iopsy result has prognosti information a$out o#erall disease $urden+ The Bleason s ore of the $iopsy spe imen is the most important prognosti fa tor for apsular e/tension of disease+ Additionally, the per ent of ore in#ol#ed and the num$er of ores in#ol#ed an gi#e predi ti#e information for apsular e/tension and lymph node in#ol#ement+ In this particular patient, where a suspicion of bony mets is there, I would request a Bone scintigraphy, as it is mu h more sensiti#e than plain radiography for dete tion of $ony metastases+ Plain radiography generally re&uires a 345 hange in the orti al $one density and of 14 to 13 mm in diameter to diagnose a $ony metastasis, whereas $one s intigraphy an dete t disease with as little as 145 hange in the orti al $one density+ @inety6fi#e per ent of $one lesions due to prostate an er are osteo$lasti , whereas fi#e per ent are osteolyti + %iagnosti a ura y of 9one S an is a$out C35 for skeletal metastati disease+ ,oughly a third of patients with prostate an er ()AP* will present with skeletal metastases+ Skeletal spread is un ommon (?05* in )AP patients with a PSA of ?0 ng/mL and present in ;C45 of ases with a PSA ;34 ng/mL D 9one s ans may also ha#e a prognosti role in that the mortality at 0 years in patients with and without a positi#e s an at presentation is 735 and 045, respe ti#ely+ D -ndo rine treatment does influen e $one s an results, with patients on hormonal manipulation for a period either demonstrating a negati#e $one s an (after $eing positi#e initially* or showing progression with appearan e of new lesions+ Abdominal or pelvic CT scanning or MRI may re#eal e/tra apsular e/tension, seminal #esi al in#ol#ement, pel#i lymph node enlargement, li#er metastases, and hydronephrosis (due to result of distal ureteral o$stru tion* in patients suspe ted of ha#ing lo ally ad#an ed disease+ E,I s anning is now the prin ipal imaging te hni&ue for )AP+ The o#erall a ura y of E, for the prostati adeno ar inoma lies $etween 315 and A05+ E, must $e deferred for at least 7 weeks in patients following T,US $iopsy or TU,P+ )T annot distinguish $etween the #arious grades of organ onfined disease+ )T a$le to dete t lo al in#asion into $ladder or seminal #esi les and the presen e of gross lymphadenopathy "#erall a ura y of )T in the staging of prostate an er #aries $etween 345 and A45 )T una$le to differentiate onfidently $etween malignant and $enign onditions in#ol#ing the prostate+ Alpha $lo kers are not always effe ti#e with a high tumour $urden in the prostate, $ut in this patient, if flow rare is low, with high P',, eg+ ; 044 mls, I would start Alpha $lo ker(Tamsulosin, $y e/plaining the side effe ts*, and start him on hormonal treatment, on e I ha#e e/ luded infe tion or other auses of

raised PSA+